Umbilical hernias: Clinical sciences

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Introduction0:00–0:55

An umbilical hernia is a defect in the abdominal wall located at the umbilicus. This type of hernia usually occurs through the weakened umbilical fascia or through a defect formed at the site of involuted umbilical vessels.
Small hernias often contain an empty sac, while larger ones can encase preperitoneal fat, omentum, or even a loop of bowel.
Most umbilical hernias are acquired in adulthood in individuals with elevated intra-abdominal pressure due to conditions such as pregnancy, ascites, or obesity.
Umbilical hernias can present in four different ways: asymptomatic, symptomatic, incarcerated, or strangulated. Keep in mind that incarcerated or strangulated hernias might require urgent surgical intervention.Alright, when you encounter a patient with signs and symptoms suggestive of an umbilical hernia, your first step is to perform an ABCDE assessment to determine whether the patient is stable or unstable.

Unstable Patient0:55–1:25

If the patient is unstable, you should stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, obtain IV access, and administer fluids before continuing with your assessment.

Stable Patient - Asymptomatic Umbilical Hernia1:25–2:25

Now that unstable patients are taken care of, let’s talk about stable patients. If the patient is stable, your first step is to obtain a focused history and physical examination.
First, you might encounter a patient with no symptoms. However, the physical exam might reveal a soft, protruding mass protruding from the umbilicus with some mild tenderness on palpation, but no overlying skin changes.
The mass will be easily reducible. This is a classic case of an asymptomatic umbilical hernia.
In terms of treatment, these hernias can often be managed with watchful waiting. However, elective repairs can be considered for defects with high potential for becoming larger, which may increase the risk of incarceration and strangulation.
If your patient wishes to wait, advise them to seek medical attention for any new-onset or worsening umbilical pain, or if they are suddenly unable to reduce the hernia.Alright, let’s go back to our history and physical examination and talk about symptomatic umbilical hernias.

Symptomatic Umbilical Hernia2:25–3:18

You can expect patients with symptomatic hernias to report some pressure and sharp pain in the umbilical area. On physical exam, you might see a soft, protruding mass in the umbilical area with tenderness on palpation.
There will be no skin changes, and the hernia will be reducible. If you find these characteristics, you can diagnose the patient with a symptomatic umbilical hernia.
These hernias should be electively repaired, so make sure to call the surgical team for a consultation. In the meantime, counsel your patient to seek immediate medical attention if the pain worsens, or if they are suddenly unable to reduce their hernia.Okay, let’s move on to patients with signs and symptoms of an incarcerated umbilical hernia.

Incarcerated Umbilical Hernia3:18–4:24

In this case, history may reveal pressure and constant, sharp pain in the umbilical area. On physical exam, you can expect to find a protruding mass in the umbilical region with tenderness on palpation.
The overlying skin might have some erythema. Now, unlike asymptomatic or symptomatic umbilical hernias, this type of hernia will not be reducible, which is diagnostic of an incarcerated umbilical hernia.
Once you make the diagnosis, you will need to call the surgical team for a consultation since the patient will require an urgent hernia repair.Here’s a clinical pearl!
The neck of the umbilical hernia sac can be quite narrow, increasing the risk of incarceration and subsequent strangulation.
So, a timely and accurate diagnosis is essential to provide appropriate surgical treatment. Now, let’s focus on a more serious condition called a strangulated umbilical hernia.

Strangulated Umbilical Hernia4:24–7:10

In strangulated hernias, the blood supply to any abdominal contents within the hernia sac becomes compromised, leading to ischemia.
If a loop of bowel is stuck in the hernia, the potential for gangrene and bowel perforation can be very high. On history, patients often report fever, severe, sharp pain, and even signs of bowel obstruction such as abdominal pain, nausea, vomiting, or obstipation.
The physical exam typically shows a protruding umbilical mass that will be very tender on palpation, and the surrounding skin might present discoloration, which can be erythematous, purple, or blue, which is concerning for ischemia.
If this is the case, you are dealing with a strangulated umbilical hernia.Here’s another clinical pearl! If your patient’s presentation is consistent with a strangulated umbilical hernia, do not attempt to reduce the hernia, since its contents might contain a necrotic bowel segment, which can quickly lead to abdominal sepsis if returned back to the abdominal cavity.
Now, once you have made your diagnosis, start the patient on IV fluids, broad-spectrum IV antibiotics, and place a nasogastric tube if there are any concerns for a bowel obstruction.
Once these treatment measures are implemented, call the surgical team for an emergent repair. Keep in mind that any necrotic tissues or segments of bowel must be removed surgically as soon as possible to avoid systemic complications like sepsis.
Lastly, here are some additional clinical pearls about umbilical hernias in special populations. In pregnant patients, surgical repair is generally delayed for asymptomatic or minimally symptomatic umbilical hernias until after the delivery.
On the other hand, severely symptomatic, incarcerated, or strangulated hernias can be repaired during pregnancy. Elective repairs are often performed during the second trimester when it is considered to be safe; however, incarcerated and strangulated hernias should be repaired as soon as possible.
Another subset of patients who warrant special consideration are individuals with cirrhosis-related ascites. Ideally, these patients should be medically optimized prior to elective surgical repair.
Their ascites needs to be controlled and portal hypertension appropriately managed preoperatively to minimize the risk of recurrence or repair failure.
If, however, the patient needs urgent or emergent repair, it should be done as soon as possible.Alright, as a quick recap… Patients with umbilical hernias can present as unstable or stable.
In unstable patients, you should stabilize the airway, breathing, and circulation before continuing with the work-up. Patients who are stable can have asymptomatic, symptomatic, incarcerated, or strangulated umbilical hernia.

Review7:10–8:07

Asymptomatic umbilical hernias usually only need watchful waiting, but elective surgical repair can be offered in some cases.
Symptomatic umbilical hernias, on the other hand, are often repaired electively. For incarcerated umbilical hernias, call the surgical team for an urgent repair.
Lastly, if the hernia is strangulated, do not attempt to reduce it! Start the patient on IV fluids and broad-spectrum antibiotics and place a nasogastric tube if there are concerns for bowel obstruction.
Then, you can call the surgical team for an emergent repair. call the surgical team for an urgent repair Lastly if the hernia is strangulated do not attempt to reduce it Start the patient on IV fluids and broad-spectrum antibiotics and place a nasogastric tube If there are any concerns for bowel obstruction then you can call the surgical