Umbilical Hernias

Hernia of the Belly Button

An umbilical hernia occurs when fatty tissue enters through the umbilical opening in the abdominal muscles. There are two types of umbilical hernias.

1. Umbilical hernia in babies: Those in babies can be common. They can be harmless and can resolve themselves over a few years as the baby grows.  Many umbilical hernias in babies close on their own by the child reaching 2-3 years of age, though some hernias take longer to heal.  Umbilical hernias that don’t disappear by age 5 may need surgical repair. Umbilical hernia in adults, however, are completely different and can be quite serious because they will never correct themselves over time, they often become larger, and may eventually require surgery to repair them.

2. Adult umbilical hernia:  Unlike umbilical hernias in babies, an adult umbilical hernia can be quite serious. A mild adult umbilical hernia may first appear like an “out-tie” belly button. It’s estimated that 10% to 15% of healthy adults have an out-tie belly button and there are no reasons for concern. However, if heavy physical activity or strain causes a hole to appear in the umbilical canal, this can be the start of an umbilical hernia. Over time more fatty tissue may protrude through an opening in the umbilical opening causing more of a visible protrusion. When a person is able to push back the protrusion, this is called a “retractable umbilical hernia” or a “reducible hernia.” The hernia may stay back in place if the person is lying down, but typically, the protrusion will reappear with any physical activity.

Symptoms of an adult umbilical hernia

The most common symptoms are:

• Bulge or protrusion in the belly button area that often increases with physical exertion or coughing.
• A person may experience a sharp pain or dull ache in the belly button area.
• If a loop of bowel moves into the space and becomes trapped, symptoms that may occur include severe pain, nausea and vomiting. This requires emergency surgery.

What causes an adult umbilical hernia?

An adult umbilical hernia relates to a defect in the umbilical canal that was probably there since birth. The hernia can be caused by any of the following:

• Aging muscles become weaker, and as we enter our 40s, 50s and 60s tissue become less elastic and more susceptible to straining when lifting something heavy or from heavy physical labor.
• Being overweight or obese can place increased pressure on abdominal muscle.
• Pregnancy: A pregnant woman may notice the appearance of an out-tie belly button as her stomach enlarges. But this type of protrusion may self resolve after childbirth.
• Family history of hernias can play a role.
• Ecess fluid in the space between the tissues in the abdomen and abdominal organs, which may be linked to alcoholism

Risks related to an adult umbilical hernia

Umbilical hernias will gradually become larger. An increasing size of the umbilical hernia can lead to herniation of a bowel / intestine that can become incarcerated and strangulated (not necessarily just the size of the hernia).

As we age, procrastination of hernia treatment creates increased risks for even a simple outpatient surgery or general anesthesia.

Incarceration of the hernia

While most adult hernias simply allow fatty tissue to protrude through the umbilical opening, over time the hole can get larger allowing more tissue to protrude. If that tissue cannot be pushed back inside the abdominal wall, it can become “incarcerated” or strangulated where no circulation reaches the tissue. In larger umbilical hernias, parts of the intestines can also protrude through the opening. When blood supply is cut off to either this fatty tissue, or the intestines, it requires emergency abdominal surgery.

When should a hernia be repaired

The biggest risks to watchful waiting with an adult umbilical hernia relates to the risks of a hernia happening unexpectedly or from lifting something heavy, tearing a larger opening in the umbilical canal causing a serious and possible life-threatening issue.

There is a huge benefit to repairing the hernia while it’s not an emergency, so the watchful waiting needs to be done under the supervision of a surgeon with close follow-up.

Once it becomes obvious to the surgeon that the hernia needs to be repaired (ex: when it becomes symptomatic ), then it should be done electively and avoid it becoming an emergency surgery.

Hernias that enlarge over time

The second risk to watchful waiting is that an adult umbilical will typically get worse over time and the hole in the umbilical channel will get larger allowing more fatty tissue, and perhaps part of the intestines, to protrude. An adult umbilical hernia will never close itself on its own and will require surgery to repair it.

Umbilical hernia surgery can be complex depend on other factors, such as patient’s body habitus, size of the hernia, and if there is an incarcerated +/- strangulated bowel. The surgery is one of the more commonly performed surgeries but requires expertise to handle complex factors which are sometimes known prior to the procedure, but may also be found during the surgery.

Mesh versus No Mesh:

Use of mesh to reinforce and strengthen the repair is the standard of care, with few exceptions. Repairs with mesh have the lowest incidence of recurrent hernia and reinforce the closure area.

How is surgery done to repair an adult umbilical hernia?

Herniorrhaphy is the medical term for the surgical repair of a hernia. Hernioplasty is the surgical repair of a hernia with artificial surgical mesh to reinforce the weak area. In all hernia surgeries, general anesthesia is necessary to enable the surgeon to push back in the protrusion and suture it closed.

Open hernia repair:

The traditional “open technique” may be required if the surgeon cannot adequately see and manipulate the area with minimally invasive techniques.  This may be due to anatomical differences including body size, scar tissue from previous surgeries, and other factors your surgeon will explain to you if it’s felt the open repair is indicated or very likely.

What to Expect After Hernia Repair

Every person will have their own response to surgery and rate of recovery, but we can address the most common experiences.

• Most people have some pain, bruising and swelling at the surgery site. Prescription-strength pain medication may be necessary the first 1 to 3 days, but by day 4 or so, over-the-counter pain medicine like Acetaminophen and Ibuprofen are sufficient.
• Activity – plan on being off of work or school for the first few days after surgery, getting around the house, eating, showering, and even light shopping are fine (don’t drive if taking prescription pain medicines!). Some people take a bit longer to recover from anesthesia, and prescription pain medicines have side effects that may limit your activity, but returning to light activity is encouraged.
• Weight restrictions – a key to proper healing that will result in the strongest repair is to avoid excessive lifting. Your surgeon will inform you of the specific weight restrictions based on your general health, abdominal wall strength, etc, but plan on lifting a maximum of 10 to 20 pounds for 6 weeks after surgery.

Laparoscopic hernia repair: 

The hernia is repaired from the inside with mesh or sutures inserted through instruments placed through small incisions made in the abdomen.

After surgery, the patient can return home and later that afternoon is encouraged to get up and walk. However, no physical activity is recommended for at least a month to enable proper heating and to reduce the risk of a recurrence. The patient is restricted from lifting anything over 10 pounds for the first two weeks and nothing over 20 pounds for the second two weeks.

The first step is a hernia assessment

The best approach related to an adult umbilical hernia is to have an assessment with a general surgeon who specializes in hernia repair who can advise you on if you should use watchful waiting for your hernia, and the pros and cons of different surgical approaches.

Watchful waiting is not recommended unless it is a very small and asymptomatic umbilical hernia.

It’s important to select a surgeon who performs a large number of hernias because like anything else, practice makes perfect. The good news is that surgeons who specialize in hernia repair are typically able to perform surgery to correct an adult umbilical hernia in an outpatient setting where the patient is home later the same day and walking around. Pain and discomfort can often be managed with over-the-counter medications like Tylenol or Advil, but stronger pain medication is often provided for those who find greater discomfort.