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354 Treatment of the Other Hernia
34
The incidence of recurrence is often quoted as be-
ing between 0 and 1.1% after mesh repairs and from
0–6.5% after sutured repair [8]. I have long suspected
these figures to be low. The suspicion was confirmed
when one of the largest series ever reported and with
which I was associated (508 cases) revealed that 50% of
femoral hernias admitted to the hospital were already
recurrences. This pattern had been noted in previous
years. That same series which reflected a careful follow-
up of the patients (84.7% after 4 years), revealed that
recurrences ranged from 11.8–75% depending on the
number of previous operations (
⊡
Table 34.1) [9].
In the selection of the patients to be followed, those
who were included were patients who had had a femoral
hernia confirmed at surgery. When a recurrence took
place, only those patients who had a femoral hernia
recur, in other words a true recurrence of the original
pathology, were included in the follow-up study. If the
recurrence after a femoral repair was an inguinal her-
nia or if a femoral hernia followed an inguinal repair,
these patients were not included in the study. The aim
of the study was to identify and confirm a pure femoral
hernia and document the recurrence of a pure femoral
hernia. Interesting additional facts which emerged was
that women made up 52.5% of 251 primary femoral
hernias while they made up only 18% of 257 recurrent
femoral hernias. All these patients underwent elective
surgery. However, when patients present in emergen-
cies with incarceration or strangulation, sometimes
requiring a bowel resection, 76.7% turn out to be
females [10].
Three significant factors have accounted for the
complexity of femoral hernia as a clinical entity. These
factors are: the intricacy of the anatomy, the flimsy na-
ture of the tissues available for repair, and tension.
Intricacy of the Anatomy
True understanding of the femoral canal was the major
contribution of Chester McVay [11] and Fruchaud [12].
In simplest terms, the femoral canal is formed by the
development of the femoral vessels which drag along
with them, the true
into the thigh. This transversalis fascia is that part of
the endopelvic fascia, flimsy as it is. It is not to be con-
fused with what is commonly called the transversalis
fascia but is, in fact, the transversus abdominis apo-
neurosis. The latter on its deepest surface is adjacent
to the true transversalis fascia and both are referred to,
erroneously, as the “transversalis fascia”. The femoral
canal is therefore lined with true transversalis fascia
which comes to lie and fit against nearby elements.
These surrounding elements create a funnel shaped
structure with an inlet and a body.
The inlet is rigid and its limits are:
▬ Posteriorly: the pubic crest and Cooper’s ligament.
▬ Anteriorly: the inguinal and Thomson’s ligaments.
▬
Medially: the lateral edge of the lacunar ligament of
Gimbernat.
▬ Laterally: the femoral vein.
The body of the funnel, however, is walled by:
▬ Anteriorly, the anterior leaf of the fascia lata.
▬ Posteriorly: the pectineus fascia (medially) and the
posterior leaf of the fascia lata (laterally).
▬ Medially: the lacunar ligament of Gimbernat.
▬ Laterally: the femoral vein.
It is important to distinguish, as pointed out by
Fruchaud, that the crural canal is that which houses
the femoral artery, femoral vein and the lymphatic canal
as they descend from the abdominal cavity into the
thigh, while the femoral canal is the most medial part
of the crural canal, covered superiorly by a fat pad and
or a lymph node. It is the canal into which a femoral
hernia will descend and enlarge in the direction of the
fossa ovalis where the latter makes room for the hook
of the saphenous vein.
Nature of the Tissues
It becomes readily apparent that the tissue forming the
femoral canal is of no substance. Laterally, where it is
called the femoral sheath and is adjacent to the femoral
vein, it is so thin that the naked eye can rarely identify it.
Certainly, it is of no surgical value in terms of retaining
a suture. Whence, the tenuous nature of suture repairs
resulting in frequent failures.
⊡
Table 34.1. Re-recurrence rate of femoral hernias
1x recurrent femoral hernia 11.8%
2x recurrent femoral hernia 34.7%
3x recurrent femoral hernia 34.6%
4x recurrent femoral hernia 30.0%
5x recurrent femoral hernia 75.0%
Average 22.0%
Mean 37.2%
355
X
The Femoral Hernia – the Bête Noire of Hernias!
Tension
All suture repairs of femoral hernias imply tension. This
tension is generated by the architecture of the groin.
The area in question is triangular with the base formed
by the femoral vein, the rounded apex of this triangle,
by the lacunar ligament of Gimbernat, the posterior
side of the triangle being the pubic ramus and pectineal
ligament while the anterior side is the iliopubic tract of
Thomson and inguinal ligament. These structures are
fixed rather rigidly and attempts to approximate them
effectively will either cause a tear in tissues or impinge
on the femoral vein. The latter is a constant if low occur-
rence in McVay repairs [13, 14]. It is in femoral hernias
that meshes have found their most efficient expression.
The literature detailing this definite advance in hernia
surgery is abundant and is the subject of an entirely
different interest.
Conclusion
There is little doubt that femoral hernias are among
the most difficult hernias to repair. Certainly the most
stressful! How does one go about “creating a femoral
hernia”. One sure way is to be unfamiliar with anatomy.
The other is to insist on a suture repair. No matter how
tension-free a suture repair may look and feel, it is only
an appearance without substance. One must not suc-
cumb to that illusion. The mesh repairs of femoral her-
nias must avoid the use of gadgets for which there is “no
need to know anatomy”! A simple sheet of mesh 6 to
8 cm in diameter (with a suture threaded at its centre if
need be) can be inserted by any method that one is most
familiar with: infrainguinal, transinguinal, suprapubic
or laparoscopic. The net result of the repair should be
a preperitoneal position of the mesh.
References
1. Bendavid R. Femoral hernias: why do they recur? Probl Gen
Surg 12 (1995) 147–149
2. Koontz A. The disaster of recurrent hernia. Curr Med Digest
29, 1962
3. Obney N, Chan CK. Repair of multiple time recurrent inguinal
hernias with reference to common causes of recurrence.
Contemp Surg 25 (1984) 25–32
4. Georgievski A. Surgeon-in-chief, Shouldice Hospital (1995–
2000). Personal communication (1990)
5. Bendavid R. A femoral “umbrella” for femoral hernia repair.
Surg Gynecol Obstetr 165 (1987) 153–156
6. David T. Strangulated femoral hernia. Med J Aust 1 (1967)
256–261
7. Ponka JL, Brush BE. The problem of femoral hernia. Arch Surg
102 (1971) 417–423
8. Bendavid R. The need for mesh. In: Bendavid R (ed) Prosthesis
and abdominal wall hernia. Landes Biomedical Publishers,
Austin, 1994, pp 116–122
9. Bendavid R. Femoral hernias: primary vs. recurrence. Int Surg
74 (1989) 99–100
10. Xavier H, Bouras-Kara T. Should prostheses be used in emer-
gency hernia surgery? In: Bendavid R (ed) Abdominal wall
hernia: principles and management. Springer, New York,
2001, pp 557–559
11. McVay CB. Hernia. The pathologic anatomy and their ana-
tomic repair of the more common hernias. Charles C Thomas,
Sprinfield, IL, 1954
12. Fruchaud H. Surgical anatomy of inguinal hernias in the
adult, translated and edited by Bendavid R and P. Cunning-
ham; University of Toronto Press (in press)
13. Barbier J, Carretier M, Richer JP. Cooper ligament repair; An
update. World J Surg 13 (1989) 499–505
14. Brown R, Kinateder RJ, Rosenberg N. Ipsilateral thrombo-
phlebitisand pulmonary embolism after Cooper’s ligament
herniorrhaphy. Surgery 87 (1980) 230–232
Discussion
Fitzgibbons: Do you think that we can reliably differen-
tiate an indirect inguinal hernia from a femoral hernia
in a female? The reason I ask this question is because,
after publishing the watchful waiting trial showing it was
safe to observe men, we specifically excluded women on
the basis of the fact you can’t reliably make the distinc-
tion and they should have immediate operation. We’re
getting lots of calls from women’s societies that we were
chauvinists and subjecting these women to surgery: Do
you agree with this statement that you can’t reliably dif-
ferentiate an indirect inguinal hernia from a femoral in a
female?
Bendavid:
I have found that differentiating it has been
easy most of the time because if you draw a line which is
called the Brown line between the anterior superior iliac
spin and the pubic crest, obviously the femoral will be
below it. It will be much more difficult to differentiate
between a direct and an indirect but I have seen situations
where the femoral sac is so large that it would actually
dissect itself back up so that it feels like either direct or
an indirect hernia. From that standpoint you cannot tell
them apart: so to answer your question: you cannot tell
them with 100% certainty.
Fitzgibbons: I personally think it’s dangerous to observe
any female with a hernia.
Bendavid:
Well, I agree, I agree. That’s a tricky question,
though: are you using that on exams?
Fitzgibbons:
No, not on exams. I questioned myself, that’s
why it’s a personal question.
356 Treatment of the Other Hernia
34
Read: Dr. Little, the great surgical anatomist from Eng-
land, has presented, as you know, quite a few studies
about the surgical anatomy of femoral hernia; his concept
was that a femoral hernia doesn’t occur until the hernia
so-called has passed the exit of the femoral canal as op-
posed to the entry. Would you comment on that?
Bendavid:
Well it was a nebulous area. Now I under-
stand that anatomically in fact the funnel does go all the
way down to the saphenous opening. It’s there, it’s been
described by many people, interestingly enough the work
of Little also was done in the 18th century in France and
I found that he derived a lot of his comments from that
work; but what happens is the fact that once a hernia
does develop and takes on volume, its covering is so thin
that it can start bulging before it gets down to the femoral
opening, the saphenous opening, and I have personally
never seen, perhaps once if I remember, a sac extend-
ing all the way. Have you? I feel that the covering of the
transversalis fascia is so thin, so distensible, and that you
should intervene way before it becomes a problem. I think,
theoretically anatomically, he is right.
Young:
Two comments, one is that ultrasound can be
an extremely accurate tool for diagnosis on femoral her-
nia and we do this in our office very frequently; second
point since you are going into that, we have two ways of
repairing femoral hernias with PHS which I think might
be very relatively straightforward. One is going directly
through the opening inessentially opening the underlay
on the inside attaching it to the ligamentum anterior or
the Coopers’s ligament on the outside and then cutting off
the overlay, the second way is going through and doing
essentially a direct repair but in that case we anchor the
underlay to Cooper’s ligament just medial to the femoral
vein and then the additional portion of the underlay lies
down in front as if you had place it in there.
Bendavid: That’s a lot of invasion but, however…
Kehlet:
I just want to add some information from the
real world in Denmark and an analysis that I will show
tomorrow. In more than 2000 femoral hernias the results
are terrible. We have a 9% recurrence rate with an ob-
servation period over 6 years.
Bendavid: Following what kind of technique?
Kehlet:
All the classical techniques, including the mesh;
the laparoscopic technique is half. So I want to ask also
the Swedish database, because you published a paper in
about 800 patients some years ago, if you can comment on
your nationwide results. You didn’t mention laparoscopic
repair for femoral hernia. Isn’t that the ideal technique?
Bendavid:
Certainly you get to the area and you will
cover it. In fact, the laparoscopic surgeons are beginning
to report incidences of femoral hernia that are far beyond
what was suspected. Some surgeons have even told me
that they see it at least 20% of the time but this is why I
have commented on the fact that if anything looks like
a meniscus, don’t disturb it, leave it alone. If you see a
sunken lymph knot, leave it alone, leave it in place and
don’t dissect it because where there was no femoral hernia
before you will definitely have one now. I think we have
seen it often enough, so one has to be careful.
Berndsen:
We made an analysis a couple of years ago on
600 femoral hernias, but we couldn’t see any differences
between the various methods. There was a slight differ-
ence in the material in favour of methods using mesh.
There were no statistically significant findings.
Schippers:
Dr. Bendavid, during my surgical education I
was taught at least for the inguinal approach to approxi-
mate the inguinal ligament and the Cooper ligament in
order to close the femoral hernia. Did I understand you
right that those structures are not reliable any longer?
Bendavid:
I don’t recommend any suture repair any more.
When you see the angle and you see the size of the vein
and when you see drawings you cannot avoid tension and
I’ve seen one case of a leg that was terribly reflective of
what I’m talking about. Today I think we have to move
with the time and I would not recommend any sutured
repair. Of course, when you look at the old texts, they
said something like you must make sure that you have
at least 2 mm between the last suture and the femoral
vein. It’s a difficult thing to do because don’t forget that
the patient starts moving and then you have a completely
different anatomy and different physiology. The moment
the person stands you cannot compare the anatomy even
in surgery with a leg outside the table dangling on the
side of the table with a bag under the pelvis in order to
duplicate the position and the function during the stand-
ing posture of the patient. So I’m not so sure, and as I’ve
said, if you can see up to 3 or 4% that’s high when you
are doing such a benign procedure to end up with such
a nasty complication.
Chan:
I think from the way that we have developed the
need to use femoral mesh is by experience in the past
– you know until 1986 then we put the mesh in. Before
that we knew that once we get femoral hernia recurrent
we threw up our hands! Now we can’t really repair. So
what I mean is, Bendavid, you first put the mesh in and
then forget about.
Kukleta:
I should like to make a comment on anatomy.
As laparoscopist I see it a little differently. I agree that
one should not remove a lymph knot out of the femoral
canal because maybe there is no hernia at all, but I’m not
absolutely sure if you’re right with the preperitoneal fat.
Sometimes when we pull on that 5–7 cm of preperito-
neal tissue comes which was the reason for the symptom.
We’ve learned something if we suspect femoral hernia
357
X
The Femoral Hernia – the Bête Noire of Hernias!
and don’t have any peritoneal sac, we have to open to
make sure that we don’t have this preperitoneal tissue in
there.
Bendavid: I would like to disagree with you strongly be-
cause we have in fact learned this. There was a time
when we did the femoral hernia from below and often
we used to find fat tab and it was so easy to actually pull
on this fat tab until you got as much of it as possible and
resected it and put it in a simple suture and that’s all. It
would certainly recur as a femoral hernia. The attitude
has changed and I think it’s fairly convincing that we
leave it alone. If you happen to be below you simply don’t
dissect it, don’t put it out. A fat tab is a very effective
plug so far and I don‘t see why you should go looking for
trouble. The Americans have a good saying: “If it isn’t
broken, don’t fix it”.
Kukleta:
We do it only for those who are symptomatic
and this is the reason why we open there because if it was
just diagnostic laparoscopy nobody would ever open the
peritoneum to look for fat pads.
X
35 The Umbilical Hernia
J. C, A. P, M. S, O. S
Introduction
In early development a connecting stalk between the
caudal end of the embryo and the chorion is established.
This stalk contains at the embryonic end a small allanto-
enteric diverticulum. Furthermore, it contains the umbilical
(allantoic) vessels: one umbilical vein and two umbilical
arteries and the urachus. It must be mentioned that a small
exocoelomic recess is also included in the proximal (em-
bryonic) part of the umbilical stalk. This recessus is also
termed umbilical coelom and it is in continuation with the
intra-embryonic coelom of the embryo. During the 6th to
10th week of development this umbilical coelom forms a
sac, which receives the physiological umbilical hernia of
the midgut. After the retraction of the physiological um-
bilical hernia, the umbilical coelom is usually obliterated
and does not further exist. At birth these structures are dis-
pensable, leading to an obliteration of the umbilical cord
structures. The following granulation and scarring process
typically leads to a fibrotic, collagenous plate characterized
by criss-crossing fibre fusion with the neighbouring um-
bilical ring. According to this complicated development,
the definitive umbilicus is a locus minoris resistentiae with
a lifelong risk for herniation.
Two main groups of umbilical hernias can be differenti-
ated easily: the infantile umbilical hernias and the adult
umbilical hernias. The first group can be derived without
any problems from a disturbed development in the um-
bilical region, where the rectus abdominis muscles fail
to approximate in the midline after the retraction of the
physiological umbilical hernia. The second group is always
an acquired hernial entity.
It is absolutely essential not to confuse the other de-
fects of the anterior abdominal wall ( omphalocele, gas-
trochisis and intussusception at the umbilicus) with an
umbilical hernia. An exact terminology and clear defini-
tions are given by Moore and Stokes, so that a precise
differential diagnosis can be established [8].
Infantile Umbilical Hernia
( Hernia Funiculi Umbilicalis)
Non-fusion of the obliterated umbilical cord structures
with the surrounding umbilical ring and disturbances
in the closure of the umbilical foramen may lead to
protrusion of the peritoneal sac. After hydroceles and
inguinal hernias they are the third common surgical
disorder in infancy, with an incidence of up to 20%
in white children and even up to over 50% in black
infants. There seems to exist a familial predisposition
of 9–12%. Most often they appear in premature and
low-weight newborns.
Beside the obvious protrusion, infantile umbilical
hernias rarely enlarge over time or become symptom-
atic. In up to 90% they even disappear without any sur-
gical action within the first 2 years. The probability of
spontaneous closure seems to correlate with defect size.
Umbilical hernias with defect diameter of more than
15 mm are unlikely to close spontaneously.
360 Treatment of the Other Hernia
35
Therefore, the indication for surgical repair should
not be made before the age of 2 years. In the case of
operation, the typical surgical procedure is a simple
single stitch or continuous suture repair with re-
sorbable suture material ( Spitzy repair). This can be
performed with a short general anaesthesia in a day-
care setting.
Adult Umbilical Hernia
In the adult the umbilical hernia are most often ac-
quired. The over-all incidence is approximately 5–6%
of all abdominal wall hernias. Typical predispositions
are rise of the intra-abdominal pressure, for example in
extreme obesity, history of multiple pregnancies, asci-
tes or large intra-abdominal tumours. Contrary to the
infantile umbilical hernias, the risk of incarceration is
much higher in the adult.
In the literature there is sometimes a differentiation
between direct umbilical and para-umbilical hernias,
though in clinical practice this remains without effect.
Direct hernias appear as a symmetric protrusion with
a circumferentially symmetric bulge after yielding of
the cicatrix tissue closing the umbilical ring. Direct
umbilical hernias result from a persistent elevation of
the intra-abdominal pressure. This is typical for pa-
tients with ascites formation or peritoneal dialysis. If
not as an emergency, a primary therapy of the actuating
disease should be aspired before any surgical action in
these cases.
In indirect, para-umbilical hernias, the yielding of
tissue around the umbilical ring leads to a semicircular
protrusion above or below the umbilicus with the naval
column building part of the hernia.
Already 2000 years ago Aulus Cornelius Celsus, au-
thor of De Medicina described the umbilical hernia as
an “indecent prominence of the naval”. He suggested
a tight constriction of the hernia with flaxen thread
and burning the part beyond the ligature with caustics.
Today, the surgical armamentarium for umbilical hernia
repair has evolved with a broad spectrum of different
procedures (
⊡
Fig. 35.1). As in inguinal or incisional
hernia, we can observe the same tendency favouring
a repair with mesh prosthesis; but unlike these her-
nias, the recurrence rates after suture repair are not
as desolate.
The suture repair of umbilical hernias can be per-
formed as a single stitch to stitch, or a continuous suture
with absorbable or non-absorbable material. In recent
publications these conventional techniques reach recur-
rence rates between 8 and 14% (
⊡
Table 35.1
). Using the
Mayo repair, suturing the overlapping fascia downward
from above, the results are even better with recurrence
rates around 4%. These results appear inconsistent com-
pared to recurrence rates of more than 40% in incisional
hernia repair. A possible explanation could be the lon-
gitudinal suture direction, with an angle of 90° to the
transverse fibre direction of the fascia.
The surgical options for mesh implantation in um-
bilical hernias are similar to inguinal and incisional
hernia repair. So far, there is no final conclusion in
terms of technique, material or mesh position, or mesh
necessity at all. In the literature the open mesh tech-
nique shows recurrences between 0 and 25%, with in-
fection in up to 15% (
⊡
Table 35. 2
). Recent descriptions
using PHS ( Prolene Hernia System) or laparoscopic
procedures show promising results, though limited
by small numbers and short follow-up (
⊡
Tables 35.3
and 35.4).
Comparing the different techniques and their results
the suture repairs facilitate a success rate in over 90%
of the patients with a minimum of costs and a surgical
procedure that can be performed in local anaesthesia
in an outpatient setting. Mesh repair is more expensive,
adding the costs for mesh material and longer opera-
umbilical hernia
suture repair mesh repair
open IaparoscopySpitzy Mayo
sublay onlay plug ipom
⊡
Fig. 35.1. Surgical options for umbilical
hernia repair
361
X
The Umbilical Hernia
⊡
Table 35.1. Umbilical hernia repair with suture repair (single stitch; continuous suture or Mayo repair)
Author No. Follow-up
[months]
Technique Ser. Inf. Rec.
Arroyo et al. 2000**
[1]
100 64 Suture, non-absorbable 5.5% 3.0% 11.0%
Wright et al. 2002 [13] 166 30 Suture, non-absorbable 9.0% 9.0% 19.0%
Schumacher et al.
2003 [11]
108 30 Suture, absorbable ? 6.5% 1
13.0%
Gonzales et al. 2003
[3]
124 28 Suture, absorbable ? ? 18.0%
Halm et al. 2005 [4] 198 32 Suture? ? 9.2% 14.3%
Aachen 2006 369 72 Spitzy 14.4% 6.0% 19.7%
Mayo (1901) 175 ? Mayo ? ? 12.6%
Bowley and Kings-
north 2000
393 25 Mayo ? ? 14.0%
Menon and Brown
2000 [7]
132 24 Mayo, non-absorbable ? 6.0% 10.0%
⊡
Table 35.2. Umbilical hernia repair with open mesh techniques
Author No. Follow-up
[months]
Technique Ser. Inf. Rec.
Bowley and Kings-
north 2000
180 25 Mesh ? ? 12.5%
Arroyo et al. 2002 [1] 213 64 147 PP-Plug (<3 cm)
70 PP-onlay mesh
(>3 cm)
15.6% 11.4% 0.95%
Wright et al. 2002 [13] 120 28 Open mesh (PP)
onlay or sublay
15.0% 10.0% 25.0%
Gonzales et. al. 2003
[3]
120 25 Open onlay mesh 40.0% 15.0% 20.0%
Kurzer et al. 2004 [5] 154 43 sublay mesh/plug (PP) ? 12.9% 10.0%
Sinha and Keith 2004
[12]
134 14 Plug (PP) 13.0% 13.0% 13.0%
Halm et al. 2005 [4] 111 32 Sublay mesh (PP) 10.0% 10.0% 10.0%
362 Treatment of the Other Hernia
35
tion time, plus general anaesthesia for laparoscopic
procedures.
In 2003, Schumacher et al. performed a follow-up
study after umbilical hernia repair and looked at the
possible risk factors for hernia recurrences. They found
a significant relationship between recurrence and body
mass index (BMI). In patients with a BMI below 30
the recurrence rate was 8.1% compared to 32% recur-
rences with a BMI above 30% [11]. These findings were
recently confirmed by Halm et al. [4].
Another risk factor for hernia recurrence identified
by Schumacher et al. was the size of the fascia defect.
After suture repair of an umbilical hernia, recurrence
occurred significantly more often in patients with fas-
cia defects of more than 3 cm diameter. Excluding the
patients at risk (BMI > 30, defect > 3 cm), the suture
repair was successful in 96% of all patients. In contrast
to incisional hernia repair, the implantation of mesh
prosthesis seems to be an overtreatment in most umbili-
cal hernias. Mesh repair should be reserved for patients
at risk with a BMI above 30 and a defect diameter of
more than 3 cm. In the patients that Schumacher et al.
followed up there were 22% at risk, concluding that ap-
proximately 80% of all umbilical hernias can therefore
be treated successfully with a suture repair and only in
20% would a mesh repair have been indicated. Besides,
the ideal technique for umbilical mesh repair has yet to
be found. There is no evidence on mesh position, mesh
size, mesh material or mesh fixation. Future studies
need to investigate the ideal mesh procedure.
References
1. Arroyo A, Garcia P, Perez F, Andreu J, Candela F, Calpena R
(2001) Randomized clinical trial comparing suture and mesh
repair of umbilical hernia in adults. Br J Surg 88: 1321 1323
2. del Pozo M, Marin P (2003) Three-dimensional mesh for ven-
tral hernias: a new technique for an old problem. Hernia 7:
197 201
3. Gonzalez R, Mason E, Duncan T, Wilson R, Ramshaw BJ (2003)
Laparoscopic versus open umbilical hernia repair. JSLS 7: 323
328
4. Halm JA, Heisterkamp J, Veen HF, Weidema WF (2005) Long-
term follow-up after umbilical hernia repair: are there risk
factors for recurrence after simple and mesh repair. Hernia
9: 334 337
5. Kurzer M, Belsham PA, Kark AE (2004) Tension-free mesh re-
pair of umbilical hernia as a day case using local anaesthesia.
Hernia 8: 104 107
6. Lau H, Patil NG (2003) Umbilical hernia in adults. Surg Endosc
17: 2016 2020
7. Menon VS, Brown TH (2003) Umbilical hernia in adults: day
case local anaesthetic repair. J Postgrad Med 49: 132 133
8. Moore TC SG (1953) Gastroschisis; report of two cases treated
by modification of Gross operation for omphalocele. Surgery
33: 112 120
⊡
Table 35.3. Umbilical hernia repair with open Prolene hernia system (PHS)
Author No. Follow-up
[months]
Technique Ser. Inf. Rec.
Perrakis et al. 2003 [9] 48 13 PHS 2% 0% 0%
Del Pozo and Marin
2003 [2]
14 ? PHS 0% 0% 0%
Polat et al. 2005 [10] 17 22 PHS 6% 6% 0%
⊡
Table 35.4. Umbilical hernia repair with laparoscopic IPOM
Author No. Follow-up
[months]
Technique Ser. Inf. Rec.
Lau and Patil 2003 [6] 26 24 Lap-IPOM (ePTFE) 10% 10% 0%
Wright et al. 2002 [13] 30 23 Lap-IPOM (ePTFE) 10% 3.3% 0%
Gonzales et al. 2003
[3]
32 25 Lap-IPOM (PP or ePTFE) 56% 0% 0%
363
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The Umbilical Hernia
9. Perrakis E, Velimezis G, Vezakis A, Antoniades J, Savanis G,
Patrikakos V (2003) A new tension-free technique for the
repair of umbilical hernia, using the Prolene Hernia System
early results from 48 cases. Hernia 7: 178 180
10. Polat C, Dervisoglu A, Senyurek G, Bilgin M, Erzurumlu K,
Ozkan K (2005) Umbilical hernia repair with the prolene
hernia system. Am J Surg 190: 61 64
11. Schumacher OP, Peiper C, Lorken M, Schumpelick V (2003)
[Long-term results after Spitzy‘s umbilical hernia repair].
Chirurg 74: 50 54
12. Sinha SN, Keith T (2004) Mesh plug repair for paraumbilical
hernia. Surgeon 2: 99–102
13. Wright BE, Beckerman J, Cohen M, Cumming JK, Rodriguez
JL (2002) Is laparoscopic umbilical hernia repair with mesh
a reasonable alternative to conventional repair? Am J Surg
184: 505–508
Discussion
Deysine:
Thank you, Dr. Conze. I will tell you that my
experience is a bit different. I used to do my umbilical
hernia repairs with either a stitch if they were very small
or a Mayo repair. My recurrence rate was close to 100%.
Then I switched to mesh repair and that improved dra-
matically. I didn’t have another recurrence, but all my
little umbilical hernias that I stitched came back.
Hahn:
I want to raise two points. Magnificent of you,
thank you very much, I want to apologize for going ahead
and mentioning it already yesterday. I’m very sorry about
that. Two things: you mentioned that you went to the fi-
nancial department and they worked out the price for you
and it included 2 days of in-house stay. I think that’s very
long. I think all patients in The Netherlands in our series
were operated in day-care so they were sent home straight
away. That’s one thing I would like you to comment on.
The second is in your overview of possible techniques, I
think you left out one maybe little experiment but it’s the
TAPP procedure of the umbilical hernia with the trans-
abdominal praeperitoneal placement of mesh which is
currently practiced by surgeons in The Netherlands. Well,
there is no report, but it looks lovely.
Conze: Give me some time. I think the problem in Ger-
many is if you look at the numbers that we get from our
insurance companies you’d be surprised. I don’t know why
the Germans love the hospitals, they like to be in hospital
and they feel they should stay there until they’re really safe
and everything is OK. Now 2 days is not overtreatment in
Germany, it’s usually around 6 days for umbilical hernia.
I know you would not survive a stay like this in America,
they kill you immediately. Germans are a little different
concerning their stay in the hospital. It will change but it
takes time. We do this also in outpatient but it’s a small
number.
Schumpelick: Fitzgibbons told us watchful waiting in the
hernia business. What about watchful waiting in umbili-
cal hernia? We see a lot of hernias, should we operate
them all? What is the indication to operate?
Conze: Well, every big hernia was once a small hernia.
Schumpelick: Operate every hernia?
Conze: Yes.
Schumpelick:
Is there agreement here? Every seen hernia
should be operated? Symptomatic hernia always has to be
operated; asymptomatic hernia, what about that?
Conze:
We should specify. We are not talking about chil-
dren. We are talking about adults and we are talking
about adults without risk factors. Who would operate
every umbilical hernia at the age over 25 with a bulge?
Chowbey: Well I think we should also keep in mind the
possibility of strangulation and obstruction.
Schumpelick: Absolutely.
Chowbey:
The smaller hernias are more notorious to
have obstruction.
Schumpelick: We all see a lot of patients because of other
diseases and you feel the umbilicus and you see small
hernia. Should we say you must be operated? No.
Chowbey:
My question is, why are you debating from the
meshes to sutures just for the matter of costs or recurrence
when today we are talking about all hernias including the
hiatal hernia, we are saying that sutures are practically
out. Why are we going back into the umbilical hernia.
Prof. Deysine just said that there is a very high recurrence
rate when you use just the suture, not the mesh.
Conze:
The literature shows a little difference in our
numbers so we have a success rate of 90% with a follow
up of 17 months. That’s quite a number. Again, there is
the trauma that you cause by placing a mesh in a small
defect of 1 cm. We saw the same problem yesterday when
we talked about trocar hernias. So the trauma you set to
repair this defect with a mesh is far bigger than trying to
do a suture repair. But this is not the question I wanted to
pose. What I meant to ask is what is a recurrent umbili-
cal hernia? Is it an incisional hernia or is it a recurrent
umbilical hernia? Because some papers mix them up; the
second question from the anatomical point of view: is a
para-umbilical hernia not an epigastric hernia?
Deysine:
The pathogenesis of an epigastric hernia is
totally different, it is located in the linea alba and the
pathogenesis has been well described. You may find
there is a weakness above the umbilical hernia, that’s
very common.
Conze:
I didn’t want to get from the track, so back to
the size of the defect. If you have an umbilical hernia of
1 cm and you want to place a mesh into it, you certainly
have to enlarge the defect to place the mesh, depending
on what kind of mesh you take. If you put in a composix
364 Treatment of the Other Hernia
35
you might have to enlarge the defect. So I think in these
cases you should try to have 90% recurrence free by tak-
ing an anterior approach. They say if it’s an obese patient
with a higher body mass index and a larger defect, no
question about it, take a mesh. But I think we need to
find the risk factors for people that develop a recurrence
after a suture repair. In our view it is the mesh, the size
of the fascia defect, and the body mass index that are the
important factors at the moment.
Chowbey:
I think also there is a case for laparoscopic
repair where you show good results.
Conze: Yes.
Young:
Regarding the DRGs. Our experience in the
United States is that as soon as they realize that you are
sending those patients home on days with zero days and
doing an outpatient that 2000 € will probably very quickly
go down to 500, so I don’t think that’s necessarily the best
way.
Chan: Most of the time we do umbilical hernia with stitch
and we are doing around 200 or 300 a year. When the
defect is bigger than 2.5 cm or larger then I will put a
mesh in. Otherwise I won’t.
Fitzgibbons: Just two sentences about the asymptomatic
umbilical hernia, and it’s only worth two sentences be-
cause nobody has any doubt. We have no large popula-
tion of people who have their umbilical hernias repaired
so there is no way to get any natural history of why we
have many hernias. The hernia that I refer to: where’s a
little pulp of defect I would not be concerned, but I am
concerned about observing patients that have palpable
visible bulges. I think it is dangerous to observe it until
we have more data.
Bendavid:
It’s not my personal experience but I’m begin-
ning to read the reports of as high as 20% infection rate
with umbilical repairs. I don’t use prophylactic antibiotics.
Should I? Have you observed any statistics or do you have
any statistics on this?
Conze: As far as I know there’s only one paper from The
Netherlands, I think, that used a prophylactic antibi-
otics, not only for umbilical hernia but also for ingui-
nal or incision hernia. If you take a mesh, certainly I
would suggest a single-shot antibiotic and I think more
important actually is the cleaning of the umbilicus be-
fore you incise, because it’s not enough just do a little
sponge the night before with iodine. What I always do
is after narcosis and after local anaesthesia just take a
swab and really clean it to make sure that you don’t have
problems.
Bendavid:
You really need to do that 2 or 3 days before
hands. Do you use antibiotics for umbilical repair?
Deysine: You have to. It’s one of the dirtiest places in the
human body.
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