Umbilical hernias are classified as spontaneously reducible, manually reducible, incarcerated, or strangulated. They have the potential to cause great discomfort, bowel obstruction, and intestinal gangrene. Symptomatic umbilical hernias should be electively repaired if spontaneously or manually reducible. Urgent or emergent repair is indicated if there is clinical suspicion of incarceration or strangulation; timing is of the essence to limit the severity of bowel ischemia and reduce the likelihood of requiring bowel resection.

Women of childbearing age deserve separate mention. Reducible umbilical hernias may progress to incarceration or strangulation as the intraabdominal pressure rises due to a growing gravid uterus. As such, pre-emptive umbilical hernia repair should be performed in all women of childbearing age. If identified during pregnancy, reducible hernias should be repaired during the second trimester if possible, while incarcerated or strangulated hernias require urgent intervention at the time they are identified. Spinal anesthesia has been used in select cases during pregnancy, along with right side up positioning to displace the uterus off the inferior vena cava and ensure adequate venous return to the heart.

There are no absolute contraindications to umbilical hernia repair. The physiologic status of the patient, medical co-morbidities, history of surgical procedures on the abdomen, and sound clinical judgment should guide the surgeon’s decision-making.

Repair of reducible umbilical hernias identified in the first trimester of pregnancy should be deferred until second trimester. Those identified during the third trimester should be deferred until the postpartum period. If not reducible, the umbilical hernia should be repaired when identified.

Liver cirrhosis and ascites are not considered contraindications. While patients with umbilical hernias in the setting of liver cirrhosis are at higher risk for complications following surgery, recent studies have shown that early elective repair is safe and should be performed. Surgical repair also decreases the risk of decompensated cirrhosis in the acute setting of a bowel obstruction or intestinal strangulation. Postoperative
medical management of ascites is critical to minimizing complications and recurrence. In patients with massive ascites, a closed suction drain should be considered along with medical management to control ascites until the incision has healed.

A complete history and thorough physical examination is usually adequate to identify most umbilical hernias. With the rising incidence of obesity in the United States, accurate assessment by examination may be increasingly difficult. Even in these cases, it is rarely necessary to employ advanced medical imaging technologies for definitive diagnosis.

The patient should be physiologically optimized for the procedure to reduce the risk of cardiopulmonary and anesthesia-related complications. Smoking cessation should be encouraged to improve wound healing. Anticoagulants and antiplatelet therapy should be held when possible. If the patient presents with signs and symptoms of a small bowel obstruction, nasogastric decompression should be performed prior to induction of general anesthesia to reduce the risk of aspiration.