Open Umbilical Hernia Repair Without Mesh for a 1-cm Hernia
Main Text
Table of Contents
Umbilical hernias are common abdominal wall defects that occur when intra-abdominal contents protrude through the umbilical opening in the abdominal muscles. These hernias are prevalent in both pediatric and adult populations with an estimated incidence of 6–14% of all abdominal wall hernias in adults.1 While congenital umbilical hernias often resolve spontaneously in children, adult-onset umbilical hernias typically require surgical intervention due to the risk of complications such as incarceration or strangulation.2
The etiology of umbilical hernias in adults is multifactorial, involving both congenital and acquired factors. Increased intra-abdominal pressure, obesity, multiparity, and connective tissue disorders have been identified as significant risk factors.3 Clinically, umbilical hernias may present as asymptomatic bulges or cause discomfort, pain, and cosmetic concerns.
Treatment options for umbilical hernias range from watchful waiting to surgical repair. The decision to operate is based on various factors, including hernia size, symptoms, risk of complications, and patient preferences. Surgical approaches can be broadly categorized into open and laparoscopic techniques, with or without mesh reinforcement.4 The use of mesh in umbilical hernia repair has been a subject of debate, particularly for small defects.
For hernias with fascial defects less than 1–2 cm in diameter, primary suture repair without mesh has been shown to be effective, with recurrence rates comparable to those of mesh repair in selected patients.5,6 This video focuses on the detailed surgical technique for open umbilical hernia repair without mesh for a 1-cm hernia, emphasizing both functional and aesthetic outcomes.
A thorough preoperative evaluation is conducted to assess the patient's overall health status, hernia characteristics, and risk factors for recurrence. The size of the fascial defect is estimated clinically and may be confirmed with imaging studies.
The procedure is typically performed under local anesthesia with or without sedation. The patient is positioned supine on the operating table. The umbilical area is prepared and draped in a sterile fashion.
A curvilinear incision is planned within a natural skin fold of the umbilicus to optimize cosmetic results. Local anesthetic (e.g., 0.5% lidocaine with epinephrine) is infiltrated into the subcutaneous tissues. An incision is made along the marked line using a scalpel. Careful dissection is performed through the subcutaneous tissues using electrocautery to maintain hemostasis.
The hernia sac is identified and carefully dissected from the surrounding tissues. If the sac contains only fat, it may be excised. If the bowel is present in the sac, they are inspected and, if viable reduced back into the peritoneal cavity. The fascial edges of the defect are delineated and measured.
The fascial defect is closed using interrupted sutures of permanent material, typically 2-0 or 3-0 polypropylene. Small tissue bites (approximately 5 mm) are taken on either side of the defect to ensure a tension-free repair. The closure is performed in a transverse orientation to distribute tension evenly. Care is taken not to overtighten the sutures, which could lead to tissue ischemia and increased postoperative pain.
To achieve an aesthetically pleasing umbilicus, it is fixated to the underlying fascia. A 3-0 absorbable suture is used to anchor the base of the umbilicus to the fascia, slightly deeper than the fascial repair. This step helps to create and maintain the desired umbilical contour. The skin is closed using a subcuticular technique with 4-0 absorbable sutures. A "no-knot" technique may be employed to minimize suture palpability and improve cosmetic outcomes.7
Sterile skin strips are applied to reinforce the skin closure. A small, non-adherent dressing is placed within the umbilicus to maintain its shape, followed by a larger protective dressing over the entire wound.
The patient is typically discharged on the same day with instructions for wound care, activity restrictions, and follow-up appointments. Patients are advised to avoid heavy lifting for 4–6 weeks postoperatively.
This video demonstration and accompanying description serve as valuable educational resources for surgical trainees, general surgeons, and plastic surgeons seeking to refine their techniques for small umbilical hernia repairs. The step-by-step approach, rationale for each decision, and emphasis on both functional and cosmetic outcomes provide insights that can help surgeons optimize their results in umbilical hernia repair.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Konaté I, Ndong AN. Tendeng J. Umbilical Hernias in Adults: Epidemiology, Diagnosis and Treatment. In: The Art and Science of Abdominal Hernia. ; 2022. doi:10.5772/intechopen.94501.
- Maia RA, Salgaonkar HP, Lomanto D, Loo L. Umbilical hernia: when and how. Ann Laparosc Endosc Surg. 2019;4. doi:10.21037/ales.2019.03.07.
- Jackson OJ, Moglen LH. Umbilical hernia. A retrospective study. Calif Med. 1970;113(4).
- Wang See C, Kim T, Zhu D. Hernia mesh and hernia repair: a review. Engin Regen. 2020;1. doi:10.1016/j.engreg.2020.05.002.
- Aiolfi A, Cavalli M, Micheletto G, et al. Open mesh vs. suture umbilical hernia repair: systematic review and updated trial sequential meta-analysis of randomized controlled trials. Hernia. 2020;24(4). doi:10.1007/s10029-020-02146-1.
- Madsen LJ, Oma E, Jorgensen LN, Jensen KK. Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis. BJS Open. 2020;4(3). doi:10.1002/bjs5.50276.
- Singh AK, Oni JA. Simplified method of skin closure with a knot-free absorbable subcuticular suture. Ann R Coll Surg Engl. 2005;87(6). doi:10.1308/003588405X71072.
Cite this article
Towfigh S. Open umbilical hernia repair without mesh for a 1-cm hernia. J Med Insight. 2025;2025(433). doi:10.24296/jomi/433.
Procedure Outline
Table of Contents
- Choose and Mark Wrinkle for Incision
- Inject Local Anesthetic
Transcription
CHAPTER 1
Hi, everyone. My name is Dr. Shirin Towfigh from the Beverly Hills Hernia Center. We are going to watch a cute little umbilical hernia repair performed on a lovely lady. She has a slight outie and it bothers her, and everyone deserves to have an innie umbilicus. So let's watch the specifics on how to do a very carefully performed umbilical hernia. And I'll walk you through the steps of why I'm doing every little technique, so that you can also recreate the perfect umbilical hernia repair. So first, you want to make sure you have the perfect incision, and I like to hide my incisions in a skin wrinkle. Everyone's belly button's a little bit different, so it depends on what the belly button looks like. Once you make that scar, you identify the herniated fat and you basically take it out. Sometimes you can push it back in. If your hernia defect is a centimeter or less, you can do a nice, tissue-based repair. And I go through all the different techniques for you during the discussion of the actual video. But basically, you want to do a tension-free repair, small little bites, and pick your suture to correlate with the strength of the tissue of the patient. You don't want a big suture or really tough sutures 'cause that's just going to tear through. And once you're done with closing the hernia defect, and I usually like to close them in a horizontal or transverse plane, then it's nice to give them a nice innie. Their final closure should be very cosmetic and they should have a nice innie when they're done.
CHAPTER 2
It's a belly button hernia. You want it to end up as an innie belly button. Right now, she's got some fat in it and she's got a cute little wrinkle here. So we're gonna use this wrinkle. She has two wrinkles. Let's use this wrinkle. That way, when you go innie, she won't see the scar at all. Local, please. So I mark it because once you put the local aesthetic, it'll change the anatomy. She's very thin, not so deep. You're gonna hit bowel. Nice, infiltrate. Good. We're good. Five CCs, at least. Some Ray-Tec's please.
CHAPTER 3
Scalpel. Another raytec, please. Adson's, next.
CHAPTER 4
Yes, and then notice that we use a protected tip, sharp needle point Bovie. I'll take a mosquito. Because we need it for this delicate procedure. Small operation, small scar. Open that a little bit more. Good. Okay, so here's her hernia. You can see how it's just fat. Senn, please. First, we'll take it off the skin. The Senn will retract the skin without causing any damage. You have sharp Senns? Oh, this is a very - okay, so buzz that off. What you can see is usually it has a narrow neck. There's a fascial neck, right there. I'm just gonna take the fat off of it. It keeps coming. There we go. So now, she's flat here. It's very familiar to have so much fat coming out. Can you tell that there's a hole in there? I think you can see it through the camera. Let's clean the camera a little bit. Okay. All right, so this fat will be discarded. Gimme a wet lap, please. If you wet the skin and you use cautery near it, you're less likely to burn the skin. Okay, so let's discard this fat. It's clearly not a tumor. It's, we don't need to send it to pathology. It'll be discarded.
CHAPTER 5
All right, so now we gotta find her hole. That's actually bowel in there, if you see. And here's her fascial defect, right there. One edge - another mosquito, please. Gotta find the other defect. Is that it? This? That's it, mhm. That's the other defect.
CHAPTER 6
So we're gonna be closing it transversely like this. Small bites, interrupted with permanent suture. You can see that the hole is actually fairly big. 3-0, Vicryl please. I mean, sorry, Ethibond. Okay, so you see how this is the fascia there? Yes. Is it buried knots? Buried knots. Fascia there. Let's go ahead. And using a 3-0 permanent suture, I prefer the braided suture because that's going to be felt less. Smaller bite. The braided suture will be felt less in the thinner patients. There we go. So we'll tie these after we're done. We'll get two out of each. So we need another set of sutures. Another set? Mhm. Snap, please. Scissors, snap. Can I get one more? So we'll get three, maybe four bites out of this. Probably three. The goal is to close the defect. She likes to play sports. Good. This does not need to be a tight closure. Scissors. It's like pediatric surgery. Let's do one more. Let's see. Let's double check. Yeah, let's do one more. Way out there. You see it? Better bite. Good. So this is about a one-centimeter defect. Maybe 1.1 centimeters. In fact, gimme a ruler if you have one. Okay. Yeah. It's exactly one centimeter. All right, go ahead and tie the first, the last knot. These are not super tight. Tighter it is, the more pain, the more ischemia. Can you cut for yourself? Scissors, please. Four, three is enough, or four. Key is small bites, interrupteds, work really well with these smaller hernias. Permanent suture. You don't want the suture stronger than her own tissues.
CHAPTER 7
And then, now we're gonna close the skin. Before we do that, double check that it looks pretty. And then you'll want to confirm she has a nice innie belly button. So we're gonna take that 3-0. See that right there? I'm gonna grab that right there. And sew that down to the fascia level. Just be on the fascia there. Mhm. It's absorbable suture. Give her more of an innie look.
CHAPTER 8
Okay, let's do a no-knot. 4-0 Monocryl, please. Vicryl back. So that's gonna go nicely, and she won't see her scar. Start out here. So the no-knot technique helps secure the suture without using a knot. She's so - her skin is so thin, she may not do well with a knot. Cosmetically, she'll do better without the knot. Just a subcuticular suture. Professionally done by a world-renowned plastic surgeon. Let's see. Lemme get this. She's got really good skin. Good skin? So she has a second hernia. It's up here. It's actually the one that bothers her the most. That's the incarcerated epigastric hernia with fat. So, she had the option of having two separate small scars or a slightly larger scar at the belly button and using that to access the epigastric region. And she chose the two smaller scars. So take that all the way through. We're gonna reuse it for the next one. All right, we'll dress those all at the end, but we're kind of done with this one. We're gonna move to the next hernia. Steri-Strip. All right, it's two by two gauze, please. Let's do one that's inside the belly button to promote an innie. Open it all up. I stick it in there. Then a second one on top. Another two by two. More local, please. Let's see if we can sneak some local anesthetic in there. Yeah, I can feel the fascia with the needle.
CHAPTER 9
So umbilical hernias are very common. Not everyone needs to have them repaired. Watchful waiting is considered safe. If you have a patient who either has symptoms from their umbilical hernia or cosmetically doesn't like an outie, then you can offer them surgery. The surgery is often based on the risk factors for the patient and also the quality of the hernia. Most hernias less than one centimeter can be repaired without mesh and with suture only. I prefer to use permanent suture. There's multiple surgical techniques as to how to put the hernia back together again. But typically, it's an open repair or a laparoscopic repair, with or without mesh. And here, you have seen an open repair without mesh for a one-centimeter hernia. You also need to take into consideration the risk factors of the patient. Are they obese? Do they cigarette smoke? Do they use nicotine at all, actually? Do they have a chronic cough? Are they constipated? Do they plan to have a pregnancy? All of these are risk factors for the hernia falling apart. And so, either you should delay the surgery until those risk factors are addressed, or revise the hernia repair to address these factors so you don't have a recurrence because it's not just a hernia.