In this episode of PodMD, experienced General Surgeon Dr Edward Tong will be discussing the topic of umbilical hernia, including what an umbilical hernia is, the risks of this condition, the treatment options available, when a GP should refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Edward Tong
Dr Edward Tong is an experienced General Surgeon providing care in Campbelltown and the surrounding areas. Dr Tong completed his Bachelor of Medicine at the University of Newcastle and his Master of Surgery at Sydney University. Following this, Dr Tong completed his General Surgical Training at Southern Health Victoria in 2013 and then completed an ASU fellowship and a UGI fellowship in the Gosford Public Hospital.
Dr Tong’s special interests include Bariatric Surgery, Gallbladder Surgery, Hernia Surgery and Skin Lesions.
Today, we’ll be discussing the topic of umbilical hernia.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Edward, thanks for talking with us on PodMD today.
Edward : Thank you for having me.
The topic of today’s discussion is Umbilical Hernia. Edward, Can you describe for our listeners what an Umbilical Hernia is?
Edward: So an umbilical hernia is a defect in the abdominal wall around the level of the belly button. And basically it can contain Omentum bowel, Omentum fat or bowel. So this defect is usually lined with the peritoneal line lining and usually presents with at the time with either a lump, it can also be quite sore and also be quite painful.
How would a patient with an Umbilical Hernia typically present?
Edward: So most of the time, patients with an umbilical hernia will present with a lump and most of the time this lump around the belly button will be something that can be pushed back in when they cough, it would come out or when they strain it would also come out. It typically comes out whenever there’s an increase in the intra abdominal pressure and as I mentioned before, it can either contain bowel or Omentum fats or preperitoneal facts.
Sometimes you can get complications with these umbilical hernia and for example you can have a bowel obstruction with an umbilical hernia and they typically present with nausea, vomiting and distension. Patients also can become very sick if the bowel obstruction proceeds to become a bowel perforation, in which they become floridly septic, whereby, you know they start to spike temperatures, their blood pressure drops and their abdominal pain would significantly worsen.
What are the risks of having an umbilical hernia?
Edward: The main risks are the life-threatening risks, as I mentioned, is really those two things. You can, if the hernia contains small bowel and it gets to a point where you actually can’t push the bowel back in, then that would cause an acute blockage. The blockage would cause the patient to become progressively more distended, they’ll be vomiting, then start to lose a lot of fluid, what we call third space losing, they become dehydrated and actually a bowel obstruction is actually a life-threatening condition. If the bowel obstruction progresses, you can also have a bowel perforation and that as I mentioned before is also can be life threatening and the way it becomes life threatening is that it basically causes the patient to become floridly septic and can impact the patients from a blood pressure point of view. They drop their blood pressure and to the point that it’s quite life threatening.
They can also, with the sepsis, it develops into multi organ failure with impact in terms of the kidneys going into acute kidney failure and going into problems with respiratory failure also. So those are the two life threatening conditions, in terms of other more long-term risk sometimes if untreated the hernia can progressively become bigger. And more tender and you know, the more difficult the, the bigger the hernia, the more difficult it is to repair. So there are both life threatening complications that can arise from having this condition untreated, and if it is not treated in a timely fashion then and if the patient is symptomatic then potentially the patient may the hernia may over time become bigger. The defect will become bigger and the technical difficulty of actually repairing the umbilical hernia can be increased as well.
What are the treatment options?
Edward: There’s a number of treatment options available, and all of them are surgical. More commonly, patients will can have an open umbilical hernia repair and that can be with mesh or without mesh. So what they do at the time of the operation is that, you know, they will make an incision around where the hernia is, they will dissect out the sack. That will open up the sack, inspect the contents. Reduce the contents back into the abdominal cavity, close the Sack or excise the excess Sack and that will be and then they will subsequently think about closing the defect with mesh or closing the the defect with just primary sutures and now commonly would use that with 30 nylon.
In terms of the selection as to how the defect will be closed will essentially depend on how big the defect is. If the defect is bigger than 1-1.5 centimetres, then more commonly you would use mesh in order to help with the repairing the defect. If it is smaller than a centimetre, then generally speaking a just closing the fascia with stitches without mesh is also a very safe option.
More recently we’ve there’s a growth in terms of utilising laparoscopic or keyhole operation to. Repair an umbilical hernia and that also presents with a number of advantages. There’s a cosmetic advantage with keyhole operation because the cuts are smaller. For some patients who are quite large, sometimes doing it as a laparoscopic or keyhole option is better because first of all there is a reported reduction in wound infections with doing this laparoscopically. However, if you are doing this laparoscopically then you will be putting in an intraperitoneal mesh. In other words, mesh that would be sitting below the peritoneal surface. So, since essentially these are the two main treatment options.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Edward: The main development that has occurred is the evolution of keyhole and laparoscopic treatment of umbilical hernia repairs. Because of the technical difficulty of laparoscopic option, initially it didn’t really have a big uptake initially, but as we’re more familiar with laparoscopic surgery in a whole range of different specialties, as trainees are more familiarised with, you know, laparoscopic operations in a whole range of different specialties, there has been a growing incidence or uptake of Umbilical hernia being repaired laparoscopically by newly graduating surgeons.
Although you know I wouldn’t necessarily say that laparoscopic is necessarily better than the open option. Both are good treatment options and both need to be tailored to the individual requirements of the patients. There are also recent developments in terms of the type of mesh that we can actually use. So there’s a quite a large industry in terms of you know what type of mesh is actually more advantageous. There’s also a growth in terms of the uptake of what we call biological mesh in a response to reduce the likelihood of having mesh infections, enterocutaneous fistulas and all those sort of nasty complications that arise from, you know, utilising mesh and sometimes, as I’ve mentioned before, we have to use mesh just because the defect size could be a bit too large.
So, I think the main areas of development in the last few years is essentially the uptake of laparoscopic surgery in the treatment of umbilical hernia repair and also the type of meshes that’s available, and more specifically the utilisation of biological measures. Now in the press there has been a bit of a negative press with regards to the utilisation of mesh. I want to assure my colleagues that the use of mesh in the appropriate setting is actually very safe. You know, I think we I try if I have to use mesh, I try to put it above the peritoneal surface. I try to make sure that you know, there’s no contact of the mesh with the bowel in order to reduce the incidence of enterocutaneous fistulas, and if I am suspicious that there is a high risk of mesh infection, but I have to use mesh in the repair, then now my selection would invariably be the utilisation of biological meshes.
So the risk of a mesh infection is actually very, very low. It’s probably less than .1% and the risk of a small bowel fistula is also less than .1% also. So although there are quite reported incidences of mesh infections and they can be quite serious and it has been quite heavily publicised in the media in recent times. I think we should be open to realise that the utilisation of mesh is a safe option, but of course it needs to be, you know, considered be used in a considered approach in the right patient population in the right clinical context.
Are there any warning signs a GP or their patient can look out for?
Edward: The main warning signs pertain to whether the patient has a bowel obstruction, a bowel perforation, or whether that whether it’s an obstructed umbilical hernia, those are serious consequences with this condition, with the umbilical hernia and they are danger signs which if the, our GP colleagues, notice those when the patient presents, then it is important that they be sent to the emergency department as soon as possible.
So the main thing would be, for example, if it’s incarcerated umbilical hernia, what that means is that the patient has a lump that’s exquisitely tender and you can’t push it back. Then you know that in that sort of context, then our GP colleagues would be it would be appropriate to refer them to the emergency department. If you suspect that the patient is clinically has a bowel obstruction due to this umbilical hernia, and by that I mean if they’re vomiting, their bowels becomes distended and you know they’re not opening valves or passing wind, then it is most certainly appropriate to send them to the emergency departments.
Clearly, if they’re spiking temperatures of if they have signs of generalised peritonitis in the context of having an umbilical hernia, then you would be suspicious, potentially of either a perforation due to the umbilical hernia, or there could be some other serious, other surgical pathology that requires urgent attention and therefore particularly for those sick patients, identification of them early is important and they should be sent to the emergency department.
What is the likelihood of recurrence of the condition?
Edward: The likelihood of recurrence of this condition is between 1 to 5%. It can be increased if the patient is obese. If they’ve got a chronic cough, if they’re a smoker. All of these things increase intra abdominal pressure and therefore any increase in intra abdominal pressure will potentially make it such that the repair of the hernia is difficult. And the healing of the tissues after hernia repair will be difficult as well.
So and in those sort of cases they can be as high as between 10-20%. If there is a tissue healing issue , for example, if the patient is on prednisone or they have a documented history of Scleroderma, then they’re likely to have problems with wound healing and then again those patients, I would expect that they would have a slightly increased recurrence rate as well. So in general, the likelihood of recurrence is low, it’s about 1%, but in certain population groups or that have those aspects whereby they have an increase in intra-abdominal pressure or if they have a tissue healing problem then the recurrence of this condition will be increased.
When should a GP refer?
Edward: A GP should look to refer when they see an umbilical hernia. I think it is a common general surgical condition that we frequently deal with, the treatment for this is an operation and whilst not all patients who get referred to us will necessarily require an operation, because we will also need to depend assess their risk of a general anaesthetic, risk of complications and so forth, it is certainly appropriate that anybody who’s got an umbilical hernia has a referral to see a general surgeon. I mentioned the danger science previously and they include if the if the lump is painful and you can’t push it back in, or if the patient is sick with sepsis or if the patient has signs of a bowel obstruction. These are symptoms or signs that will require our GP colleagues to refer to the emergency departments and have an emergency assessment of the situation.
What role does the GP play in the treatment of the condition?
Edward: Our GP colleagues play a highly important role in this condition. First of all, they’re the frontline in terms of when patients present when patients present having a lump and the initial assessment is a lot of it is actually done by our GP colleagues and they include an assessment of the how fit the patient is, you know, in the ordering of appropriate scans and also directing the patient to see a surgeon where it is appropriate. A lot of the times it is certainly appropriate to order a CT scan, and that helps us because we can see a what’s the content of the hernia and B) how big is the defect and that helps us plan our operation as well to realise or am I likely to require a mesh? And is this operation likely to be difficult?
So our GP colleagues play an extremely important role in terms of identifying patients who require an appropriate referral. Our GP colleagues also are critical in terms of helping us follow up patients and helping us identify post operative issues because after the operation I often will refer the patients who see the GP in the next couple of days in order to just to make sure that the patient is doing well. I invariably will ask the patient to see me in at the two week mark just to make sure that the hernia has healed well and the wound and the skin and the patient is actually doing well. So I will also have my own follow up plan as well but in terms but in the interim before the patient actually gets to see me after the operation, as I said, I think GP colleagues play a very critical role in following up our post operative patients.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on umbilical hernia?
Edward: So I think the three critical take home messages are first of all, an irreducible lump that’s tender, I.e. a strangulated hernia requires an emergency referral. #2 it is very important for our GP colleagues to look out for a symptoms and signs of a small bowel obstruction. And thirdly, I want to inform everyone that the use of mesh in an appropriate setting is a safe and is an accepted routine management in the elective repair of an umbilical hernia.
Thanks for your time and the insights you’ve provided.
Edward: Thank you so much for everyone’s time