Umbilical Hernia Repair, the Scar Also Matters: Open Umbilical Hernioplasty with Nearly Invisible Scar

INTRODUCTION

There are many repairs described for umbilical hernia, and there is no gold standard technique. While open hernia surgery gives a disfiguring scar, a cosmetic incision gives less exposure. Laparoscopic hernia repair is expensive as far as equipment and mesh cost [high in intraperitoneal onlay mesh (IPOM)], and at the same time, new potential hernia sites are created. In this technique, we describe a cost-effective open surgical cosmetic approach for umbilical hernioplasty. Along with proper repair, attention is also given to the cosmetic part of the surgery.

Technique

We use an incision along the right or left border of the stretched umbilicus and extend it cranially and caudally. It measures about 5–7 cm. Subcutaneous dissection is performed to go around the umbilical tube. The hernia sac is opened, leaving a good amount of tissue towards the umbilicus. Subcutaneous dissection is further extended all around for 5–7 cm. The defect in the linea alba is extended above and below. Dissection is initiated in the preperitoneal plane, taking care not to create buttonholes. If it seems very delicate and is leading to multiple rents, the posterior rectus sheath is incised, and the retromuscular plane is dissected. The peritoneum is closed in the midline, and the pocket created is measured. A synthetic mesh (polypropylene mesh of 15 cm × 15 cm) with a 3–5 cm overlap all around is placed. It is fixed with transfascial sutures. The defect in the anterior rectus sheath is closed. A suction drain is placed in the subcutaneous plane and brought out laterally away from the main incision. About 2–3 cm of the drain is placed in front of the mesh. During closure of the cutaneous layer, the subcutaneous tissue is gently drawn towards the midline and fixed to the anterior rectus sheath. Subcuticular sutures with a monofilament absorbable suture (poliglecaprone 3–0) are taken at the skin edges and pulled to create a purse-string effect, maintaining the umbilical contour and keeping the scar within the umbilicus.

A good scar is every patient’s as well as the surgeon’s expectation. When the scar is closer to the umbilicus, the skin tension is minimum. It is important to understand the relationship between relaxed skin tension lines and scar formation, which is crucial for optimising outcomes and minimising visible scarring.^[1] Subcuticular sutures, in addition, do not include more tissue to jeopardise the vascularity of the edges of the incision. Poliglecaprone is a synthetic, monofilament, absorbable suture that is non-antigenic and non-pyrogenic, exhibiting minimal tissue reaction, which is an important factor in scar formation [Figure 1-4].^[2]

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Figure 1:

Incision along right border of stretched umbilicus.

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Figure 2:

Mesh placed in retromuscular plane.

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Figure 3:

At closure.

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Figure 4:

Site of drain tube exit.

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DISCUSSION

Umbilical hernia comprises about 6%–14% of primary abdominal wall hernias.^[3] It could be congenital or acquired. In adults, it is most often acquired due to stretching of the abdominal wall following pregnancy, obesity, or liver disease with cirrhosis. It is more common in females between the third and fifth decades. Mayo’s technique of overlapping abdominal wall fascia in a ‘vest over pants’ manner, described in 1895 by William Mayo, leaves an undesirable scar.^[4,5] It is also associated with a high recurrence rate of up to 50%.^[5] There have been various modifications to make this surgery efficient with a good cosmetic outcome. Small incisions at the inferior umbilical border or through the umbilicus give a minimum exposure and can be used for smaller defects of 1–2 cm. But for larger defects or when BMI > 30 kg/m², mesh placement is mandatory.^[6,7] In such cases, onlay placement is done, which is not a preferred plane where the mesh has to be placed due to increased incidence of seroma or haematoma and eventually surgical site infection.

The mesh placement can be (1) IPOM, using the laparoscope; (2) in the retro-muscular space (sublay technique); (3) in the extraperitoneal space; and (4) in the subcutaneous plane after closing the linea alba vertically (onlay technique). Mesh plug repairs have been described but may cause migration or enterocutaneous fistula formation. Bilayer prosthetic devices have also gained popularity among a few surgeons. Laparoscopic inlay mesh and IPOM plus (defect closure with intraperitoneal mesh) are being commonly performed. Laparoscopy adds to the cost, and at the same time, the patient has a risk of developing port site hernias, the overall incidence of which is 0%–5.2%.^[8]

The selection of the mesh depends on the technique chosen for repair. A polypropylene mesh is used for onlay, sublay, and extraperitoneal mesh placement. For intraperitoneal onlay, i.e., IPOM or IPOM plus, a composite mesh or dual-sided mesh is preferred to prevent bowel adhesion to the mesh. Apart from the cost of laparoscopy, the cost of mesh adds to the total cost of surgery. In obese patients with umbilical hernia, laparoscopy has proven to be of definite advantage.

Open repair with a good cosmetic scar has been gaining more popularity over the years. Smaller hernias requiring tissue repair can be performed with ease. For larger defects, onlay mesh placement is performed without much difficulty. Kurpiewisky described a technique of placing a preperitoneal mesh using a 3–3.5 cm incision.^[9] Vertical, intraumbilical incisions are also described by Milowsky.^[10] and Arslan et al.^[11] have reported intraumbilical curved, median incisions, which were extended horizontally, either at the upper or lower end, for better exposure. All these approaches pose difficulty in creating an adequate space for mesh placement due to the size of the incision.

In our technique, we go along one lateral border of the stretched umbilicus, and the incision is around 5–7 cm. The defect in the linea alba is enlarged both above and below to ease the dissection in the preperitoneal or retrorectus plane. Subcutaneous dissection all around helps in drawing the skin edges into the umbilicus to bring the surgical scar within the area of the umbilicus. It also helps in taking transfascial sutures to prevent mesh displacement. Care should be taken to preserve the perforators supplying the subcutaneous tissue, which maintain vascularity of the umbilicus. Deeper bites into the subcutaneous tissue must be avoided during closure so as to prevent umbilical necrosis. Another important point to be kept in mind is to leave a part of the sac on the umbilicus, which otherwise would jeopardise its vascularity. Long blade retractors and a good headlight aid in dissection. It can be done under spinal anaesthesia. But in obese patients, general anaesthesia is preferred. Our experience with this technique emphasises that open umbilical hernia repair can be done with an adequate-sized polypropylene mesh, tailored to the defect size, placed in the appropriate plane, thereby reducing the total cost of surgery with an optimum outcome. At the same time, we can give a good cosmetic scar and avoid new sites for potential hernia [Figures 5-7].

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Figure 5:

Nearly invisible scar.

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Figure 6:

Mesh seen (yellow arrow) after 8 years in a patient with a body mass index of 39.5.

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Figure 7:

Scar in the same patient with body mass index of 39.5.

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CONCLUSION

The surgical technique described for umbilical hernia repair is a good procedure that can be performed with ease and requires minimum instrumentation. It is a low-cost procedure with proper repair, and at the same time, addresses the fact that the scar also matters when we perform an open surgery for an umbilical hernia.