Hernia (2004) 8: 104–107
DOI 10.1007/s10029-003-0182-5
O R I GI N A L A R T IC L E
M. Kurzer Æ P.A. Belsham Æ A.E. Kark
Tension-free mesh repair of umbilical hernia as a day
case using local anaesthesia
Received: 7 February 2003 / Accepted: 2 October 2003 / Published online: 13 March 2004
Springer-Verlag 2004
Abstract Background: Umbilical hernias are a common
surgical problem with a high recurrence rate using
conventional suture techniques. This prospective study
examined the feasibility of tension-free mesh repair as a
day case using local anaesthetic (LA) for all primary
umbilical hernias. Method: Fifty-four patients (eight
women) were operated on; 49 using LA. Through a
periumbilical skin incision the margins of the sac were
freed from the edges of the defect, and a space was made
in the extraperitoneal plane. In defects <3 cm in
diameter, a cone of polypropylene (pp) mesh was
inserted and attached with nonabsorbable sutures. In
defects >3 cm, a flat piece of pp mesh was inserted into
the extraperitoneal space as a sublay. No attempt was
made to close the fascial defect. Results: Postoperative
pain was graded as mild (n=37) and moderate (n=17).
No patient had severe postoperative pain. Seven superficial wound infections responded to oral antibiotics. In
no case it was necessary to remove the mesh. There were
no other complications. Patients were recalled between 2
and 6 years postopertively—mean follow-up 43 months
(28–67). There were no recurrences. Conclusion:
Umbilical hernia repair can be carried out safely and
securely under LA with a tension-free mesh technique
(cone or a sublay patch) with a low morbidity, negligible
recurrence rate, and a high degree of patient satisfaction.
It should be the procedure of choice for all such hernias.
Keywords Umbilical hernia Æ Day-case surgery Æ
Ambulatory surgery Æ Local anaesthesia Æ
Surgical mesh Æ Treatment outcome
Introduction
Umbilical hernias in adults are a common surgical
problem with wide variation in techniques of repair and
results [1, 2]. Recurrence rates as high as 40% using
conventional sutured techniques have been reported [3],
although there are sparse data in the literature [4].
Prosthetic mesh is now widely and routinely used for
many abdominal wall hernias and virtually all inguinal
hernias. This study examined the feasibility, results, and
medium-term follow-up of tension-free mesh repair for
adult umbilical hernia repair.
Patient and methods
Over a 38-month period between August 1995 and November 1998,
73 patients with an umbilical hernia were seen. Eight patients had a
BMI (Body Mass Index) greater than 40, were advised to lose
weight, and were not operated on. Patients with a recurrent hernia
were considered to present a complex surgical problem and were
also not included in this study. In all, 19 patients were excluded,
and 54 patients with a primary umbilical hernia were entered into
the study.
The majority (49) of patients were ASA 1 or 2, and the mean
BMI was 31 (22–39.5). The mean age was 52 years (range 30–76),
eight patients were women. No patients had liver failure. In 49
patients, the procedure was carried out using local anaesthesia with
an anaesthetist present to monitor and administer sedation. In five
patients, the procedure was carried out using general anaesthetic;
one because of patient preference, two because of the size of the
hernia, and two because of the size of the patient (BMI>35).
Operative technique
Presented to the 24th International Congress of the European
Hernia Society, Amsterdam, the Netherlands, June 2002
M. Kurzer (&) Æ P.A. Belsham Æ A.E. Kark
British Hernia Centre, 87 Watford Way,
NW4 4RS London, U.K.
E-mail: surgeons@hernia.org
Tel.: +44-020-82017000
Fax: +44-020-82026714
A broad spectrum antibiotic was given at the start of the procedure,
and the local anaesthetic used was 0.25% bupivacaine plain. Midazolam up to a maximum of 10 mg iv was administered by the
anaesthetist as appropriate.
Through a hemicircumferential periumbilical skin incision, the
margins of the sac were freed from the edges of the defect, and a
space was made in the extraperitoneal plane beneath the rectus
sheath. In defects <3 cm in diameter, a cone of polypropylene
mesh was made by the operating surgeon from a 5 cm·5 cm square
of polypropylene mesh of such a size that diameter of the cone was
105
no recurrences, and all patients felt that the appearance of
the umbilicus was cosmetically acceptable.
Discussion
Fig. 1 Cone-shaped plug made from a square piece of mesh and a
single nonabsorbable suture
slightly greater than the size of the defect (Fig. 1). The cone was
inserted so that the rim lay just beneath the edges of the defect, and
four 2/0 polypropylene sutures were inserted at the four quadrants
of the defect to anchor it. In defects >3 cm in diameter, a flat piece
of polypropylene mesh was shaped so that its diameter was
approximately 5 cm–6 cm greater than the diameter of the defect
(there was at least a 2.5–3 cm overlap all round) and was inserted
into the extraperitoneal space and held in place with polypropylene
sutures. Four sutures were inserted initially and additional sutures
as appropriate. No attempt was made to close the fascial defect. If
there was a large remaining dead space, a vacuum drain was
inserted. The umbilical skin was attached to the fascia or anterior
rectus sheath in order to reconstitute the umbilical depression and
the incision closed with an absorbable subcuticular suture. In larger
hernias, a vacuum drain was inserted and was removed just prior to
discharge. A pressure dressing was used in all cases.
Seven patients with particularly large hernias in whom a vacuum drain had been inserted remained in hospital overnight for
observation. The remainder were discharged the same day. Postoperative pain was controlled with oral analgesics supplemented by
self-administered diclofenac suppositories.
Patients went home with detailed postoperative instructions and
a 24-hour contact number. Patients were asked to grade their pain
using a visual analogue scale on the second postoperative day.
Results
Postoperative pain on the second postoperative day was
graded by patients as mild (n=37) and moderate
(n=17). No patient had severe postoperative pain.
Patients were seen at 1 week for follow-up and removal
of dressing. There were seven superficial wound infections, and all responded to appropriate oral antibiotics.
In no case it was necessary to remove the mesh, and
there were no other complications. Patients were recalled
between 2 and 6 years postoperatively—mean followup 43 months (28–67). Forty-four patients were reassessed, and ten patients were lost to follow-up. There were
The reported results of umbilical hernia repair vary
widely. While some claim that simple suture and a
combined closure of peritoneum and fascia yields good
results [5, 6], these reports are anecdotal. Recurrence
rates as high as 40% [3], rising to 60% in patients with
cirrhosis [7], have been reported. More recent studies
have revealed recurrence rates of 11% [8] and 15% [2]
for sutured repair.
Askar [3] has highlighted how physiologically
unsound the sutured repair is, particularly with large or
recurrent defects. Failure of the treatment of hernia
defects is almost certainly due to excessive tension [9],
and while various manoeuvres have been proposed to
lessen tension when repairing large umbilical hernias,
they are all technically complex. A sublay (placement
beneath the rectus muscle) of prosthetic mesh achieves a
tension-free repair much more simply and reliably and
has been employed with great success in incisional hernia [10] and in a small series of umbilical hernias in
cirrhotic patients [11], both known to be at high risk of
recurrence and morbidity. The recurrence rate of 0 in
this series, with a follow-up period of up to 6 years
represents a significant improvement over nonmesh
repairs and is in line with the findings of other authors
using prosthetic mesh [4, 8, 12]
Garcia-Urena [2] retrospectively reviewed the charts
of 101 patients who had undergone urgent repair of an
incarcerated umbilical hernia. They were able to contact
and reassess 80 of the patients and found a recurrence
rate of 15% with a mean follow-up of 7 years. The
majority of patients had undergone some form of suture
repair, but, interestingly, in the three in whom mesh had
been used, there was no recurrence.
Celdran [12] reported no recurrences using mesh in 21
cases with a relatively short follow-up of 13 months.
Because of difficulties in developing a preperitoneal
plane, an H-shaped piece of mesh was used, part of
which was placed intraperitoneally with omentum
interposed to separate the mesh from bowel. However,
in the present study, we found, similarly to Arroyo, that
we were able to make an adequate space in the preperitoneal plane (with defects >2.5 cm in diameter),
although it required careful and meticulous sharp dissection. The decision whether to use a flat piece of mesh
or a cone in this series was a pragmatic one. Accurate
placement and positioning of a flat piece of mesh
through a 3.0 aperture was found to be difficult, and the
authors were reluctant to enlarge the defect in order to
facilitate this. Insertion of a small cone to fill the defect
proved to be a straightforward solution. Mesh cones or
plugs have been used successfully in a similar way in the
repair of primary indirect, femoral, and recurrent groin
hernias [13, 14]. Theoretical fears that the cone might
106
shrink, giving rise to local discomfort or recurrence
would seem to be without foundation.
Bowley and Kingsnorth [15] retrospectively reviewed
the case notes on 473 primary adult umbilical hernias
operated on over a 5-year period by a number of surgeons in a large hospital, using various techniques.
During the period of study, 18 patients were reoperated
on for recurence. However, the remaining 455 patients
were not contacted for review, so we cannot assess the
overall recurrence rate. Of the 18 known patients whose
hernias recurred, two out of 80 (4%) were open mesh
repairs, and 16 out of 393 (2.5%) were nonmesh.
The only randomised clinical trial of umbilical hernia
repair in the world literature is that of Arroyo and colleagues [8]. Two hundred patients were randomised to
receive mesh or simple suture, mostly (95%) under local
anaesthesia. The mean follow-up was 64 months, and
there was a ten-fold difference in recurrence rates (1% vs
11%) comparing suture with mesh repair. This group
subsequently reported on 213 patients with umbilical
hernia repaired with polypropylene mesh [4]. Complications were minimal, and the recurrence rate at
64 months was 0.95%.
We also found the use of local anaesthesia in this
situation to be feasible, and it meant that cardiac,
respiratory, and thrombotic complications did not
occur. Patients were able to walk immediately, and there
was no nausea or vomiting. The majority of general
surgeons still seem reluctant to employ local anaesthesia
despite evidence of its efficacy in terms of patient safety,
comfort, and overall cost [8, 16, 17, 18, 19, 20, 21, 22].
Despite using prophylactic antibiotics in the present
series, 7% of patients developed a superficial infection
postoperatively, characterised by local tenderness and
redness of the skin. No patient had a purulent discharge
or evidence of deep infection. All responded to antibiotics, and no mesh required removal. Umbilical hernias
seem to be at greater risk of developing a wound infection than groin hernias. Abramov found a 33% incidence of wound infection [23], possible reasons being the
poorly vascularised thin skin flap and the intrinsic bacterial colonisation of the area. Some have cautioned
against the indiscriminate use of prosthetic mesh for
umbilical hernia repairs because of fears of infection
[24]. However, reported wound infection rates vary
widely. Arroyo found an incidence of wound infection of
2–3% [8] and 1.4% [4], while Celdran reported no
wound infections at all in his series consisting only of
mesh repairs [12]. In Garcia-Urena’s study [2] (all nonmesh repairs) 18% developed a wound infection, the
commonest complication. In contrast to inguinal hernia
repair, prophylactic antibiotics should be given routinely
in umbilical hernia repair. If a postoperative infection
does occur, it would appear to be readily treatable with
appropriate antibiotics.
Laparoscopic repair of umbilical hernia has also been
advocated. Nguyen reported what was essentially a
feasibility study of a small series of small hernias
repaired laparoscopically by suturing [25]. No compli-
cations were reported in this group of 16 patients, followed up for only 5 months. Wright and colleagues [26]
retrospectively reviewed 112 patients who had undergone umbilical hernia repair with one of three techniques: open operation without mesh, open with mesh,
or laparoscopic. Open without mesh had the highest
incidence of recurrence and the highest rate of complications. In 75% of the open mesh repairs, the technique
was fascial closure plus onlay mesh—not a true tensionfree sublay technique. Nevertheless, both types of mesh
repair had comparable recurrence and complication
rates, although operative time and length of hospital
stay was less in the open mesh group.
Thus laparoscopic repair requires an obligatory
general anaesthetic, and all that that entails in terms of
staff, equipment, safety, and cost [27, 28, 29]. There is
also the creation of additional potential defects at port
sites and the need to place mesh intraperitoneally [30].
While advocates of laparoscopic groin hernia repair
claim reduced postoperative discomfort to offset these
disadvantages, this benefit has not been demonstrated
with primary umbilical hernia repair.
The present study, along with others [8], has demonstrated the effectiveness with which this type of hernia
can be repaired using an open approach and local
anaesthetic, with high patient acceptance, low morbidity, and a very low (in this series 0) recurrence rate.
Conclusion
This straightforward open technique of placing ‘tensionfree’ mesh in a sub-fascial plane is applicable to all
umbilical hernias with minimal morbidity and an
extremely low incidence of recurrence. The procedure is
admirably suited to the use of local anaesthesia and
ambulatory surgery in the majority of patients.
Acknowledgements Cone drawn by K. Daly, Dept. of Medical
Illustration, Royal Free Hospital, London, U.K.
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