Umbilical hernia overview

# Overview
Umbilical hernia is a congenital malformation, especially common in infants of African descent. However, it can be an acquired condition as well. In 1855, Dr. Henry Porter was the first to publish a case of umbilical hernia with rupture. In 1876, Dr. MG Oxley published a case of umbilical hernia operation. The pathophysiology of umbilical hernia involves the weakness of abdominal fascia or failure to fully form the fascia which may lead to an umbilical hernia in the newborn. During the fifth to tenth weeks of gestation, the intestinal tract undergoes rapid growth with protrusion of the abdominal content outside the abdominal cavity. This is followed by a gradual re-entry of the abdominal cavity and then the narrowing of the umbilical ring which completes the process of abdominal wall formation. Umbilical hernia may be caused by congenital malformation of the navel or it can be acquired due to increased intra-abdominal pressure caused by obesity, lifting, coughing, or multiple pregnancies. It should be differentiated from epigastric hernia, Spigelian hernia, and incisional hernia. The prevalence of umbilical hernia is approximately 0.015 to 0.023 per 100,000 of newborns affected in USA. It affects males and females equally. Common risk factors in the development of umbilical hernia includes infants, pregnancy, African American, mucopolysaccharide storage diseases, Beckwith-Wiedemann syndrome, and down syndrome. Umbilical hernias are usually asymptomatic and resolve on their own. Common complications of umbilical hernia include incarceration, strangulation, skin color changes, and ascites. Umbilical hernia presents with a soft swelling over the belly button that often bulges when the baby sits up, cries, or strains. The bulge may be flat when the infant lies on the back and is quiet. Treatment is by the size of the defect, the age of the patient, and the cosmetic appearance of the abdomen. Most defects close spontaneously by the age of two years. Physical examination of patients with umbilical hernia is usually remarkable for a protruding umbilical mass examined in the standing and supine positions to determine the size of a hernia +/- valsalva maneuver. There are no ultrasound findings associated with umbilical hernia. However, an ultrasound may be helpful in the diagnosis of complications of umbilical hernia, which include incarceration, strangulation, and size of the hernia. Umbilical hernia surgery is indicated when umbilical hernia is larger than 2cm, elephants trunk appearance, does not spontaneously close by 5 to 6 years of age, symptomatic, strangulation, or increases in size after the age of 1 to 2 years. Surgical repair for an uncomplicated umbilical hernia is done under general anesthesia as an outpatient procedure. Mesh implantation include bridging the defect and placing a preperitoneal mesh with suture repair. Recurrence is seen in patients with elevated intra-abdominal pressures. Laparoscopic technique is reserved for large defects or recurrent umbilical hernias.

# Historical Perspective
In 1855, Dr. Henry Porter was the first to publish a case of umbilical hernia with rupture. In 1876, Dr. MG Oxley published a case of umbilical hernia operation.

# Classification
There is no established system for the classification of umbilical hernia.

# Pathophysiology
The pathophysiology of umbilical hernia involves the weakness of abdominal fascia or failure to fully form the fascia which may lead to an umbilical hernia in the newborn. During the fifth to tenth weeks of gestation, the intestinal tract undergoes rapid growth with protrusion of the abdominal content outside the abdominal cavity. This is followed by a gradual re-entry of the abdominal cavity and then the narrowing of the umbilical ring which completes the process of abdominal wall formation.

# Causes
Umbilical hernia may be caused by congenital malformation of the navel or it can be acquired due to increased intra-abdominal pressure caused by obesity, lifting, coughing, or multiple pregnancies.

# Differentiating Umbilical hernia from other Diseases
Umbilical hernia must be differentiated from epigastric hernia, Spigelian hernia, and incisional hernia.

# Epidemiology and Demographics
The prevalence of umbilical hernia is approximately 0.015 to 0.023 per 100,000 of newborns affected in USA. Commonly seen in low-birth-weight babies, African-Americans, and Hispanics. It affects males and females equally.

# Risk Factors
Common risk factors in the development of umbilical hernia includes infants, pregnancy, African American, mucopolysaccharide storage diseases, Beckwith-Wiedemann syndrome, and down syndrome.

# Screening
There is insufficient evidence to recommend routine screening for umbilical hernia.

# Natural History, Complications, and Prognosis
Umbilical hernias are usually asymptomatic and resolve on their own. Common complications of umbilical hernia include incarceration, strangulation, skin color changes, and ascites.

# Diagnosis

## Diagnostic Criteria
There is no established diagnostic criteria for umbilical hernia.

## History and Symptoms
Umbilical hernia presents with a soft swelling over the belly button that often bulges when the baby sits up, cries, or strains. The bulge may be flat when the infant lies on the back and is quiet. The width can vary from less than 1 centimeter to more than 5 centimeters. All families of babies with an umbilical hernia should be counseled about signs of incarceration; abdominal pain, bilious emesis, and a tender, hard mass protruding from the umbilicus. Treatment is by the size of the defect, the age of the patient, and the cosmetic appearance of the abdomen. Most defects close spontaneously by the age of two years.

## Physical Examination
Physical examination of patients with umbilical hernia is usually remarkable for a protruding umbilical mass examined in the standing and supine positions to determine the size of a hernia +/- valsalva maneuver.

## Laboratory Findings
There are no diagnostic laboratory findings associated with umbilical hernia.

## Imaging Findings
There are no ultrasound findings associated with umbilical hernia. However, an ultrasound may be helpful in the diagnosis of complications of umbilical hernia, which include incarceration, strangulation, and size of the hernia.

## Other Diagnostic Studies
There are no other diagnostic studies associated with umbilical hernia.

# Treatment

## Medical Therapy
Management for umbilical hernias include watchful waiting, educating the parents of the natural course of the condition as most hernias resolve in the first few years of life. If umbilical hernia is incarcerated, then it is treated with IV fluids, nasogastric tube, and emergent surgery.

## Surgery
Umbilical hernia surgery is indicated when umbilical hernia is larger than 2cm, elephants trunk appearance, does not spontaneously close by 5 to 6 years of age, symptomatic, strangulation, or increases in size after the age of 1 to 2 years. Surgical repair for an uncomplicated umbilical hernia is done under general anesthesia as an outpatient procedure. Mesh implantation include bridging the defect and placing a preperitoneal mesh with suture repair. Postoperative recovery is usually uneventful. Recurrence is seen in patients with elevated intra-abdominal pressures. Laparoscopic technique is reserved for large defects or recurrent umbilical hernias.

## Prevention
There are no established measures for the primary prevention of umbilical hernia.