In adults most hernias in the umbilical region occur above or below a patient's umbilicus, through a weak place in his linea alba, rather than directly through the umbilicus itself. In Africa, a few of these may be true umbilical ones, which may be so huge that they can accommodate a pregnant uterus.
The patient is usually an obese multiparous woman, with a large multilocular hernia in the upper part of her umbilicus. Its margins are firm, so that obstruction and strangulation, particularly Richter type strangulations of the large gut (14-1), are common.
If a paraumbilical hernia is small, you should be able to repair it quite easily. Repairing a large one is difficult, because: (1) The viscera in the sac stick to its wall, and in freeing them you may damage gut. (2) There are usually several loculi, divided by fibrous septa. (3) The sac often extends to the skin. (4) You have to raise flaps, under which blood and exudate can collect and become infected postoperatively. Minimize this risk by closing the dead spaces under any flaps you make, as best you can.
Fig. 14-21 MAYO'S OPERATION FOR A PARAUMBILICAL HERNIA. A, clearing the tissues towards the neck of the sac. B, cutting round the neck. C, inserting mattress sutures, so as to pull one flap under the other. D, the complete repair. E, and F, if the defect is very large, you may have to extend it longitudinally, make relaxing incisions in the rectus sheath on either side, and then overlap the aponeurosis laterally.
PARAUMBILICAL HERNIAS IN ADULTS PREPARATION. If the patient is very fat, encourage him to lose weight before you operate. Obesity makes surgery difficult. Clean his umbilicus carefully to remove all debris that might contaminate the wound.
SMALL PARAUMBILICAL HERNIAS These are hernias in which the lump (not the ring) is less than 5 cm in diameter. Preserve his umbilicus if you can.
INCISION. Put a plastic-covered pillow under his knees to help relax his abdomen. Make a curved transverse incision 1 cm above or below his umbilicus (A, Fig. 14-21). Above, make the incision concave downwards; below, make it concave upwards. Extend it so that it goes 5 cm beyond the lump on either side.
Deepen the incision down to his linea alba and his rectus sheath on either side. Reflect flaps above and below, so that you can see all round under his umbilicus. Control bleeding carefully.
Define the margins of the neck of the hernia. This is seldom as neat as in other hernias. You will not be able to grasp the fundus because of its attached umbilical skin, so define the neck on all sides, and ignore the fundus initially. Open the sac close to its neck, because this will be free of adhesions. Do this between haemostats, as if you were opening the peritoneum (9-2).
Continue to open the sac with blunt-tipped scissors, working from the neck towards the fundus. As soon as you have made a sufficient opening, put your finger into it and feel for adhesions. Cut round the circumference of the sac with scissors (B). The ellipse of skin containing the umbilicus will then only be attached to the patient by any viscera that are adherent to it. Carefully examine the contents of the sac.
If a loop of gut has stuck to the sac, pass your finger up beside it. Find a part of the sac wall which is free of adhesions, and open this up as best you can[md]it is better to leave a piece of sac adherent to the gut than to injure it.
If his omentum has stuck to the sac, clamp, transfix, tie, and divide small sections of it at a time, and return it to his abdomen.
Turn the sac inside out, so that you can see its contents and peel them away. Remove adherent omentum along with the sac, and separate adhesions between loops of gut. Finally, cut the ellipse of skin with his umbilicus free.
Enlarge the opening in his abdominal wall laterally, without trying to separate the peritoneum as a separate layer. His rectus muscles will probably be so widely separated, that you will not need to open their sheaths. If necessary, incise his anterior rectus sheath at the ends of these incisions, but don't injure his rectus muscle.
You will probably be unable to separate his peritoneum as a separate layer, so suture it with his linea alba, which is likely to be broad. Overlap the upper and lower edges of the defect. Clear the under surface of the superficial flap free of as much fat as you can. Then insert several mattress sutures of No.1 monofilament (C). When these have drawn one flap under the other, insert some simple interrupted sutures (D).
Apply two corrugated rubber drains under the skin through separate stab wounds. Close his skin incision, and apply a pressure bandage over the wound.
LARGE PARAUMBILICAL HERNIAS Under general anaesthesia, proceed as above, making a transverse elliptical incision to include and excise his umbilicus. Dissect down to the fascia above and below his umbilicus on either side. Open the sac at its neck. Expect it to have several locules, and be prepared to find firmly adherent transverse colon. Evert the sac, and carefully free his viscera from the loculated pockets of the sac.
You may be able to overlap the edges of the sac longitudinally. Make a long midline incision and lateral relaxing incisions in his rectus sheath, as E, and F, in Fig. 14- 21. Overlap them and suture them with No.1 monofilament.
Suture his superficial fascia to his anterior rectus sheath. If possible, insert suction drains. Apply pressure dressings, and hold them in place with an abdominal binder, or plenty of adhesive strapping.
DIFFICULTIES [s7]WITH PARAUMBILICAL HERNIAS If a paraumbilical hernia DISCHARGES PUS OR FAECES, or both, a loop of gut has strangulated and perforated, and caused a faecal fistula (rare). General peritonitis is usually prevented by the tight fit of the neck of the sac, which seals off the rest of his peritoneal cavity. The differential diagnosis includes other causes of a discharging umbilicus, carcinoma of the transverse colon or stomach, and a persistent urachus, etc. Treat him as if a faecal fistula had formed in a strangulated inguinal hernia, and see 14.6D.
Fig. 14-22 AN EPIGASTRIC HERNIA. Note that it has occurred through the linea alba above the umbilicus. After Dunphy and Way, ''Current Surgical Diagnosis and Treatment', Fig. 36-7. With the kind permission of Jack Lange.