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ORIGINAL RESEARCH ARTICLE
published: 01 September 2014
doi: 10.3389/fsurg.2014.00032
Minimal incision scar-less open umbilical hernia repair in
adults – technical aspects and short-term results
Sanoop K. Zachariah*, Najeeb Mohamed Kolathur, Mahesh Balakrishnan and Arun Joseph Parakkadath
Department of General, Laparoscopic and Gastrointestinal Surgery, Malankara Orthodox Syrian Church Medical College, Cochin, India
Edited by:
Vincenzo Neri, University of Foggia,
Italy
Reviewed by:
Rajat Goel, Primus Super Speciality
Hospital, India
Ulf Gunnarsson, Karolinska Institutet,
Sweden
Prashant Verma, Wockhardt Hospital,
India
*Correspondence:
Sanoop K. Zachariah, Department of
General, Laparoscopic and
Gastrointestinal Surgery, MOSC
Medical College, Kolenchery, Cochin
682311, India
e-mail: skzach@yahoo.com
Background: There is no gold standard technique for umbilical hernia (UH) repair. Conven-
tional open UH repair often produces an undesirable scar. Laparoscopic UH repair requires
multiple incisions beyond the umbilicus, specialized equipments, and expensive tissue sep-
arating mesh. We describe our technique of open UH repair utilizing a small incision. The
technique was derived from our experience with single incision laparoscopy. We report the
technical details and short-term results.
Methods:This is a retrospective analysis of the first 20 patients, who underwent minimal
incision scar-less open UH repair, from June 2011 to February 2014. A single intra-umbilical
curved incision was used to gain access to the hernia sac. Primary suture repair was
performed for defects up to 2 cm. Larger defects were repaired using an onlay mesh.
In patients with a BMI of 30 kg/m2or greater, onlay mesh hernioplasty was performed
irrespective of the defect size.
Results: A total of 20 patients, 12 males and 8 females underwent the procedure. Mean
age was 50 (range 29–82) years. Mean BMI was 26.27 (range 20.0–33.1) kg/m2. Aver-
age size of the incision was 1.96 range (1.5–2.5) cm. Mesh hernioplasty was done in nine
patients. Eleven patients underwent primary suture repair alone.There were no postopera-
tive complications associated with this technique.Average postoperative length of hospital
stay was 3.9 (range 2–10) days. Mean follow-up was 29.94 months (2 weeks to 2.78years).
On follow-up there was no externally visible scar in any of the patients. There were no
recurrences on final follow-up.
Conclusion:This technique provides a similar cosmetic effect as obtained from single port
laparoscopy. It is easy to perform, safe, offers good cosmesis, does not require incisions
beyond the umbilicus, and cost effective, with encouraging results on short-term follow-up.
Further research is needed to assess the true potential of the technique and the long-term
results.
Keywords: umbilical hernia, hernia, hernioplasty, scar-less surgery, ventral hernia, visceral surgery
INTRODUCTION
An umbilical hernia (UH) is an abnormal protrusion of peri-
toneum through the umbilical canal, which is bounded by the
linea-alba anteriorly, the umbilical fascia posteriorly, and the rec-
tus sheath laterally on either side. The umbilicus represents one
of the weak areas of the abdomen and predisposes it to hernia
formation. UHs comprise 6–10% of the primary abdominal wall
hernias (1). The hernia can be found centrally within the umbili-
cus or even laterally, superiorly, and inferiorly. UHs are classified
into three types, namely, congenital, infantile, and adult types. In
90% of the cases, the adult UH is acquired (2). The formation of
an UH is a complex process from an embryologic and anatomic
perspective. After birth, the umbilical arteries and the vein get
thrombosed and the umbilical ring contracts due to cicatrization.
Impaired cicatrization coupled with the lack of elastic fibers in
the obliterated umbilical vein leads to an area of potential weak-
ness over the umbilical scar. In adults, conditions like pregnancy,
obesity, and liver disease with cirrhosis, may cause the umbilical
ring to stretch and reopen leading to the formation of an UH.
Adult UHs are commonly seen to occur in females, with a peak
incidence between the third and the fifth decades of life. They
are also frequently found to be associated with obesity and liver
cirrhosis.
There is no gold standard technique for UH repair. The conven-
tional “Mayo’s technique” of open UH repair, initially described
by “William Mayo” in 1895 had been the treatment of choice for
more than a century and is still being performed in many parts
of the world. However, this technique is becoming less popular
owing to the influx of minimally invasive techniques, which uti-
lize smaller incisions. Mayo’s technique often leaves an undesirable
scar below the umbilicus (3). The standard textbooks mention
than UHs can be repaired either using the suture repair tech-
nique or hernioplasty, utilizing a mesh. We have followed the
same standard repair for many years. However, until now the
size of the incision had not been given much importance. There
is no consensus regarding the size of the incision for open UH
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Zachariah et al. Scar-less umbilical hernia repair
repair. It is generally understood that open techniques require
larger incisions when compared to laparoscopic surgery. How-
ever, laparoscopic UH repair requires multiple incisions beyond
the umbilicus, specialized equipments, and expensive tissue sepa-
rating mesh. Here, we describe our technique of open UH repair,
which offers the advantages of a single small incision. The idea
of placing such an incision was derived from our experience with
single port laparoscopy. Our intention was to offer the patient
the benefit of smaller incisions just as in laparoscopic surgery,
without altering the surgical principle. The method described
here shows that it is possible to perform the standard or con-
ventional UH repair through a smaller incision. The aim of
the study is to present the surgical technique and short-term
results.
MATERIALS AND METHODS
This study is a retrospective analysis of the first 20 consecutive
cases of minimal incision scar-less open UH repair performed
by a single surgeon at the MOSC Medical College (Kolenchery,
Cochin, India),for patients who presented with symptomatic UHs
between June 2011 and February 2014. Data were collected from
the medical records of these patients. Prior to surgery all patients
underwent routine abdominal ultrasonography to confirm the
presence of the hernia, rule out additional pathologies and have a
preoperative assessment of the defect size. The study group com-
prised patients with UHs with defect size not exceeding 4 cm in
diameter. The patients selected were adults, who had not under-
gone a previous laparotomy. All patients were advised to have a
preoperative shower with a thorough cleansing of the umbilicus
on the day of surgery. The patients were administered a single dose
of intravenous cefuroxime at the time of induction of general anes-
thesia. Patients who had liver cirrhosis were initially treated by the
medical gastroenterologist in order to reduce the ascites prior to
surgery. The patients underwent surgery under general or regional
anesthesia, depending on their preferences and also as advised by
the anesthetist.
OPERATIVE TECHNIQUE (FIGURES 1A–M)
The patient was placed in the supine position and the operative
field was cleaned with 10% povidone iodine solution. An intra-
umbilical curved skin crease incision was made as done routinely
for multiport single incision laparoscopy (Figure 1A). The size of
the incision depends on the diameter of the umbilicus and the size
of the sac. The upper flap was held taut by an Allis forceps and the
umbilical cicatrix (containing the sac) was delineated by a combi-
nation of blunt and sharp dissections. The blades of a closed Allis
forceps were introduced by side of the cicatrix and after which the
blades were opened (Figure 1B). By doing so all the soft tissue were
separated from the sides of the cicatrix. This was repeated on the
other side also. The remaining posterior portion of the umbilical
cicatrix was then freed by inserting a right angled forceps, dissect-
ing, and hooking it all around (Figure 1C). Now that the cicatrix
was free all around, a small incision was made transversely over the
middle of the cicatrix to open the sac (Figure 1D). The contents
were identified and reduced into the peritoneal cavity after releas-
ing any adhesions. The transverse incision was then completed all
around the cicatrix. Thus, the upper flap now comprised the skin
of the umbilicus above with a layer of the distal sac attached on
its undersurface (Figure 1E). This is important as it prevents the
skin from becoming too thin and also prevents direct contact of
the skin to the mesh. The size of the defect was measured with a
sterile scale and recorded. Based on this we decided on the type of
repair. No artificial enlargement of the defect was performed and
the edges of the sac were retained to be used as flaps for tension
free closure. Using diathermy, a surrounding subcutaneous space
was created by undermining it for 2 cm (suture repair) to 4 cm
(mesh placement) all around depending on the size of the defect
and also depending on whether or not a mesh had to be placed
(Figure 1G). This was also done with a view to reduce the tension
over the umbilical ring in addition to creating a space for mesh
placement. Care was taken not to inadvertently incise the rectus
sheath.
For defects up to 2 cm in greatest diameter, a primary
suture repair was performed. This was done using number one
polypropylene suture, by taking bites not more than 1 cm from
the edge of the defect in a continuous fashion vertically in a way
so as to just close the fascial defect and at the same time avoiding
tension (Figure 1F).
For defects larger than 2 cm, a polypropylene mesh of size
8 cm ×8 cm was anchored in place over this sutured line (onlay)
so as to obtain an overlap of 4 cm all around from the center of
the defect (Figure 1H). The mesh needs to be rolled into the space
and then spread out using a forceps. We secured the mesh by pac-
ing the central stitch first and then subsequently at 12, 6, 3, and
9 o’clock positions, followed by a few more anchoring sutures in
between (Figure 1J). For patients with a BMI of 30 kg/m2or more,
onlay mesh hernioplasty was performed irrespective of the size of
defect.
After repair of the defect, the umbilical flap containing (the
distal end of the sac) was then anchored to the surface of the
mesh at the center using a 3-0 vicryl single stitch to create an
inverted umbilicus in its original place (Figure 1K). The skin was
the approximated using clips or 4-0 nylon sutures. A sterile padded
dressing was applied and to be removed after 48h. A suction drain
was placed in the subcutaneous space only for one patient who
had liver cirrhosis with ascites. The drain was removed after 48 h
(Figure 1N).
Following discharge, they were advised to follow-up at 1week,
1 month, 3months, 6 months, and thereafter, once a year. For the
present study, all these 20 patients were contacted over phone
and asked to come for follow-up in the outpatient during the
months of March and April 2014 to assess the scar and record the
symptoms related to the surgery and to identify if there were any
recurrences.
RESULTS
A total of 20 patients underwent minimal incision scar-less open
UH repair. There were 12 males and 8 females. The mean age was
50 (range 29–82) years. The mean BMI was 26.27 (range 20.0–
33.1) kg/m2. There were five patients who had a BMI ≥30 kg/m2
of which two patients had a defect size of more than 2 cm in great-
est diameter. The mean defect size was 1.75 (range 0.5–3.4) cm.
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Zachariah et al. Scar-less umbilical hernia repair
FIGURE 1 | The operative steps (A–M). The appearance of the umbilicus 1year following surgery (O).
The average size of the incision was 1.96 range (1.5–2.5) cm. In
three patients, the hernia was irreducible and contained omentum.
Hernioplasty with onlay mesh was done in 9 patients and while
11 patients underwent primary suture repair alone. A drain was
placed only in one patient, who was diagnosed to have liver cir-
rhosis, portal hypertension, and ascites. The mean operating time
was 48 minutes and 30seconds. The mean operating time for pro-
cedures requiring placement of mesh was 1 hour and 33 seconds
while that for primary suture repair was 38 min and 38 s. The aver-
age postoperative length of hospital stay was 3.9 (range 2–10) days.
The mean follow-up was 29.94 months, ranging from 2 weeks to
2.78 years. On follow-up there was no externally visible scar in
any of the patients, as the scar was well hidden in the umbilicus
(Figure 1O). The associated co-morbidities were systemic hyper-
tension and type 2 diabetes mellitus (10%); chronic liver disease
with portal (5%), hypertension (10%), and dyslipidemia (10%);
and chronic obstructive pulmonary disease (5%). There were no
postoperative complications associated with this technique. None
of the patients had recurrences on short-term follow-up. None
of the patients complained of pain over the surgery site on final
follow-up.
DISCUSSION
The treatment of UH has not gained sufficient importance from
the surgical fraternity in comparison with other types hernias (4).
Although a common and relatively simple procedure, there is no
exact protocol or universal consensus on how the repair should be
carried out (3,5).
Standard textbooks describe those small defects of <1 cm may
be primarily closed with non-absorbable monofilament sutures
either by a figure of eight stitch or by darning (6). Defects between
1 and 2 cm diameter may be sutured primarily just to close the
defect with minimal tension. For defects larger than 2 cm, mesh
repair is recommended. Schumacher et al. (7) suggested that repair
with mesh should be reserved for patients with a BMI >30 kg/m2
and hernia orifice larger than 3 cm. A number of techniques of
mesh placement have also been described and there is no prospec-
tive data demonstrating clear advantages of one technique over
another. The mesh may be placed: (1) intraperitoneally, (2) in the
retro-muscular space, (3) in the extra-peritoneal space, and (4) in
the subcutaneous plane after closing the linea-alba vertically (onlay
technique), which is the simplest. Moreover,there is no consensus
on the size of the incision utilized for open repair of UHs.
In this modern era of “minimal access surgery,” the trend
is toward developing surgical procedures that require signifi-
cantly smaller incisions, with an attempt to reduce pain, shorten
the length of hospital stay, and particularly to improve cosme-
sis (8). These advantages of laparoscopic surgery are attributed
to the use of smaller incisions for surgical access. However,
laparoscopic surgery for UHs has certain disadvantages. A recent
systematic review (9), comparing the conventional open tech-
nique with the laparoscopic technique showed that the risks
www.frontiersin.org September 2014 | Volume 1 | Article 32 | 3
Zachariah et al. Scar-less umbilical hernia repair
FIGURE 2 | Our technique of multiport single incision laparoscopy,
where the similar type of incision is made to identify the umbilical
cicatrix for placement of the ports.
Table 1 | Proposed advantages of minimal incision scar-less open
umbilical hernia repair.
Advantages
1 Needs only a small incision, which is hidden within umbilicus
2 Avoids the need for additional incisions beyond the umbilicus
3 Specialized instruments are not required
4 Eliminates the need for expensive tissue separating meshes
5 The same technique could be modified to incorporate: sub-lay or plug
techniques
6 Provides good cosmesis and virtually scar-less effect as in single
incision laparoscopy
7 Can be used in patients who may be otherwise unfit for laparoscopic
procedure
8 Can be performed in patients with liver cirrhosis
9 No possibility of additional trocar site hernias
10 Less expensive and cost effective
of the hernia recurrence with laparoscopic technique are rel-
atively unknown and that laparoscopic repairs were associated
with higher in-hospital costs and also an increased risk of intra-
operative bowel injury. Laparoscopic procedures have an inher-
ent risk of developing trocar site hernias with an overall inci-
dence of 0–5.2% (10). Mason et al. (11) studied 71,054 patients
who underwent abdominal wall hernia repair and reported that
there were no differences noted between laparoscopic and open
repairs in patients when the hernias were reducible, but offered
lower morbidity, particularly, when hernias were complicated.
The use of laparoscopic procedures may be beneficial for larger
defects, especially for cosmetic considerations to be justified by
the higher cost.
Our aim was to offer the patient the benefit of smaller inci-
sions without altering the surgical principle. A few others too have
published reports on cosmetic approach to open UH repair by
making use of smaller incisions. Kurpiewski et al. (12) described
a technique of using 3–3.5 cm incisions for placement of mesh
in the preperitoneal space. Mislowsky et al. (13) described a scar-
less suture repair technique (without mesh) for UHs <2 cm in
size by utilizing a vertical intra-umbilical incision. Arslan et al.
(14) reported their technique of UH repair utilizing small intra-
umbilical curved incisions for hernias <4 cm in size. The idea
of making a small incision and raising flaps was derived from
our experience with single incision laparoscopy. In single incision
laparoscopy, all the ports are positioned through a single incision
located in and around or sometimes entirely through the umbili-
cal cicatrix (Figure 2). There is only one incision that is concealed
within the umbilicus and there is no visible scar. This is beneficial
from a cosmetic point of view. In addition to the “scar-less” or
“virtually scar-less” effect, the claimed benefits include less post-
operative pain, lesser hospital stay, and earlier return to work (15,
16). The proposed advantages of our technique are outlined in
Table 1.
CONCLUSION
The technique described here shows that it is possible to perform
the standard or conventional UH repair by means of a smaller
incision. The classic repair and the surgical principles are not
altered. It obviates the need for special instruments and expen-
sive meshes. The technique is easy to perform, safe, offers good
cosmesis, does not need incisions beyond the umbilicus, and cost
effective, with encouraging results on short-term follow-up. Fur-
ther research is needed to assess the true potential of the technique
and its long-term results.
ACKNOWLEDGMENTS
We acknowledge the administration of the MOSC Medical College,
Kolenchery for their encouragement in publishing this article.
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Conflict of Interest Statement: The authors declare that the researchwas conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 18 May 2014; accepted: 06 August2014; published online: 01 September 2014.
Citation: Zachariah SK, Kolathur NM, Balakrishnan M and Parakkadath AJ (2014)
Minimal incision scar-less open umbilical hernia repair in adults – technical aspects
and short-term results. Front. Surg. 1:32. doi: 10.3389/fsurg.2014.00032
This article was submitted to Visceral Surgery, a section of the journal Frontiers in
Surgery.
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