Open Umbilical Hernia Repair Without Mesh for a 1-cm Hernia

Umbilical hernias are common abdominal wall defects that occur when intra-abdominal contents protrude through the umbilical opening in the abdominal muscles. These hernias are prevalent in both pediatric and adult populations with an estimated incidence of 6–14% of all abdominal wall hernias in adults.¹ While congenital umbilical hernias often resolve spontaneously in children, adult-onset umbilical hernias typically require surgical intervention due to the risk of complications such as incarceration or strangulation.²

The etiology of umbilical hernias in adults is multifactorial, involving both congenital and acquired factors. Increased intra-abdominal pressure, obesity, multiparity, and connective tissue disorders have been identified as significant risk factors.³ Clinically, umbilical hernias may present as asymptomatic bulges or cause discomfort, pain, and cosmetic concerns.

Treatment options for umbilical hernias range from watchful waiting to surgical repair. The decision to operate is based on various factors, including hernia size, symptoms, risk of complications, and patient preferences. Surgical approaches can be broadly categorized into open and laparoscopic techniques, with or without mesh reinforcement.⁴ The use of mesh in umbilical hernia repair has been a subject of debate, particularly for small defects.

For hernias with fascial defects less than 1–2 cm in diameter, primary suture repair without mesh has been shown to be effective, with recurrence rates comparable to those of mesh repair in selected patients.^5,6 This video focuses on the detailed surgical technique for open umbilical hernia repair without mesh for a 1-cm hernia, emphasizing both functional and aesthetic outcomes.

A thorough preoperative evaluation is conducted to assess the patient's overall health status, hernia characteristics, and risk factors for recurrence. The size of the fascial defect is estimated clinically and may be confirmed with imaging studies.

The procedure is typically performed under local anesthesia with or without sedation. The patient is positioned supine on the operating table. The umbilical area is prepared and draped in a sterile fashion.
A curvilinear incision is planned within a natural skin fold of the umbilicus to optimize cosmetic results. Local anesthetic (e.g., 0.5% lidocaine with epinephrine) is infiltrated into the subcutaneous tissues. An incision is made along the marked line using a scalpel. Careful dissection is performed through the subcutaneous tissues using electrocautery to maintain hemostasis.

The hernia sac is identified and carefully dissected from the surrounding tissues. If the sac contains only fat, it may be excised. If the bowel is present in the sac, they are inspected and, if viable reduced back into the peritoneal cavity. The fascial edges of the defect are delineated and measured.

The fascial defect is closed using interrupted sutures of permanent material, typically 2-0 or 3-0 polypropylene. Small tissue bites (approximately 5 mm) are taken on either side of the defect to ensure a tension-free repair. The closure is performed in a transverse orientation to distribute tension evenly. Care is taken not to overtighten the sutures, which could lead to tissue ischemia and increased postoperative pain.

To achieve an aesthetically pleasing umbilicus, it is fixated to the underlying fascia. A 3-0 absorbable suture is used to anchor the base of the umbilicus to the fascia, slightly deeper than the fascial repair. This step helps to create and maintain the desired umbilical contour. The skin is closed using a subcuticular technique with 4-0 absorbable sutures. A "no-knot" technique may be employed to minimize suture palpability and improve cosmetic outcomes.⁷

Sterile skin strips are applied to reinforce the skin closure. A small, non-adherent dressing is placed within the umbilicus to maintain its shape, followed by a larger protective dressing over the entire wound.
The patient is typically discharged on the same day with instructions for wound care, activity restrictions, and follow-up appointments. Patients are advised to avoid heavy lifting for 4–6 weeks postoperatively.
This video demonstration and accompanying description serve as valuable educational resources for surgical trainees, general surgeons, and plastic surgeons seeking to refine their techniques for small umbilical hernia repairs. The step-by-step approach, rationale for each decision, and emphasis on both functional and cosmetic outcomes provide insights that can help surgeons optimize their results in umbilical hernia repair.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.