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title: "Umbilical Hernia"
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docid: "ff51faeb-9832-4e87-a6cc-ca45673d754f"
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authors:
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- key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
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value: "Siva P. Raman, MD"
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breadcrumbs:
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-
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name: "Gastrointestinal"
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slug: "gastrointestinal"
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treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
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-
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name: "Peritoneum, Mesentery, and Abdominal Wall"
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slug: "peritoneum-mesentery-and-abdominal-"
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treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
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-
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name: "External Hernias"
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slug: "external-hernias"
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treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
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-
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name: "Umbilical Hernia"
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slug: "umbilical-hernia"
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treeNodeId: null
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category: "Gastrointestinal"
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documentVersionId: "b7132216-076e-4ae9-9af4-60ff52ce0ef7"
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imageCount: 7
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lastUpdated: "04/21/25"
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pageDescription: "Umbilical Hernia"
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pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Umbilical Hernia"
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pageTitle: "Umbilical Hernia | STATdx"
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enhancedTitle: "Umbilical Hernia"
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type: "DX"
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references: true
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ddx: true
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cases: 1
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breadcrumbs:
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- "Gastrointestinal"
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- "Diagnosis"
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- "Peritoneum, Mesentery, and Abdominal Wall"
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- "External Hernias"
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- "Umbilical Hernia"
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---
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# KEY FACTS
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- ## Terminology
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- Protrusion of abdominal contents (omental fat ± bowel) into or through anterior abdominal wall via umbilical ring
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- ## Imaging
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- Hernia sac located at midline (usually upper 1/2 of umbilicus) with protrusion of omental fat ± bowel loops
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- Fat stranding/fluid within hernia sac (in absence of abnormal bowel) suggests fat necrosis due to incarceration
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- Can cause patient symptoms but does not necessitate urgent surgery
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- Findings of bowel ischemia include evidence of bowel obstruction, bowel wall thickening, fat stranding, etc.
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- ## Top Differential Diagnoses
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- Omphalocele
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- Congenital defect in abdominal wall at umbilicus
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- May allow some or nearly all abdominal contents to herniate
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- Ventral hernia
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- Epigastric and hypogastric hernias develop above and below umbilicus, respectively
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- Incisional hernias develop through prior incision site
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- Spigelian hernia
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- Between linea semilunaris and lateral rectus abdominis
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- Often has intact external oblique muscle or aponeurosis
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- ## Pathology
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- Congenital: Due to incomplete closure of umbilical ring
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- More likely in children with Down syndrome, trisomy 18, mucopolysaccharidoses, Ehlers-Danlos syndrome, and Beckwith-Wiedemann syndrome
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- Acquired: Results from weakening of cicatricial tissue that normally closes umbilical ring
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- Usually secondary to ↑ intraabdominal pressure (e.g., obesity, multiple pregnancies, tense ascites, etc.)
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- ## Clinical Issues
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- Congenital type: Diagnosed in infancy
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- 8x more common in Black patients
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- > 90% close spontaneously by 1 year of age
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- Surgical repair of congenital hernias (unless symptomatic) not considered until at least 3 years of age
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- Treatment only if hernia is large, symptomatic, or persistent (present > 5 years)
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- Acquired type: Develops in later life (usually middle age)
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- More common in women (M:F = 1:3)
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- Incarceration is more likely in men and less likely in women (particularly when nonobese)
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- Small and asymptomatic hernias do not undergo repair
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- Symptoms, large hernia size, and incarceration all necessitate surgical repair
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# TERMINOLOGY
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- ## Definitions
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- Protrusion of abdominal contents (omental fat ± bowel) into or through anterior abdominal wall via umbilical ring
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- Congenital: Diagnosed in infancy
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- Acquired: Develops in later life
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- Defined by European hernia society as midline hernia located within 3 cm of umbilicus (either above or below)
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- Hernia bounded by umbilical fascia posteriorly, linea alba anteriorly, and medial margins of rectus sheath bilaterally
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- CT demonstrates protrusion of omental fat ± bowel loops through umbilical ring
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- ### Location
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- Midline and usually located in upper 1/2 of umbilicus (through opening in linea alba)
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- ### Size
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- Varies but typically small in most cases
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- ### Morphology
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- Hernia sac containing fat ± bowel
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- Most commonly contains omental fat and small bowel with colonic involvement less common
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- Often demonstrates narrow neck, feature that can ↑ risk of strangulation
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- ## CT Findings
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- Hernia sac at midline of abdomen (usually superior aspect of umbilicus)
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- Protrusion of omental fat ± bowel loops
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- Fat stranding and fluid within hernia sac (in absence of abnormal-appearing bowel) may suggest fat necrosis due to incarceration
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- Can be cause of patient symptoms but does not necessarily necessitate urgent surgery
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- Findings in bowel ischemia include wall thickening, abnormal mural enhancement, fat obliteration, vessel engorgement, mesenteric haziness, ascites
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- ## Ultrasonographic Findings
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- Offers advantage of acquiring images with patient standing or during Valsalva, as some hernias may not be apparent with patient in supine position
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- ## Imaging Recommendations
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- ### Best imaging tool
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- CECT
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- Multiplanar views can offer additional information to help guide treatment/surgery
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- Useful to evaluate possible bowel obstruction
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- Many umbilical hernias are diagnosed clinically with imaging utilized in cases with clinical doubt or suspicion for complications
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- ## Fluoroscopic Findings
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- ### Contrast enema
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- Can theoretically be helpful to show large bowel in hernia sac or demonstrate Richter hernia (only part of bowel wall herniated)
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- Limited utility in modern era with CECT considered primary modality for diagnosis and assessment of complications
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# DIFFERENTIAL DIAGNOSIS
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- [Omphalocele](/document/omphalocele/30c2da7f-e14e-4053-90d3-715f7c10c932)
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- Congenital defect in abdominal wall at umbilicus, evident at birth or in utero
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- May allow some or nearly all abdominal contents to herniate
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- [Ventral Hernia](/document/ventral-hernia/ab08cd87-4342-4825-948b-d02fc178078f)
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- Epigastric and hypogastric hernias develop above and below umbilicus, respectively
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- Incisional hernias develop through prior incision site
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- [Spigelian Hernia](/document/spigelian-hernia/3bbee7e5-dcd2-423c-a079-ce530cdb08c0)
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- Hernia protruding between linea semilunaris and lateral edge of rectus muscle
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- Often has intact external oblique muscle or aponeurosis
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Congenital
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- Incomplete closure of umbilical ring fascia (which should normally close during development)
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- Exact etiology is unknown, although thought to be related to umbilical vein portion of ring
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- Acquired
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- Weakening of cicatricial tissue that normally closes umbilical ring
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- Usually secondary to any number of processes, which can result in ↑ intraabdominal pressure, including obesity, multiple pregnancies, chronic bowel distension, ascites, etc.
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- ### Associated abnormalities
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- Cirrhosis with tense ascites very frequently can be associated with umbilical hernia (and also ↑ risk of recurrence after umbilical hernia surgical repair)
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- More likely in children with Down syndrome, trisomy 13, trisomy 18, mucopolysaccharidoses, Ehlers-Danlos, Marfan syndrome, and Beckwith-Wiedemann syndrome
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- Peritoneal dialysis
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- Hypothyroidism
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- ## Gross Pathologic & Surgical Features
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- Portions of greater omentum, properitoneal fat, or bowel loop protrude anteriorly through umbilical ring
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Mass protruding via umbilicus, which often enlarges when coughing or straining
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- Pain in region of umbilicus
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- ### Other signs/symptoms
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- Bowel obstruction
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- ## Demographics
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- ### Sex
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- Acquired type more common in women (M:F = 1:3)
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- Incarceration is more likely in men and less likely in women (particularly when nonobese)
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- ### Ethnicity
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- Congenital type 8x more common in Black patients
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- ### Epidemiology
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- Most common ventral hernia comprising 4% of all hernias
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- 175,000 umbilical hernia repairs performed every year in USA
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- Congenital umbilical hernias seen in up to 23% of all newborns, although many close spontaneously, and incidence drops to 2-10% by 1 year of age
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- Congenital umbilical hernias more common in premature and low-birth-weight infants
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- ## Natural History & Prognosis
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- Congenital type
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- Vast vast majority of congenital umbilical hernias close spontaneously (> 90% by 1 year of age)
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- Umbilical hernias > 1.5 cm in size less likely to close spontaneously
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- Incarceration or strangulation is very rare
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- Acquired type
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- Incarceration is unusual
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- Ischemia of incarcerated bowel occurs quickly due to nonelasticity of ring and because these hernias often demonstrate relatively narrow neck
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- Rupture of hernia may result from massive ascites
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- Skin over hernia is often very thinned
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- Danger of infected fluid (peritonitis)
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- Erythema and ↑ pain suggest strangulation
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- ## Treatment
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- Surgical repair can be performed using either primary suture repair or mesh repair
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- Suture repair is traditional method and tends to be more commonly utilized for small abdominal wall defects (< 3 cm) but carries higher risk of recurrence
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- Mesh repair carries lower risk of recurrence and relatively comparable risk of infection and other complications (compared to suture repair)
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- Surgical mesh repair can be performed either laparoscopically or with open technique with decision often based primarily on surgeon preference (although complication rate for laparoscopic repair may be slightly lower)
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- Recurrence of hernia after surgery more common in setting of patient obesity, large abdominal wall defects, and ascites
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- Common indications for surgery
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- **Congenital**
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- Hernia persists beyond 5 years, incarceration, defect > 2 cm, ventriculoperitoneal shunt
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- Surgical repair of congenital hernias (unless symptomatic) not considered until at least 3 years of age as well > 90% of these hernias will close spontaneously
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- Surgery often performed in asymptomatic patients after 5 years of age in cases where abdominal wall defect is > 1.5 cm (although symptoms may necessitate earlier repair)
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- **Acquired**
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- Patient symptoms, large hernia, or incarceration
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- Small and asymptomatic hernias generally do not undergo repair and should be treated as incidental finding on imaging
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9ee7579c-287b-49a0-b521-282b515f31c9
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## References
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# Selected References
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1. [Coste AH et al: Umbilical hernia. StatPearls, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=29083594%5Bpmid%5D)
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1. [He K et al: Age and probability of spontaneous umbilical hernia closure. JAMA Pediatr. 178(5):497-8, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38466296%5Bpmid%5D)
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1. [Shrestha BB et al: Incarcerated Littre's umbilical hernia: a case report. JNMA J Nepal Med Assoc. 62(270):139-41, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38409995%5Bpmid%5D)
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1. [Hager M et al: Primary uncomplicated ventral hernia repair: guidelines and practice patterns for routine hernia repairs. Surg Clin North Am. 103(5):901-15, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37709395%5Bpmid%5D)
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1. [Henriksen NA et al: Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg. 107(3):171-90, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31916607%5Bpmid%5D)
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1. [Kulaçoğlu H: Current options in umbilical hernia repair in adult patients. Ulus Cerrahi Derg. 31(3):157-61, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26504420%5Bpmid%5D)
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1. [Konerman M et al: Image of the month: umbilical hernia with ascites and a collateral paraumbilical vein in decompensated cirrhosis. Am J Gastroenterol. 108(8):1237, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23912403%5Bpmid%5D)
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1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
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1. [Khati NJ et al: Imaging of the umbilicus and periumbilical region. Radiographics. 18(2):413-31, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9536487%5Bpmid%5D)
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## Differential diagnosis
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### Abdominal Wall Mass
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DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
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## Cases
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- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '02021248-bc54-4489-b241-0198dd405ab9', 'description': 'A series of contrast-enhanced axial CT sections (#1-10) show loculated ascites (arrows, #1-2, 9) and a peritoneal dialysis catheter (open arrow, #10). There is a small umbilical hernia (open arrows, #4-6) containing a short segment of bowel. The small bowel segments "upstream" from the herniated bowel are dilated with air-fluid levels (curved arrows, #2-5), while the segments "downstream" from the hernia are collapsed (arrows, #8), indicating that the hernia is the cause of the bowel obstruction.\n\nComment: The presence of ascites with a SBO usually raises concern for ischemic complication of the obstructed bowel; however, in this case it was due to the peritoneal dialysate and chronic renal failure. Umbilical hernias occur more frequently in patients with ascites.', 'history': 'Patient with chronic renal insufficiency treated with peritoneal dialysis; presents with abdominal pain and distention.', 'imagePoolId': '736c54ba-48f2-42bc-a3e0-656b2e3029cf', 'name': 'Causing partial small bowel obstruction', 'teachingPoint': None, 'demographics': '67 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '39d6b7cd-50aa-4837-beb1-13eacf5ff0ac', 'description': 'There is a focal bulge of omental fat (arrow) toward the umbilicus and between the rectus muscles, representing a small umbilical hernia.', 'history': 'Asymptomatic finding.', 'imagePoolId': '86a67b82-565a-4b79-b5b4-cfa444a8ffa6', 'name': 'Small bulge of fat', 'teachingPoint': None, 'demographics': '35 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'cec54390-3da4-414b-bcbc-4865210fd557', 'description': 'A series of axial (#1-7) and coronal reformatted (#8-12) CECT images demonstrate protrusion of a portion of the transverse colon and omental fat through a defect in the anterior abdominal wall in the midline, representing an umbilical hernia (arrows). There is no sign of colonic obstruction nor infarction of the herniated fat, which are 2 of the common complications of abdominal wall hernias.', 'history': 'Obese patient with periumbilical discomfort and palpable mass effect.', 'imagePoolId': 'c6e429c1-2af1-406e-99d7-d078acc89eff', 'name': 'Containing transverse colon', 'teachingPoint': None, 'demographics': '82 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'f580aa4a-399f-460f-aa85-8c1e37d9f4fd', 'description': 'CECT images (#1-3) shows ascites and dilated proximal small bowel (arrows, #1-3). There is an umbilical hernia (curved arrow, #1,2) containing ascites and bowel. Dilated bowel leads into the hernia and collapsed bowel (open arrow, #2) leaves the hernia, confirming bowel obstruction caused by a strangulated umbilical hernia.', 'history': 'Patient with cirrhosis and tense ascites with bulging umbilicus and crampy abdominal pain.', 'imagePoolId': 'a68928b9-a77e-4259-9f32-86340f4f1487', 'name': 'With bowel obstruction & ascites', 'teachingPoint': None, 'demographics': '48 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
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## Images
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### Selected Images
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*Axial CECT demonstrates protrusion of the transverse colon through a defect in the abdominal wall at the midline, representing an umbilical hernia <img src='img/arrows/WS.png'/>. There is no sign of obstruction nor infarction of the herniated fat, 2 of the common complications of abdominal wall hernias.*
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*Axial CECT demonstrates an umbilical hernia <img src='img/arrows/WS.png'/> filled with ascites fluid in this patient with cirrhosis. Umbilical hernias frequently fill with fluid in cirrhotic patients with tense ascites due to portal hypertension.*
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*Sagittal CECT demonstrates an umbilical hernia <img src='img/arrows/WS.png'/> containing a loop of bowel <img src='img/arrows/WC.png'/> with surrounding ascites. Note the dilated small bowel <img src='img/arrows/WO.png'/> upstream from the hernia, compatible with bowel obstruction. The strangulated bowel was found to be ischemic at surgery.*
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*Axial CECT demonstrates an umbilical hernia <img src='img/arrows/WC.png'/> containing a short segment of bowel. Dilated bowel <img src='img/arrows/WS.png'/> leads into the hernia, suggesting bowel obstruction caused by a strangulated umbilical hernia.*
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### Additional Images
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*Axial CECT demonstrates protrusion of a portion of the transverse colon and omental fat through a defect in the anterior abdominal wall in the midline, representing an umbilical hernia <img src='img/arrows/WS.png'/>. There is no sign of colonic obstruction nor infarction of the herniated fat, which are 2 of the common complications of abdominal wall hernias.*
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*Axial CECT in a middle-aged man with cirrhosis shows ascites, a dilated small bowel <img src='img/arrows/WS.png'/>, and an umbilical hernia <img src='img/arrows/WC.png'/> containing ascites and small bowel.*
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*Axial CECT in the same patient again demonstrates the umbilical hernia <img src='img/arrows/WC.png'/>. Note the collapsed loop of small bowel <img src='img/arrows/WO.png'/> leaving the hernia sac, confirming the hernia as the cause of the small bowel obstruction. Umbilical hernias are common among patients with cirrhosis and ascites due to thin abdominal wall musculature and chronically increased intraabdominal pressure.*
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