Surgical approaches
Two main skin incision options are used to expose the hernia ring, the choice of which is dictated by the patient's constitution.
- Standard approach. A longitudinal midline abdominal incision is performed. It should be initiated a few centimeters above the level of the umbilicus. A crucial topographical nuance: the umbilicus is always bypassed on the left. The incision line terminates approximately 3–4 centimeters below the umbilical ring.
- Approach in obese patients. Due to pronounced subcutaneous adipose tissue, the standard longitudinal incision is inconvenient. In such cases, a semilunar or elliptical incision is used, which neatly skirts the hernial protrusion from below.
Isolation and management of the hernia sac
After skin incision, the adipose tissue is dissected deeply down to the dense structures—the aponeurosis of the linea alba (linea alba abdominis). The dermato-subcutaneous flap is dissected from left to right. This provides the surgeon with a clear visualization of the hernia ring, formed by the dense fibrous edge of the umbilical ring.
To safely open the ring and prevent organ damage, a grooved probe is inserted between the neck of the hernia sac and the umbilical ring. The ring is dissected strictly along the probe: the incision direction can be transverse or longitudinal (up and down the linea alba).
Then, the hernia sac is completely isolated on all sides and opened. Prolapsed internal organs are gently reduced back into the abdominal cavity, and the excess sac is resected. The peritoneum must be sutured with a continuous absorbable suture (catgut). In the presence of a sliding hernia, an internal purse-string suture may be applied to close the ring.
Mayo hernioplasty of the hernia ring
This technique is the standard if the umbilical ring was incised in a transverse direction during the surgery. The essence of the operation consists in forming a reliable transverse duplication (overlapping one edge of the aponeurosis over the other).
- First row of sutures. Strong silk threads are used to create U-shaped sutures (usually three: one in the center, two on the sides). The upper aponeurotic flap is pierced from outside in, stepping back 1.5 cm from its edge. Then, the same thread captures the lower flap, but closer to the edge—stepping back only 0.5 cm (piercing from outside in and back outward). The thread is brought out at the upper edge at the initial level.
- Formation of the duplication. When these knots are tied, the lower edge of the aponeurosis shifts and goes under the upper flap, forming a strong overlap.
- Second row of sutures. For final fixation, the free edge of the upper flap is sutured to the outer surface of the lower one with conventional interrupted sutures.
Sapozhkov hernioplasty of the hernia ring
The technique is used in cases where the umbilical ring was incised longitudinally (vertically). The goal of the surgery is to create a longitudinal duplication of the abdominal wall, the principle of which is often compared to buttoning a double-breasted coat.
The execution technique includes the following steps:
- The assistant securely grasps the left edge of the incised aponeurosis with Kocher forceps, pulls it away, and bends it so that the inner surface is turned outward as much as possible.
- The surgeon places the left aponeurotic flap deep under the right one, tucking it in as far as possible.
- The edge of the right aponeurotic flap is sutured with interrupted (or U-shaped silk) sutures to the posterior wall of the rectus abdominis sheath on the left.
- The remaining free left aponeurotic flap is placed on top and sutured to the anterior wall of the rectus abdominis sheath on the right.
Lexer technique
This method is considered the least traumatic, which is why it is used primarily in pediatric surgery for treating small umbilical hernias.
The essence of the technique boils down to two stages:
- The umbilical aponeurotic ring is tightened circularly using a strong silk purse-string suture.
- For additional reinforcement of the area, several interrupted sutures are placed over the tied purse-string, capturing the anterior wall of the rectus abdominis sheaths.
Briefly: answers to topical questions
Which layers of the anterior abdominal wall are sequentially incised during access to an umbilical hernia?
When accessing an umbilical hernia, the skin and subcutaneous adipose tissue are sequentially incised down to the aponeurosis of the linea alba. In the umbilical region itself, the muscle layer is absent, so the abdominal wall here is represented by the following layers:
- Skin—detached as a flap along with the adipose tissue.
- Scar tissue—closes the umbilical ring.
- Transversalis fascia (fascia transversalis).
- Peritoneum—its parietal layer forms the hernia sac.
What are the features of surgical tactics and the sequence of actions in an incarcerated umbilical hernia?
Surgical tactics for an incarcerated umbilical hernia include the following sequence of actions:
- Isolation of the surgical field—draping with gauze pads.
- Opening of the hernia sac—with fixation of the incarcerated organ using fingers.
- Decompression—incision of the incarcerating ring.
- Revision—partial extraction of the organ to assess its viability; in retrograde incarceration, adjacent loops from the abdominal cavity are also examined.
- Completion—after plunging the viable organ or the stump after resection, hernioplasty of the hernia ring is performed.
What tension-free hernioplasty methods (using mesh implants) exist for umbilical hernias?
For tension-free hernioplasty in abdominal wall hernias, alloplasty using mesh prostheses is used.
- Lichtenstein method (I. Lichtenstein)—the "gold standard" of modern hernioplasty and a tension-free technique.
- Modern standards involve polypropylene meshes.
- The technique is performed increasingly often due to excellent outcomes.
To avoid confusing the indications for plasty: Mayo—"Minus" (transverse incision and suturing), Sapozhkov—"Pillar" (longitudinal/vertical direction).
Class and exam questions
How is the surgical approach performed in the classic operation?
The skin is incised with a longitudinal midline incision. It begins a few centimeters above the umbilicus, then bypasses the umbilicus strictly on the left, and ends 3–4 cm below the umbilical ring.
What is the difference between the indications for Mayo and Sapezhko repair?
The choice of technique directly depends on how the surgeon incised the umbilical ring. If the incision is transverse, Mayo hernioplasty is used; if longitudinal, Sapozhkov hernioplasty is used.
What instrument is used for safe dissection of the umbilical ring?
To protect the abdominal organs, a grooved probe is inserted between the neck of the hernia sac and the edge of the umbilical ring, along which the tissues are incised.
How is a sliding umbilical hernia managed?
In the presence of a sliding hernia, closure of the hernia ring can be performed by applying an internal purse-string suture.
What else to study on this topic
- Topographic anatomy of the linea alba and the umbilical ring
- Structural features of the rectus abdominis sheaths
- Rules for using a grooved probe in operative surgery
- Technique for placing U-shaped sutures when creating duplications
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