Umbilical hernia

Overview

•Soft, painless, reducible swelling at the umbilicus - most prominent when infant cries/strains

•Cough impulse present; gurgling on reduction if bowel in sac

•Asymptomatic in most children - typically parental concern

•Irreducibility, tenderness, erythema - suggest incarceration/strangulation; urgent assessment required

Risk factors

Higher risk groups

Premature infants

Afro-Caribbean children (up to 10x higher incidence)

Down syndrome (trisomy 21)

Hypothyroidism

Beckwith-Wiedemann syndrome

Chronic raised intra-abdominal pressure (e.g. ascites, VP shunts)

Investigations

•Clinical diagnosis in the vast majority - examine relaxed then crying/straining

•Ultrasound abdomen - if diagnosis uncertain or another cause suspected (e.g. urachal remnant, granuloma)

•Bloods (FBC, CRP, lactate) - if strangulation suspected; raised lactate indicates bowel ischaemia

Differential diagnosis

Key differentials of umbilical swelling

Condition	Key distinguishing features
Exomphalos	Present at birth; contents herniate through cord base; covered by membrane; neonatal emergency
Umbilical granuloma	Fleshy pink/red tissue at stump post-separation; no fascial defect; treat with silver nitrate
Paraumbilical hernia	Through linea alba just above/below umbilical ring; adults; does NOT self-resolve - requires repair
Diastasis recti	Widening of linea alba; no true fascial defect; no strangulation risk
Urachal remnant	Persistent bladder-umbilicus connection; presents as sinus, cyst or fistula

Management

•Children - first-line: watchful waiting; most defects <1.5 cm close spontaneously by age 4-5 years

•Strapping, binding, or coin taping - no evidence base; not recommended

•Children - surgical referral if: persists beyond age 4-5 years, defect >1.5 cm, symptoms/parental concern, or any complication

•Adults - first-line: elective surgical repair; adult hernias do not resolve spontaneously and carry meaningful strangulation risk

•Adults, high surgical risk: conservative management with supportive binder - does not prevent strangulation; not definitive

🚨

Strangulated umbilical hernia = surgical emergency. Features: irreducible swelling, tenderness/erythema, fever, tachycardia, vomiting, signs of bowel obstruction. Manage with IV access, fluids, analgesia, NBM, urgent bloods including lactate, and emergency surgical repair.

•Surgical repair - primary suture (small defects) or mesh overlay (larger defects/adults); day case under general anaesthesia

Complications

•Incarceration - contents cannot be reduced; urgent assessment required

•Strangulation - blood supply compromised; narrow-necked hernias highest risk; can progress to bowel ischaemia → necrosis → perforation → peritonitis

•Recurrence after repair - reduced with mesh vs primary suture

💡

Defect size is the key prognostic factor: <1.5 cm likely to self-resolve; >1.5 cm less likely to close spontaneously and more likely to need surgery.