UMBILICAL AND EPIGASTRIC HERNIA REPAIR: A SYSTEMATIC REVIEW

Umbilical and epigastric hernias are among the most common hernias of the abdominal wall; however, there is a lack of standardization for their treatment.

AIMS:

To clarify the controversies regarding therapeutic possibilities, indications, and surgical techniques for umbilical and epigastric hernia repair.

METHODS:

A systematic review and qualitative analysis of randomized clinical trials published in the last 20 years, involving adults (aged 18 years and over) with umbilical and/or epigastric hernias, was performed by systematically searching the PubMed/Medline, Cochrane, SciELO, and LILACS databases. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias Tool.

RESULTS:

Initially, 492 studies were selected and, subsequently, 15 randomized controlled clinical trials were chosen that met the inclusion criteria and underwent full reading and qualitative analysis, considering possible bias.

CONCLUSIONS:

This review concluded that it is evident the superiority of the use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm, even in certain emergency situations. However, suture repair is a good option for patients with a defect smaller than 1 cm. In the laparoscopic approach, recent evidence points towards possible superiority in fixation with fibrin sealant, and fascial defect closure is recommended. In addition, due to a scarcity of randomized controlled trials with low risk of bias, further studies are needed on types, positioning and fixation techniques, as well as the real role of video-assisted laparoscopic surgery in the correction of hernias, especially umbilical.

HEADINGS:
Umbilical Hernia; Ventral Hernia; Abdominal Wall; General Surgery

Studies	Random sequence generation	Allocation concealment	Selective reporting	Blinding participants	Blinding outcome assessment	Incomplete outcome data	Other sources of bias
Kaufmann et al.¹⁰10. Kaufmann R, Halm JA, Eker HH, Klitsie PJ, Nieuwenhuizen J, van Geldere D, et al. Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Lancet. 2018;391(10123):860-9. https://doi.org/10.1016/S0140-6736(18)30298-8 https://doi.org/10.1016/S0140-6736(18)30...	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Arroyo et al.³3. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpena R. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg. 2001;88(10):1321-3. https://doi.org/10.1046/j.0007-1323.2001.01893.x https://doi.org/10.1046/j.0007-1323.2001...	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Ponten et al.¹⁹19. Ponten JEH, Leclercq WKG, Lettinga T, Heemskerk J, Konsten JLM, Bouvy ND, et al. Mesh OR Patch for Hernia on Epigastric and Umbilical Sites (MORPHEUS-Trial): the complete two-year follow-up. Ann Surg. 2019;270(1):33-7. https://doi.org/10.1097/SLA.0000000000003086 https://doi.org/10.1097/SLA.000000000000...	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Abdel-Baki et al.¹1. Abdel-Baki NA, Bessa SS, Abdel-Razek AH. Comparison of prosthetic mesh repair and tissue repair in the emergency management of incarcerated para-umbilical hernia: a prospective randomized study. Hernia. 2007;11(2):163-7. https://doi.org/10.1007/s10029-007-0189-4 https://doi.org/10.1007/s10029-007-0189-...	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Christoffersen et al.⁵5. Christoffersen MW, Olsen BH, Rosenberg J, Bisgaard T. Randomized clinical trial on the postoperative use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair. Hernia. 2015;19(1):147-53. https://doi.org/10.1007/s10029-014-1289-6 https://doi.org/10.1007/s10029-014-1289-...	Low risk	Low risk	Low risk	High risk	Low risk	Low risk	Low risk
Malik¹¹11. Malik AM. Laparoscopic versus open repair of para-umbilical hernia. Is it a good alternative? J Pak Med Assoc. 2015;65(8):865-8. PMID: 26228333.	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Polat et al.¹⁸18. Polat C, Dervisoglu A, Senyurek G, Bilgin M, Erzurumlu K, Ozkan K. Umbilical hernia repair with the prolene hernia system. Am J Surg. 2005;190(1):61-4. https://doi.org/10.1016/j.amjsurg.2004.09.021 https://doi.org/10.1016/j.amjsurg.2004.0...	Low risk	High risk	Low risk	High risk	High risk	High risk	High risk
Bessa et al.⁴4. Bessa SS, El-Gendi AM, Ghazal AH, Al-Fayoumi TA. Comparison between the short-term results of onlay and sublay mesh placement in the management of uncomplicated para-umbilical hernia: a prospective randomized study. Hernia. 2015;19(1):141-6. https://doi.org/10.1007/s10029-013-1143-2 https://doi.org/10.1007/s10029-013-1143-...	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Eriksen et al.⁸8. Eriksen JR, Bisgaard T, Assaadzadeh S, Nannestad Jorgensen L, Rosenberg J. Randomized clinical trial of fibrin sealant versus titanium tacks for mesh fixation in laparoscopic umbilical hernia repair. Br J Surg. 2011;98(11):1537-45. https://doi.org/10.1002/bjs.7646 https://doi.org/10.1002/bjs.7646...	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Pietro Díaz et al.²¹21. Prieto-Díaz Chávez E, Medina-Chávez JL, Avalos-Cortes LO, Atilano-Coral A, Trujillo-Hernández B. Comparison of transumbilical approach versus infraumbilical incision for the repair of umbilical hernia in adults. Cir Cir. 2012;80(2):122-7. PMID: 22644006.	Low risk	Low risk	Low risk	High risk	Low risk	Low risk	Low risk
Purushotham and Madhu²²22. Purushotham B, Madhu S. Comparative study between laparoscopic and open repair of umbilical and paraumbilical hernia. Int Surg J. 2015;2(2):204-13. https://doi.org/10.5455/2349-2902.isj20150516 https://doi.org/10.5455/2349-2902.isj201...	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Abo-Ryia et al.²2. Abo-Ryia MH, El-Khadrawy OH, Moussa GI, Saleh AM. Prospective randomized evaluation of open preperitoneal versus preaponeurotic primary elective mesh repair for paraumbilical hernias. Surg Today. 2015;45(4):429-33. https://doi.org/10.1007/s00595-014-0907-3 https://doi.org/10.1007/s00595-014-0907-...	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Tunio²³23. Tunio NA. Hernioplasty: tension free mesh repair versus Mayos repair for umbilical hernias. J Pak Med Assoc. 2017;67(1):24-6. PMID: 28065949.	Low risk	Low risk	Low risk	High risk	High risk	Low risk	Low risk
Othman et al.¹⁵15. Othman IH, Metwally YH, Bakr IS, Amer YA, Gaber MB, Elgohary SA. Comparative study between laparoscopic and open repair of paraumbilical hernia. J Egypt Soc Parasitol. 2012;42(1):175-82. https://doi.org/10.12816/0006305 https://doi.org/10.12816/0006305...	Low risk	High risk	Low risk	High risk	High risk	Low risk	Low risk
Christoffersen et al.⁶6. Christoffersen MW, Westen M, Rosenberg J, Helgstrand F, Bisgaard T. Closure of the fascial defect during laparoscopic umbilical hernia repair: a randomized clinical trial. Br J Surg. 2020;107(3):200-8. https://doi.org/10.1002/bjs.11490 https://doi.org/10.1002/bjs.11490...	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk

Studies	Type of hernia included	Selected theme	N	Intervention group	Control group	Criteria for mesh indication	Statistically significant outcome
Kaufmann et al.¹⁰10. Kaufmann R, Halm JA, Eker HH, Klitsie PJ, Nieuwenhuizen J, van Geldere D, et al. Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Lancet. 2018;391(10123):860-9. https://doi.org/10.1016/S0140-6736(18)30298-8 https://doi.org/10.1016/S0140-6736(18)30...	Umbilical	Mesh use	300	Mesh repair	Suture repair	Defect between 1 and 4 cm	Fewer recurrence rate within two years in the mesh group (3.6% vs 11.4%)
Arroyo et al.³3. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpena R. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg. 2001;88(10):1321-3. https://doi.org/10.1046/j.0007-1323.2001.01893.x https://doi.org/10.1046/j.0007-1323.2001...	Umbilical	Mesh use	200	Mesh repair	Suture repair	Defect above 3 cm	Fewer recurrence rate within five years in the mesh group (1% vs 11%)
Ponten et al.¹⁹19. Ponten JEH, Leclercq WKG, Lettinga T, Heemskerk J, Konsten JLM, Bouvy ND, et al. Mesh OR Patch for Hernia on Epigastric and Umbilical Sites (MORPHEUS-Trial): the complete two-year follow-up. Ann Surg. 2019;270(1):33-7. https://doi.org/10.1097/SLA.0000000000003086 https://doi.org/10.1097/SLA.000000000000...	Umbilical and epigastric	Mesh use	348	Mesh repair	PVP repair	Defect wider than 2 fingers’ width	Fewer reoperation rate (4.0% vs 10.7%) and local complications rates (22.1% vs 32.5%) in the mesh group
Abdel-Baki et al.¹1. Abdel-Baki NA, Bessa SS, Abdel-Razek AH. Comparison of prosthetic mesh repair and tissue repair in the emergency management of incarcerated para-umbilical hernia: a prospective randomized study. Hernia. 2007;11(2):163-7. https://doi.org/10.1007/s10029-007-0189-4 https://doi.org/10.1007/s10029-007-0189-...	Umbilical (acute incarcerated)	Mesh use	42	Mesh repair	Suture repair	Any size defect	Fewer recurrence rate within one and a half year in the mesh group (0% vs 19%)
Tunio²³23. Tunio NA. Hernioplasty: tension free mesh repair versus Mayos repair for umbilical hernias. J Pak Med Assoc. 2017;67(1):24-6. PMID: 28065949.	Umbilical	Mesh use	86	Mesh repair	Suture repair	Defect above 3 cm	Fewer local complications, post-operative pain, recurrence rate within three years (2.3% vs 7.0%) and hospitalization days (4.30 days vs 6.14) in the mesh group
Bessa et al.⁴4. Bessa SS, El-Gendi AM, Ghazal AH, Al-Fayoumi TA. Comparison between the short-term results of onlay and sublay mesh placement in the management of uncomplicated para-umbilical hernia: a prospective randomized study. Hernia. 2015;19(1):141-6. https://doi.org/10.1007/s10029-013-1143-2 https://doi.org/10.1007/s10029-013-1143-...	Umbilical	Mesh position	80	Pre-peritoneal position	Pre-aponeurotic position	Defect between 4 and 10 cm	There were no significantly distinct outcomes between different positions
Abo-Ryia et al.²2. Abo-Ryia MH, El-Khadrawy OH, Moussa GI, Saleh AM. Prospective randomized evaluation of open preperitoneal versus preaponeurotic primary elective mesh repair for paraumbilical hernias. Surg Today. 2015;45(4):429-33. https://doi.org/10.1007/s00595-014-0907-3 https://doi.org/10.1007/s00595-014-0907-...	Umbilical	Mesh position	60	Retrorectal position	Pre-aponeurotic position	Any size defect	Retrorectal position was associated with fewer post-operative pain rate (VAS score of 4.87 vs 7.07)
Eriksen et al.⁸8. Eriksen JR, Bisgaard T, Assaadzadeh S, Nannestad Jorgensen L, Rosenberg J. Randomized clinical trial of fibrin sealant versus titanium tacks for mesh fixation in laparoscopic umbilical hernia repair. Br J Surg. 2011;98(11):1537-45. https://doi.org/10.1002/bjs.7646 https://doi.org/10.1002/bjs.7646...	Umbilical	Mesh fixation	40	Fixation with fibrin sealant	Fixation with titanium grapples	Defect between 1.5 and 5.0 cm	Fixation with fibrin sealant was associated with fewer post-operative pain rate (VAS score of 1.9 vs 4.7)
Malik¹¹11. Malik AM. Laparoscopic versus open repair of para-umbilical hernia. Is it a good alternative? J Pak Med Assoc. 2015;65(8):865-8. PMID: 26228333.	Umbilical	Laparoscopic surgery	337	Laparoscopic repair	Open repair	Any size defect	Fewer hematoma rate (1.61% vs 23.64%), seroma rate (4.03% vs 11.48%), chronic pain rate (2.41% vs 8.7%), and hospitalization days (2 vs 5) in the laparoscopic group
Purushotham et al.²²22. Purushotham B, Madhu S. Comparative study between laparoscopic and open repair of umbilical and paraumbilical hernia. Int Surg J. 2015;2(2):204-13. https://doi.org/10.5455/2349-2902.isj20150516 https://doi.org/10.5455/2349-2902.isj201...	Umbilical	Laparoscopic surgery	42	Laparoscopic repair	Open repair	Any size defect	Fewer post-op pain rate (VAS score of 3.05 vs 7.48) and hospitalization days (2 vs 4) in the laparoscopic group
Othman et al.¹⁵15. Othman IH, Metwally YH, Bakr IS, Amer YA, Gaber MB, Elgohary SA. Comparative study between laparoscopic and open repair of paraumbilical hernia. J Egypt Soc Parasitol. 2012;42(1):175-82. https://doi.org/10.12816/0006305 https://doi.org/10.12816/0006305...	Umbilical	Laparoscopic surgery	40	Laparoscopic repair	Open repair	Any size defect	Fewer post-operative pain rate in the laparoscopic group (VAS score of 2.76 vs 4.73)
Christoffersen et al.⁶6. Christoffersen MW, Westen M, Rosenberg J, Helgstrand F, Bisgaard T. Closure of the fascial defect during laparoscopic umbilical hernia repair: a randomized clinical trial. Br J Surg. 2020;107(3):200-8. https://doi.org/10.1002/bjs.11490 https://doi.org/10.1002/bjs.11490...	Umbilical	Laparoscopic surgery	80	Fascial defect closure	Without fascial defect closure	Defect between 2 and 6 cm	Fewer than 2-year recurrence (13.88% vs 32.43%) and seroma (35% vs 55%) rate in closure group
Christoffersen et al.⁵5. Christoffersen MW, Olsen BH, Rosenberg J, Bisgaard T. Randomized clinical trial on the postoperative use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair. Hernia. 2015;19(1):147-53. https://doi.org/10.1007/s10029-014-1289-6 https://doi.org/10.1007/s10029-014-1289-...	Umbilical and epigastric	Complication prevention	56	Abdominal binders use	Without abdominal binders	Defect between 2 and 8 cm	There were no significantly distinct outcomes in abdominal binder use
Polat et al.¹⁸18. Polat C, Dervisoglu A, Senyurek G, Bilgin M, Erzurumlu K, Ozkan K. Umbilical hernia repair with the prolene hernia system. Am J Surg. 2005;190(1):61-4. https://doi.org/10.1016/j.amjsurg.2004.09.021 https://doi.org/10.1016/j.amjsurg.2004.0...	Umbilical	New techniques	50	PHS repair	Others techniques	Defect below 4 cm	Fewer post-op pain rate in the PHS group (McGill pain score of 0.6 vs 0.9)
Pietro Díaz et al.²¹21. Prieto-Díaz Chávez E, Medina-Chávez JL, Avalos-Cortes LO, Atilano-Coral A, Trujillo-Hernández B. Comparison of transumbilical approach versus infraumbilical incision for the repair of umbilical hernia in adults. Cir Cir. 2012;80(2):122-7. PMID: 22644006.	Umbilical	New techniques	82	Transumbilical incision	Infraumbilical incision	Any size defect	There were no significantly distinct outcomes between different incision types

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[1] Correspondence:Luis Felipe Mondardo Spengler. E-mail: luisfelipespengler@gmail.com