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

CHAPTER 1

Hi, everyone. My name is Dr. Shirin Towfigh from the Beverly Hills Hernia Center. We are going to watch a cute little umbilical hernia repair performed on a lovely lady. She has a slight outie and it bothers her, and everyone deserves to have an innie umbilicus. So let's watch the specifics on how to do a very carefully performed umbilical hernia. And I'll walk you through the steps of why I'm doing every little technique, so that you can also recreate the perfect umbilical hernia repair. So first, you want to make sure you have the perfect incision, and I like to hide my incisions in a skin wrinkle. Everyone's belly button's a little bit different, so it depends on what the belly button looks like. Once you make that scar, you identify the herniated fat and you basically take it out. Sometimes you can push it back in. If your hernia defect is a centimeter or less, you can do a nice, tissue-based repair. And I go through all the different techniques for you during the discussion of the actual video. But basically, you want to do a tension-free repair, small little bites, and pick your suture to correlate with the strength of the tissue of the patient. You don't want a big suture or really tough sutures 'cause that's just going to tear through. And once you're done with closing the hernia defect, and I usually like to close them in a horizontal or transverse plane, then it's nice to give them a nice innie. Their final closure should be very cosmetic and they should have a nice innie when they're done.

CHAPTER 2

It's a belly button hernia. You want it to end up as an innie belly button. Right now, she's got some fat in it and she's got a cute little wrinkle here. So we're gonna use this wrinkle. She has two wrinkles. Let's use this wrinkle. That way, when you go innie, she won't see the scar at all. Local, please. So I mark it because once you put the local aesthetic, it'll change the anatomy. She's very thin, not so deep. You're gonna hit bowel. Nice, infiltrate. Good. We're good. Five CCs, at least. Some Ray-Tec's please.

CHAPTER 3

Scalpel. Another raytec, please. Adson's, next.

CHAPTER 4

Yes, and then notice that we use a protected tip, sharp needle point Bovie. I'll take a mosquito. Because we need it for this delicate procedure. Small operation, small scar. Open that a little bit more. Good. Okay, so here's her hernia. You can see how it's just fat. Senn, please. First, we'll take it off the skin. The Senn will retract the skin without causing any damage. You have sharp Senns? Oh, this is a very - okay, so buzz that off. What you can see is usually it has a narrow neck. There's a fascial neck, right there. I'm just gonna take the fat off of it. It keeps coming. There we go. So now, she's flat here. It's very familiar to have so much fat coming out. Can you tell that there's a hole in there? I think you can see it through the camera. Let's clean the camera a little bit. Okay. All right, so this fat will be discarded. Gimme a wet lap, please. If you wet the skin and you use cautery near it, you're less likely to burn the skin. Okay, so let's discard this fat. It's clearly not a tumor. It's, we don't need to send it to pathology. It'll be discarded.

CHAPTER 5

All right, so now we gotta find her hole. That's actually bowel in there, if you see. And here's her fascial defect, right there. One edge - another mosquito, please. Gotta find the other defect. Is that it? This? That's it, mhm. That's the other defect.

CHAPTER 6

So we're gonna be closing it transversely like this. Small bites, interrupted with permanent suture. You can see that the hole is actually fairly big. 3-0, Vicryl please. I mean, sorry, Ethibond. Okay, so you see how this is the fascia there? Yes. Is it buried knots? Buried knots. Fascia there. Let's go ahead. And using a 3-0 permanent suture, I prefer the braided suture because that's going to be felt less. Smaller bite. The braided suture will be felt less in the thinner patients. There we go. So we'll tie these after we're done. We'll get two out of each. So we need another set of sutures. Another set? Mhm. Snap, please. Scissors, snap. Can I get one more? So we'll get three, maybe four bites out of this. Probably three. The goal is to close the defect. She likes to play sports. Good. This does not need to be a tight closure. Scissors. It's like pediatric surgery. Let's do one more. Let's see. Let's double check. Yeah, let's do one more. Way out there. You see it? Better bite. Good. So this is about a one-centimeter defect. Maybe 1.1 centimeters. In fact, gimme a ruler if you have one. Okay. Yeah. It's exactly one centimeter. All right, go ahead and tie the first, the last knot. These are not super tight. Tighter it is, the more pain, the more ischemia. Can you cut for yourself? Scissors, please. Four, three is enough, or four. Key is small bites, interrupteds, work really well with these smaller hernias. Permanent suture. You don't want the suture stronger than her own tissues.

CHAPTER 7

And then, now we're gonna close the skin. Before we do that, double check that it looks pretty. And then you'll want to confirm she has a nice innie belly button. So we're gonna take that 3-0. See that right there? I'm gonna grab that right there. And sew that down to the fascia level. Just be on the fascia there. Mhm. It's absorbable suture. Give her more of an innie look.

CHAPTER 8

Okay, let's do a no-knot. 4-0 Monocryl, please. Vicryl back. So that's gonna go nicely, and she won't see her scar. Start out here. So the no-knot technique helps secure the suture without using a knot. She's so - her skin is so thin, she may not do well with a knot. Cosmetically, she'll do better without the knot. Just a subcuticular suture. Professionally done by a world-renowned plastic surgeon. Let's see. Lemme get this. She's got really good skin. Good skin? So she has a second hernia. It's up here. It's actually the one that bothers her the most. That's the incarcerated epigastric hernia with fat. So, she had the option of having two separate small scars or a slightly larger scar at the belly button and using that to access the epigastric region. And she chose the two smaller scars. So take that all the way through. We're gonna reuse it for the next one. All right, we'll dress those all at the end, but we're kind of done with this one. We're gonna move to the next hernia. Steri-Strip. All right, it's two by two gauze, please. Let's do one that's inside the belly button to promote an innie. Open it all up. I stick it in there. Then a second one on top. Another two by two. More local, please. Let's see if we can sneak some local anesthetic in there. Yeah, I can feel the fascia with the needle.

CHAPTER 9

So umbilical hernias are very common. Not everyone needs to have them repaired. Watchful waiting is considered safe. If you have a patient who either has symptoms from their umbilical hernia or cosmetically doesn't like an outie, then you can offer them surgery. The surgery is often based on the risk factors for the patient and also the quality of the hernia. Most hernias less than one centimeter can be repaired without mesh and with suture only. I prefer to use permanent suture. There's multiple surgical techniques as to how to put the hernia back together again. But typically, it's an open repair or a laparoscopic repair, with or without mesh. And here, you have seen an open repair without mesh for a one-centimeter hernia. You also need to take into consideration the risk factors of the patient. Are they obese? Do they cigarette smoke? Do they use nicotine at all, actually? Do they have a chronic cough? Are they constipated? Do they plan to have a pregnancy? All of these are risk factors for the hernia falling apart. And so, either you should delay the surgery until those risk factors are addressed, or revise the hernia repair to address these factors so you don't have a recurrence because it's not just a hernia.