For many years, a 71-year-old multiparous woman had a painless swelling around her umbilicus that intermittently and spontaneously decreased in size. Progressive, dull pain at the site that had lasted for 7 days prompted her to seek medical evaluation. The patient also noticed recent maceration of the skin on the surface of the affected area.
The swelling was tender and irreducible; the remainder of the abdomen was soft. Bowel sounds were normal. Dr Virendra Parikh of Fort Wayne, Ind, suspected a large umbilical hernia.
Urgent surgery was performed. An incarcerated omentum in the large umbilical hernia was found; the bowel was viable. The nonviable omentum was resected, and the hernia was repaired.
In adults, these herniations occur through the umbilical canal that is bordered by the umbilical fascia posteriorly, the linea alba anteriorly, and the medial edges of the 2 rectus sheaths on each side. These hernias tend to incarcerate and strangulate more often than inguinal hernias. Approximately 90% of patients with this type of hernia are women, almost all of whom are multiparous. This condition also is common in patients who have cirrhosis with ascites. The cause of these hernias appears to be persistent increased intra-abdominal pressure that is exerted against the thinned umbilical ring and fascia.
The complete reduction of very large hernias is often unsuccessful because the omentum adheres to the sac. As the hernia enlarges, it becomes oval in shape and tends to sag downward. Episodes of intermittent, colicky abdominal pain may be caused by subacute intestinal obstruction. As in this patient, very large hernias that cannot be reduced require surgical repair.
This patient's surgery was successful; she recovered without sequelae.