2022

2023

Case Write Up Report 5

Umbilical Hernia

Jana Amr Alshafei- U18100316

Dubai hospital

SURGERY 1- 2022/2023
 Patient demographics

 Initials: K.M.A
 MRN: 920280375
 Age: 50 years
 Gender: male
 Nationality: Oman
 Marital Status: married with 2 children
 Occupation: desk job in airport
 Date of admission: 20 October 2022

History taking

 Chief complaint:
Umbilical pain that is present in the last one year

 History of presenting illness:

Patient is a 50-year-old Omani male came to the clinic with peri-umbilical pain in the last one
year. Pain comes and goes and cramping in nature. Pain was in the umbilicus that didn’t
radiate anywhere. The patient scaled the pain as 3 out of ten. Pain was not relieved by
anything and was made worse by straining and heavy weight. He has chronic constipation
and comes now because he noticed a bulge in his umbilicus region. This bulge is
compressible but reproducible. The bulge is chronic more than 1 cm, soft in consistency with
an oval shape and movable, but no incarceration or gangrene or obstruction symptoms but
he reported heart burn. Patient denied fever, anorexia or change in eating habits, nausea,
vomiting, any change in bowel pattern or urine changes, trauma, bleeding per rectum, or
change in diet. Patient knew about it being a hernia, and his concerns and expectations
revolved around fixing the bulge.

Review of symptoms:

1. No headaches or dizziness
2. No vision or hearing problems
3. No difficulty swallowing
4. No chest pain, shortness of breath, palpitations, cough, or difficulty breathing
5. No change in bowel habits including pain, diarrhoea, no stool changes and no
bleeding per rectum, urine output including initiation, sensation, colour, and
frequency are unchanged
6. No rash or skin abrasion
7. No problems in lower and upper limbs. No back, neck, or joint pain
 PMHx and PSHx: patient had an gastroscopy last year in Thailand due to his heartburn and
was diagnosed with GERD. The patient didn’t take any pain killers. There are no known
allergies. The patient has diabetes and hypercholesterolaemia that are controlled with
medication. He reported recent travel history last month from Thailand.

Family history: no other significant family history.

Social history: the patient has a desk job in the airport and travels for Thailand couple times
yearly. He is not active but does some walking. His diet is variable but focuses on rice. He is
not a smoker or a drinker. He is married with 2 children.

 Physical examination
Vital signs upon admission

Patient was acute pain but alert and oriented

- Temp: 36.2° C
- Heart rate: 87 Bpm, regular
- Respiratory Rate: 18 Bpm
- Blood pressure: 145/87
- SpO2: 100%
- Height: 166 cm
- Weight: 95.6 kg
- BMI: 34.69
Physical exam

- General inspection (chest until the knees, in flat and standing): patient is alert and
conscious. He is not in pain or acute distress. The patient is obese, with no jaundice or
pallor.
- Focused abdominal exam:
o Inspection: mildly distended. Symmetrical, no abnormal masses, caput medusa,
visible peristalsis, bruises. There is a 2 cm bulge in the umbilicus that is present
while standing and on cough impulse and tensing of the abdomen.
o Palpation: mild peri-umbilical pain and tenderness, no abdominal guarding or
rigidity. Bulging mass felt and positive on cough sign. The swelling is compressible
and reducible. Swelling is soft in consistency with an oval shape and movable
o Auscultation: present bowel sounds
- Genital exam: No groin swelling or scars. Normal genitalia.
- PR exam was normal. No bleeding per rectum
- Cardiac exam: normal rhythm, rate, character and volume with no added sound or murmurs
- Respiratory exam: bilateral air entry on clear auscultation with normal rate and No added
sounds or laboured breathing

Differential diagnosis

- Hernia
- Malignant mass
- lymphadenopathy
 Electrolyte profile Normal range:
Cl-, serum 98 98 – 107 mmol/L
Urine analysis Normal range:
Investigations
K+, serum 4.3 3.5 - 5.1 mmol/L
UA appear Clear Clear
Na+, serum 135 136 - 145 mmol/L
UA colour Yellow Pale yellow
Creatinine 83 61.9 to 114.9 µmol/L
UA pH 6.5 4.5 - 8
CBC Normal Range Bilirubin 0.9 0-1.0mg/dL
UA protein Negative Negative
Hgb 15.1 13.8 to 17.2 g/dL UA RBC Negative Negative
WBC 7.2 4.5 - 11.00 x10^9/L UA Haemoglobin negative Negative
RBC 5.59(high) 3.8 - 5.2 x10^12/L UA urobilinogen 0.2 < 0.2 mg/dL
Hct 45.3 34 – 47 % UA Glucose Negative Little to none
MCV 81.1 80 – 101 fL
MCH 27 27 – 35 pg
RDW 12.7 12% to 15%
Platelet 194 150 – 450 x10^9/L
Glucose 230(high) 65-140 mg/dl

Radiological modalities

- Abdominal ultrasound:
* Liver is normal size with no focal lesions or intrahepatic
biliary tract dilatation. Grade 1 changes of fatty liver
* Gallbladder showing normal filling and wall, no stones,
masses, mud collection or pericholecystic fluid
* Spleen is normal size with no focal lesion
* Pancreas appears normal
* Kidneys are normal, shape, and size with no masses or cysts or abnormalities
* Urinary bladder is normal shape and wall thickness
* Umbilical hernia noted with small omental fat. The neck of the hernia is 2.62 cm

- abdominal CT and pelvis with contrast:

* No consolidation or pleural effusions
* Liver: no focal lesions or ductal dilatation
* Pancreas: no calcifications, mass, or ductal dilatation
* Spleen: no focal lesions
* GIT: fat containing infra umbilical hernia with anterior
abdominal wall defect measures about 3.2 cm. small supra
umbilical fat containing hernia seen with anterior abdominal
wall defect about 10.9 cm
* Adrenals: no mass or nodules
* Kidneys and ureters: no focal lesions or hydronephrosis
* Vessels: are well opacified
* Peritoneum and mesentery: few reactive mesenteric lymph nodes
in the right lower quadrant. No pneumoperitoneum
* Pelvic viscera: prostate shows homogenous enhancement
 * Osseus: loss of normal lumbar lordosis

Diagnosis

- Non incarcerated, non-obstructive Umbilical Hernia

My Plan of management

- admit the patient

- start analgesic pain relief medication
- NPO
- Manage glucose level

Hospital’s Plan of management

- Admit the patient

- Keep patient under NPO
- Order lab investigations
- Start medications including acetaminophen and insulin.
- IV fluids
- Schedule surgery for repair

 Follow Up on 21st of October (1 day Post Op.)

- Subjective: the patient is alert and conscious and engaging conversation. Mild abdominal
pain.
- Objective: vitals are stable and within normal ranges. Abdomen is soft, no generalised
tenderness or guarding except for the mild pain peri umbilicus. Patient passed urine but not
motion yet.
- Assessment: 31-year-old man, on day 1 post medication. Recovering well
- Plan: two doses of prophylactic antibiotics. Monitoring of patient condition including input
and output. fluid diet to soft diet. Active mobilization. Stool softeners ex: lactulose. Wearing
a supportive binder for minimum of 2 weeks with no straining, no heavy lifting for min of 3
months, and praying while sitting.

 Learning points:
1. In patients undergoing ascites or peritoneal dialysis, chronic abdominal wall swelling,
abdominal muscle fiber swelling, and connective tissue weakness with increased intra-
abdominal pressure, as in pregnancy, contribute to the development of umbilical hernias.
There is a possibility it may contain preperitoneal fat tissue, omentum, and small intestine or
a combination may be involved. Involvement of the transverse colon is very rare.
Imprisonment and strangulation are common because the neck of the hernial sac is usually
narrow compared to the size of the hernial sac
2. There are two main surgical repair options for umbilical hernias: suture repair and mesh.
Primary suture repair is performed either by simple primary suture repair which can be used
 for small defects (<2 cm) or by using Mayo technique which is basically an overlapping
abdominal wall fascia in a “vest-over-pants” manner. Unfortunately, primary suture repair
associate with 10% recurrence rate. Therefore, it is recommended for umbilical hernia of
>1cm to repaired by mesh.
3. Open and laparoscopic techniques can both be used for mesh repair. Onlay or sublay mesh
implantation can be used for open mesh repair; onlay mesh placement is technically simpler
but is sometimes associated with increased wound complications such seroma or hematoma
and surgical site infection. Placement of preperitoneal or sublay mesh involves greater
surgical expertise and experience but results in fewer wound problems and recurrences.

 Literature review: Abdominal wall hernia and pregnancy: a systematic

review
There is no agreement on the best course of action for treating abdominal wall hernias in fertile
women. The aim of this study is to review the current research on treating abdominal wall hernias in
fertile women either before or during pregnancy.

Methodology included a cross-reference search of relevant papers was done along with a literature
search in PubMed and Embase. 31 papers total, 23 of which were case reports.

Results show that A few patients who underwent sutured or mesh repair in fertile women claimed
experiencing pain in the third trimester of a future pregnancy. Pregnant women who have
incarcerated hernias may undergo emergency surgery and combining hernia treatment and
caesarean section appears to be a safe approach. Following hernia repair before or during
pregnancy, there have been no serious problems recorded. 102 patients who underwent an elective
caesarean delivery and an abdominal wall hernia repair operation reported no significant problems.

There is little research on abdominal wall hernia with pregnancy. Pain may develop in the third
trimester of a subsequent pregnancy after abdominal wall hernia treatment with sutures or mesh.
The best course of action for a pregnant patient with a bothersome abdominal wall hernia appears
to be hernia repair in combination with caesarean section.

References:

Jensen, K.K., Henriksen, N.A. & Jorgensen, L.N. Abdominal wall hernia and pregnancy:
a systematic review. Hernia 19, 689–696 (2015). https://doi.org/10.1007/s10029-015-1373-6