Umbilical and Epigastric Hernia

Overview

Umbilical and Epigastric hernias are types of Primary Ventral abdominal wall hernias. Epigastric hernias are two to three times more common in men. 

Umbilical hernias are three times more likely in females. Most epigastric hernias contain preperitoneal fat, while most umbilical hernias contain omentum or bowel. These hernias are usually asymptomatic unless incarcerated, obstructed or strangulated. 

A strangulated hernia is a surgical emergency due to high risk of perforation and sepsis. Treatment can be conservative for small asymptomatic hernias but is otherwise surgical.^{1 2}

Anatomy

Abdominal wall

• Encloses abdominal cavity
• Can be divided into Anterolateral and Posterior wall

Anterolateral wall layers

1. Skin
2. Superficial fascia – composition depends on location
   1. Above umbilicus – single sheet of connective tissue
   2. Below umbilicus – divided into:
      1. Camper’s fascia: fatty superficial layer
      2. Scarpa’s fascia: membranous deep layer
3. Muscles
   1. Lateral wall
      1. External oblique
      2. Internal oblique
      3. Transversus abdominis
   2. Anterior wall
      1. Pyramidalis
      2. Rectus abdominis
4. Transversalis fascia
5. Extraperitoneal fat
6. Peritoneum

Rectus abdominis

• Linea alba: divides the muscle into two
  • Area of weakness predisposed to epigastric hernia formation
• Linea semilunaris: represents the lateral border
• Rectus sheath: formed by the aponeuroses of three flat muscles and encloses rectus abdominis and pyramidalis
  • Anterior sheath: formed by external oblique and half of internal oblique
  • Posterior sheath: formed by half of internal oblique and transversus abdominis
• Arcuate line: point where posterior layer of rectus sheath ends – midway between umbilicus and pubic symphysis – the posterior aponeuroses move to the anterior rectus sheath

Umbilical ring – natural weakness of abdominal wall, where the Umbilical vessels and Urachus passed through during foetal life.

Aetiology and Risk factors

Epigastric hernia risk factors	Umbilical hernia risk factors
Increased intra-abdominal pressure: Chronic cough, constipation, heavy lifting, obesity
Smoking	Abdominal distension
Chronic steroid use	Ascites
Diabetes	Pregnancy
Older age	Female sex
Male sex	—

Pathophysiology

Classification

Umbilical hernia

Origin:

• Congenital: occurs in infants when umbilical ring fails to close; most close spontaneously in the first 2 to 5 years of life
• Acquired: occur in adulthood due to increased intra-abdominal pressure

Epigastric hernia

Contents:

• Adipose: consists solely of preperitoneal fat (most common)
• Uninhabited peritoneal sac: empty peritoneal sac with no abdominal organs
• Complete: contains abdominal viscera such as omentum and bowel

Ventral wall hernias (both Umbilical and Epigastric)

Defect size:

• Small (<1cm)
• Medium (1-4cm)
• Large (>4cm)

Clinical state:

• Reducible: contents can be pushed back into abdominal cavity
• Incarcerated: contents cannot be pushed back into abdominal cavity
• Strangulated: blood supply is compromised^{1 3}

Clinical Manifestation

Most are asymptomatic, unless obstructed or strangulated

Patient might be able to hear bowel sounds from the hernia if there is bowel involvement

Small epigastric hernias may be painful – preperitoneal fat becomes trapped within narrow defect causing local nerve irritation

Red flag symptoms suggesting strangulation:

• Increasing pain
• Erythema
• Discolouration of skin over hernia
• Hard or tender lump
• Systemic symptoms: high fever, fatigue, rapid heart rate

Red flag symptoms suggesting obstruction:

• Obstipation
• Abdominal distension
• Nausea and vomiting

Examination

General inspection – midline swelling or mass

• Observe hernia when patient is:
  • Standing
  • Lying supine
  • Coughing
• Determine location – umbilical or epigastric

Palpation – assess:

• Reducibility
• Tenderness
• Cough impulse: expansion with coughing suggests hernia

Differential diagnosis

Lipoma	Benign tumour of adipose tissue
Sebaceous cyst	Benign keratin-filled cyst arising from a blocked hair follicle or epidermis
Rectus sheath haematoma	Collection of blood within the rectus sheath
Rectus abdominis diastasis	Separation of the rectus abdominis muscles caused by widening of the linea alba without a fascial defect
Desmoid tumour	A benign but locally invasive fibroblastic tumour arising from musculoaponeurotic tissues
Urachal anomalies	Congenital abnormalities resulting from incomplete closure of the embryological urachus
Umbilical endometriosis	Endometrial tissue within the umbilicus
Metastatic umbilical nodule (Sister Mary Joseph node)	Umbilical metastasis from an intra-abdominal or pelvic malignancy

Investigations

Diagnosis is primarily clinical and imaging is not routinely required

Imaging can be used

• Ultrasound – when physical examination is inconclusive; however, it has limited effectiveness in patients with significant obesity or large hernias
• CT – useful for preoperative planning when assessing defect size in patients without palpable hernia or with obesity³

Treatment

Conservative management

Used for: Asymptomatic hernias (very low risk of strangulation) and for patients with Significant surgical risk

Includes:

• Weight reduction
• Smoking cessation
• Management of chronic cough
• Constipation treatment

Surgical management

For hernias that are symptomatic, obstructed, incarcerated or strangulated

Repair can be open or laparoscopic

Two types of repair:

Primary suture repair	Mesh repair
Used for small defects (<1-2cm)	Used for larger defects
Higher risk of recurrence	Lower risk of recurrence
High tension	Minimal tension
Lower risk of infection	Higher risk of infection

For strangulated hernia – resection of necrotic bowel might be necessary³

Complications 

Untreated hernia

• Incarceration
• Strangulation
• Bowel obstruction
• Perforation and sepsis

Post-operative

• Recurrence
• Seroma
• Haematoma
• Adhesions
• Mesh infection or migration³

References

1. Brooks DC. Overview of abdominal wall hernias in adults. In: Rosen M, Chen W, editor. [Internet]. [updated 2026 Apr 16; cited 2026 Jun 15]. Available from: UpToDate
2. Conze J, Klinge U, Schumpelick V. Hernias. Surgical Treatment: Evidence-Based and Problem-Oriented [Internet]. Munich: Zuckschwerdt; 2001 [cited 2026 Jun 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6888/ 
3. Holt AC, Bamarni S, Leslie SW. Umbilical hernia [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan- [cited 2026 Jun 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459312/