I Had Double Hernia Surgery as a Baby, Can I Now Carry a Full Term Pregnancy?

Umbilical Hernia Repair and Pregnancy: Before, during, after…

Hakan Kulacoglu

ⁱAnkara Hernia Center, Ankara, Turkey

Received 2017 Nov iii; Accepted 2018 January 3.

Abstract

Umbilical hernias are well-nigh common in women than men. Pregnancy may cause herniation or render a preexisting one apparent, considering of progressively raised intra-abdominal pressure. The incidence of umbilical hernia among pregnancies is 0.08%. Surgical algorithm for a pregnant woman with a hernia is non thoroughly articulate. There is no consensus almost the timing of surgery for an umbilical hernia in a woman either who is already pregnant or planning a pregnancy. If the hernia is incarcerated or strangulated at the time of diagnosis, an emergency repair is inevitable. If the hernia is non complicated, simply symptomatic an elective repair should be proposed. When the patient has a small and asymptomatic hernia it may exist improve to postpone the repair until she gives birth. If the hernia is repaired by suture alone, a loftier risk of recurrence exists during pregnancy. Umbilical hernia repair during pregnancy can be performed with minimal morbidity to the female parent and baby. Second trimester is a proper timing for surgery. Asymptomatic hernias can be repaired, following childbirth or at the time of cesarean section (C-section). Elective repair after childbirth is possible equally early as postpartum of eighth calendar week. A 1-twelvemonth interval can give the patient a very smooth convalescence, including hormonal stabilization and render to normal body weight. Moreover, surgery can exist postponed for a longer time even after another pregnancy, if the patients would similar to accept more children. Diastasis recti are very frequent in pregnancy. It may persist in postpartum menses. A high recurrence adventure is expected in patients with rectus diastasis. This risk is especially high subsequently suture repairs. Mesh repairs should be considered in this situation.

Keywords: umbilical hernia, pregnancy, mesh, recurrence, diastasis recti

Introduction

Umbilical hernias are near common in women than men. Pregnancy may cause an umbilical hernia, or render a preexisting one apparent, because of progressively increasing intra-abdominal pressure level. Hernia symptoms nowadays in the second trimester in virtually patients. A hernia may exist diagnosed during first, second, or tertiary pregnancies (i). The incidence of an umbilical hernia in pregnant women has been reported to be every bit depression as 0.08% in a very recent big series (ii). Still, it is possible to meet complicated cases, like a full-term pregnancy in umbilical hernia (3), peritonitis due to skin ulceration (4), or incarcerated pregnant uterus within the hernia rims (5).

A surgical algorithm for a pregnant woman with a hernia is not articulate to date, but newer and better scientific data has been cumulated (1, 2, 6). There is no consensus about the timing of surgery for an umbilical hernia in a woman who is already pregnant or planning a pregnancy. In fact, these two types of cases should be taken into consideration separately. Augustin and Majerovic recommended that hernias that are symptomless or have minimal symptoms—including slight discomfort or hurting—should be examined regularly and cured electively after delivery and uterine involution (7). Recently, it has been shown that watchful waiting, even up to 5 years, appears to be a rubber strategy for ventral hernias in the adult population (8).

Information technology seems to be ameliorate and more understandable to stratify the cases into several scenarios regarding the relationship betwixt umbilical hernia and pregnancy. In fact, discussing the issue on a case-by-example basis may be the all-time approach.

Umbilical Hernia in Women Planning for a Pregnancy

In this situation, we have several concerns.

• Should we repair the hernia before pregnancy?

• Which repair technique should be used?

• Can the repair remain intact during pregnancy?

• Can the repair crusade pain and discomfort during pregnancy?

• How long should the interval betwixt the hernia repair and the pregnancy or birth be?

• What complications tin can happen during pregnancy if we exit the hernia unrepaired?

When the hernia is incarcerated or strangulated at the time of diagnosis, an emergency repair is inevitable. If the hernia is not complicated, merely symptomatic, an elective repair should be proposed. A symptom may be hurting or a large bulging. When the patient has a pocket-sized and asymptomatic hernia, it may exist meliorate to postpone the repair until after she gives birth. Fortunately, about of the cases we see are in this group. During pregnancy, the enlarged uterus pushes the abdominal loops to superior and posterior parts of the intestinal cavity. The size and pushing force of the uterus during the first trimester does not seem enough to push the intestines into a small umbilical opening. The uterus reaches the level of the navel at virtually the 20th–22nd week (nine, x). Thereafter, no close contiguity between umbilical hernia defect and intestinal segments exist (Effigy ​ i). If an incarceration occurs during this time, there is less concern about the surgical intervention, because an operation in the first or second trimester would not carry high risks for preterm labor or other adverse effects (xi).

Changes in the size of the uterus and its relation to the umbilicus by the weeks of pregnancy.

A proper repair technique for an umbilical hernia in a woman planning a pregnancy is likewise a question. It has been shown that mesh repairs provide better outcomes than suture repairs (12). Repairing with merely sutures may bring a recurrence during pregnancy (6). Lappen et al. reported that pregnancy acquired an increased gamble of intestinal hernia recurrence. This information should exist given to the patients who are planning an elective hernia repair before a subsequent gestation (xiii). As the uterus enlarges and intra-intestinal force per unit area rises, even mesh repairs will not make a significant woman immune to hernia recurrence. In concordance, Oma et al. reported that pregnancy after umbilical hernia repair was independently associated with ventral hernia recurrence and mesh use could not lower the risk of recurrence (14). A repair with mesh may restrict the flexibility of the abdominal wall (15) and may cause pain during a subsequent pregnancy (16).

Unfortunately, there is no substantial show about the adequate interval between hernia repair and pregnancy or birth. Surgeons usually propose their patients that a pregnancy is not allowed until afterward the beginning year of the surgical repair. However, no clinical or experimental studies be on this specific instance. At that place is no consensus on if this 1-year interval ends at the beginning of the pregnancy or at the time of nascency. It tin can simply be said that an early pregnancy may cause recurrence.

Every hernia carries a run a risk of incarceration and strangulation. Therefore, patients with an umbilical hernia and planning a gestation should be instructed about this risk. No one tin predict which hernias volition go complicated or when this volition occur. Nonetheless, every surgeon tin can tell his or her patient what the malicious effects of an incarcerated or strangulated hernia are on the mother and the baby. An emergency repair, peculiarly during the first or tertiary trimester, will bring the burden of anesthesia and surgical trauma. It should be recommended that patients with large hernias, including intestinal loops, umbilical hernias with a suspicious history of incarceration, and recurrent umbilical hernias previously repaired with a mesh undergo a definitive repair before planning a pregnancy (Figure ​ two).

Surgical strategy for umbilical hernia in women planning a pregnancy.

Umbilical Hernia Diagnosed during Pregnancy

Again, in that location is no solid recommendation for this type of example. Unfortunately, no randomized controlled trial or prospective assay about hernia repairs in pregnancy existed in the literature (6). Nevertheless, a small asymptomatic or minimally symptomatic umbilical hernia diagnosed in the early phase of a pregnancy can be managed like a hernia in women planning to become significant (Figure ​ 3). Symptomatic umbilical hernias tin emerge in every trimester of pregnancy, and they may get incarcerated or strangulated during pregnancy, although the exact rates of these complications have never been reported. Haskins et al. reviewed the American College of Surgeons National Surgical Quality Improvement Program and found that 126 pregnant women were operated on for umbilical hernia repair in a x-twelvemonth menses (17). Ninety-five percent of the repairs performed with open technique. Incarceration or strangulation existed in one-half of the cases. Surgery was accomplished with minimal 30-day morbidity for the mother and no fetal loss, even in cases of emergencies. Buch diagnosed v female person patients with umbilical hernias occurring during pregnancy at the Mount Sinai Medical Center from September 2004 to July 2006 (i). All patients presented with symptoms in the second trimester with reducible hernias. None of them adult incarceration until an open repair following delivery. This finding supports watchful waiting approach during pregnancy (1).

Surgical strategy for an umbilical hernia diagnosed during pregnancy.

Thirty-one papers, including twenty-iii case reports, were plant in a recent literature search by Jensen et al. (6). Apart from the higher up cases mentioned by Haskins and Buch (one, 17), 7 patients with an umbilical hernia underwent emergency repair during pregnancy. Suture repair was used in all cases, but one. Wai et al. from Yale Academy, reported the unique case, describing an intraperitoneal mesh repair for an irreducible umbilical hernia in a woman in the second trimester (18). In Jensen et al.'s literature review, no postoperative complications were recorded (6). This included Ahmed'due south emergency repair case with spontaneous rupture in a young, multiparous woman in 28th calendar week of pregnancy (19). In that case, there was pare ulceration due to pressure, and the uterus was completely in the hernia sac with gangrenous intestinal loops of approximately 75 cm. The hernia defect was airtight with a suture and the patient gave birth uneventfully 6 weeks later (nineteen).

Oma et al. published the well-nigh recent serial (2). In this series, 17 pregnant women with an umbilical hernia were recorded within xx,714 pregnancies in a single institution. At that place were five pregnant patients with an umbilical hernia. Two women noticed the hernia during previous pregnancies, ane patient in the nowadays gestation, and the other two at 5th week of pregnancy. All patients completed their pregnancies with no hernia complication.

Cesarean Section (C-Department) and Simultaneous Hernia Repair

Hernia repair during C-department is a mutual surgical arroyo. Notwithstanding, these simultaneous surgeries were not well-documented until the 2000s. In 2004, Ochsenbein-Kölble et al. reported the first instance series of C-sections and simultaneous inguinal or umbilical hernia repairs (twenty). Three patients were offered and underwent combined surgery with their informed consent. In one of them, the sign for C-section was the presence of the umbilical hernia itself. The duration of surgery was longer in cases with inguinal hernia repair, only non umbilical hernia repair versus C-section alone. However, Ghnnam et al. reported that the simultaneous umbilical hernia repair and cesarean needed more than time than merely a cesarean (21). They compared 48 patients, who underwent cesarean delivery along with paraumbilical hernia repair versus 100 patients undergoing a C-section. Inpatient periods were similar. Only 2 patients complained of pain at the umbilicus. The control group needed significantly fewer analgesics. Combined surgery was preferred by all patients. 1 hernia recurred (two.8%), following suture repair inside 2 years (21). Mesh repairs were free of recurrence.

Gabriele et al. reported on 28 pregnant women with an inguinal or an umbilical hernia. These patients who underwent simultaneous C-section and hernia repair were compared with 100 patients who only underwent a C-section (22). Combined surgeries took more time for both an umbilical and inguinal hernia than C-section lone. Surgeries were uneventful, and no recurrence developed. The authors concluded that combined surgery is safe and avoids readmissions. Also, Jensen et al. came to a solid conclusion after their literature search that combined hernia repair and C-section is the optimal therapeutic option (6).

Steinemann et al. recently published a retrospective accomplice–control written report (23). Fourteen patients underwent suture repair of umbilical hernia during C-section by using different techniques. External umbilical hernia repair with suture was used in seven cases via a paraumbilical semilunar peel incision subsequently the closure of the Pfannenstiel incision. Internal umbilical hernia repair with suture was used in the other seven patients. Internal suturing required less time than external suturing. Both approaches lengthen the fourth dimension in operation compared to the control group. Unfortunately, 2 recurrences were revealed past ultrasonography in each repair subgroup (28%). The authors recommended mesh repairs in these cases (23).

Interestingly, no patient underwent combined surgery in Haskins et al.'southward almost recent review (17). Yet, the reason for the absence of whatever case with simultaneous C-section and hernia repair are non explained in the paper.

Hernia Repair after Childbirth following an Interval

Some pregnant women with an umbilical hernia exercise not undergo simultaneous hernia repair at the time of C-section. The reason for that may be a patient'due south or surgeon'due south choice.

Oma et al. followed 8 women with an umbilical hernia and no surgical intervention throughout their pregnancy. The umbilical hernia persisted in all these patients who had a clinical re-evaluation postpartum and no spontaneous disappearance of the hernia was recorded. Elective umbilical hernia repairs were done in five patients within v months to three years after delivery (2).

Buch et al. reported five cases that underwent hernia repair in the postpartum period. The patients underwent surgery at postpartum for 8–52 weeks. No complications or recurrence were recorded in postoperative follow-upwards for two–34 weeks. Two out of five women conceived again subsequently hernia repair. The authors ended that pregnant patients presenting with reducible groin or umbilical hernias during pregnancy tin can safely exist managed non-operatively during their pregnancy and undergo surgical repair in the postpartum menstruum (1).

Combined surgery may not increase the hazard of local and systemic complication (twenty), nevertheless, there are still other concerns about simultaneous surgery. Autonomously from maternal and fetal health, in that location are issues regarding the quality and durability of the hernia repair. What would exist the advantages of surgical repair in the postpartum period rather than during C-department? In other words, could a concomitant repair during C-section be less reliable? Permit us take a look at potential hazards of repair during C-section.

Changes in Muscles and Fascial Structures during Pregnancy

The gross structure of rectus abdominis muscle is altered during pregnancy. Significant increases happen in muscle length, separation, and angles of insertions as the pregnancy progressed (24). The functional ability of the intestinal muscles is also altered, and the ability to stabilize the pelvis is decreased. For all abdominal exercises, upper rectus abdominis relative integrated electromyography (EMG) increased while external oblique and lower rectus abdominis relative integrated EMG decreased. Relative EMG for all tested muscles returned to levels seen at xviii weeks and 26 gestations by 18 weeks post-birth. Functional changes found in the rectus abdominis and external and internal obliques. During the immediate mail service-nativity period, separation of the rectus abdominis was resolved past iv weeks post-birth and abdominal muscle inter-relationships returned to early on pregnancy levels past 8 weeks post-nascence. Even so, the ability to stabilize the pelvis remained low at 8 weeks postal service-nativity. This sustained decrement in the ability to stabilize the pelvis at viii weeks post-birth may reflect the poor resolution of abdominal muscle length increases due to pregnancy (24).

In fact, the pregnant of the alterations in abdominal musculus groups for the fate of an umbilical hernia repair is obscure. Whether the changes increment or decrease, hernia recurrence rates is unknown to surgeons. However, the abdominal muscles during pregnancy differ from usual. It may exist better to wait for a while to let the muscles render to their normal beefcake and function before repairing the umbilical hernia. However, there is no recommendation in the literature for the exact time to wait for a repair.

Relaxin. Is it ImWportant?

Another issue that may affect the fate of hernia repair in a pregnant or early on postpartum woman is hormonal changes during gestation. Relaxin is a peptide hormone in the insulin family, secreted by the corpus luteum (25). It is also released from the placenta during pregnancy. It relaxes pelvic ligaments and softens and widens the cervix. Relaxin reduces extracellular matrix (ECM) synthesis and induces collagen degradation (26). In a report on rats, relaxin caused a pregnant reduction in tissue collagen content (27). Relaxin limited collagen production, while stimulating increased collagen degradation (28). Also, Naqvi et al. documented relaxin'south degradative effects on articulation fibrocartilaginous tissue with matrix degradation by metalloproteinases (MMPs) (29).

Collagen, ECM, and MMPs have of import implications for hernia formation. Collagen is the most abundant ECM protein. Collagenase, a member of the MMP family, is the master enzyme in collagen degradation (30).

Considering the studies on the relationship between collagen, ECM, and MMPs, nosotros can recollect any endogenous or exogenous substance that affects these mechanisms may cause recurrence after hernia repair, especially following suture repairs. Therefore, we can say there may be a risk of recurrence when the repair is done and the relaxin level is high. Although there is no evidence for this assumption, at that place are interesting reports in the literature. Information technology has been reported that a higher expression of relaxin receptors within the muscles of the pelvic diaphragm in dogs with a perineal hernia. This may suggest that relaxin plays a role in the pathogenesis of this blazon of hernia past causing muscular atrophy (31). Relaxin may as well be a factor in perineal hernia formation with connective tissue degeneration in dogs (32). In human being beings, in that location is only ane report on the relation betwixt relaxin and intestinal hernias (33). In this study, all the children born in Malmö, Sweden in a v-year period were checked for congenital dislocation of the hip (CDH) and for an inguinal hernia. Hernia was diagnosed five times more than oft in girls with CDH than girls without, and three times in boys with CDH than boys without. The authors stated that relaxin could stimulate collagenase, induce structural changes in the connective tissue, and cause development of both CDH and the hernia (33). This newspaper was published in 1988 and no further data on the subject field has been collected since.

Would Lifting and Conveying Babe Create a Burden on the Repair?

Surgeons generally put patients on a weight lifting restriction after hernia repairs. Fifty-fifty mesh repairs are vulnerable to rises in intra-abdominal pressure in the early postoperative period. Biomechanical studies accept revealed that the tensile strength provided by tissue ingrowth into the mesh reaches approximately 80% after only vi weeks (34). Although at that place is no consensus on weight lifting restriction after hernia repairs, surgeons exercise not desire their patients to lift any weight for the first 2 weeks. Moderate lifting (<10 kg) is allowed after two–4 weeks. Patients are advised to lift over 10 kg simply afterward 8 weeks (35). In fact, carrying and lifting a baby would stay within the limits of the advice. However, a woman who does not have a infant and undergoes umbilical hernia repair would be on a weightlifting brake for a much longer fourth dimension.

Although umbilical hernia repair can be performed after childbirth, there is no need for surgery on modest asymptomatic hernias in the early postpartum period. A 1-yr interval tin give the patient a very shine convalescence, including hormonal stabilization and render to normal torso weight. Surgery can be postponed for a longer time, fifty-fifty later some other pregnancy, if the patient would like to take more children.

Significance of the Concomitant Diastasis Recti (DR)

Diastasis recti is the midline separation of the rectus abdominis muscles. It is an harm, simply not a true hernia, and does not carry a hazard for incarceration. There is a positive correlation between parity and DR (36). The prevalence during pregnancy is about 30–70%. The normal width of the linea alba is 15 mm at the level of xiphoid, 22 mm at the level of iii cm cranial to the umbilicus, and 16 mm at the level of 3 cm caudal to the umbilicus in nulliparous women (37). Mechanical forces and hormonal changes during pregnancy may play a role in the etiology.

The most frequent localization is in the periumbilical region and persistence postpartum is found in about 60% of cases (38). Liaw et al. reported that diastasis may persist in the postpartum period and the abdominal musculus function improved, simply did non return to normal, even after six months (39). Sperstad et al. followed 300 first-time pregnant women from pregnancy until 12 months postpartum. They reported that DR existed in 33.one, 60.0, 45.4, and 32.six% of the women at 21 weeks of pregnancy, and at 6 weeks, 6 months, and 12 months following commitment, respectively (xl). This written report revealed that the gamble for DR was twofold higher in women reporting heavy lifting 20 times a week or more than in women reporting less weight lifting. The authors did not depict the heavy lifting in the text, but we can presume that a postpartum woman lifts her baby many times a week. The weight of a baby is about viii kg at 6 months and 10 kg at 12 months (41). These weights are plenty to raise intra-abdominal pressure equally high as a Valsalva maneuver does (35).

Although RD is not a hernia, it may cause recurrence as a larger hernia following umbilical hernia repairs. In umbilical hernia repairs with sutures, the bites pass through a weak rectus sheet at the region of diastasis. This may cause tears and create push hole defects, consequently resulting in recurrence. Köhler et al. evaluated 231 suture repairs for modest primary umbilical or epigastric hernias (42). Hernia defects were smaller than 2 cm. Patients with rectus diastasis developed hernia recurrence at a significantly increased rate. The authors hypothesized that thin and stretched rectus sheath is a risk factor for recurrence. They recommended mesh repair for umbilical hernia patients with rectus diastasis. Although Emanuelsson et al.'s recent prospective randomized study showed that two-row suture plication with delayed absorbable cloth provided similarly skilful results with retromuscular lightweight polypropylene mesh without an increase in recurrence charge per unit in treatment of RD (43), mesh use remains a improve option for patients with concomitant umbilical hernia and RD (42). In add-on, one tin assume that a recurrence still may develop from the sites of mesh fixation if there is a vulnerable linea alba due to RD. Therefore, information technology is better to use no fixation in case of stiff restoration of the line alba or to apply an autraumatic mesh fixation like glues (e.m., fibrin) (44) or a self-gripping mesh in retromuscular mesh repairs (45).

Conclusion

At that place is no consensus nearly the timing of surgery for an umbilical hernia in a adult female who is already meaning or planning a pregnancy. If the hernia is incarcerated or strangulated at the fourth dimension of diagnosis, an emergency repair is inevitable. If the hernia is not complicated, just symptomatic, an elective repair should be proposed. If the hernia is repaired past suture, the risk of recurrence is high during pregnancy. Repair with a mesh may restrict the flexibility of the intestinal wall and may cause pain during a subsequent pregnancy. When the patient has a small and asymptomatic hernia, information technology may exist improve to postpone the repair until she gives birth.

Umbilical hernia repair during pregnancy tin be performed with minimal morbidity to the mother and no fetal loss even in emergency cases. If a modest hernia becomes larger and symptomatic, the second trimester is a proper flow for surgery. Umbilical hernias can exist repaired following childbirth or at the time of C-section. Patient satisfaction is high for combined C-department and hernia repair. However, a high recurrence rate is expected.

Constituent repair after childbirth is well-documented. It is possible as early equally the postpartum at 8 weeks. There is no need for surgery for small asymptomatic hernias in the early postpartum period. A 1-yr interval can give the patient a very smoothen convalescence, including hormonal stabilization and return to normal body weight. Surgery tin be postponed for a longer time, even after another pregnancy, if the patient would like to take more children.

Diastasis recti are very frequent during pregnancy. It may persist in the postpartum period. Patients with rectus diastasis may develop umbilical hernia recurrence after repair. This gamble is especially loftier following suture repairs. Mesh repairs should exist considered in this situation (Table ​ 1).

Tabular array one

Pros and cons for specific conditions in the relation of umbilical hernia and pregnancy.

	Suture repair	Mesh repair
Umbilical hernia in woman planning a new infant	High risk of recurrence	Pain in third trimester	Repair is postponed until birth for small and asymptomatic hernias
Umbilical hernia diagnosed during pregnancy	High chance of recurrence	Infection risk for meaning adult female especially in emergency repairs	Repair is postponed until birth for pocket-size and asymptomatic hernias
Cesarean section and simultaneous hernia repair	Easier	Requires separate incision	Patient satisfaction tin exist loftier
	May be performed without divide incision	Lengthen operative fourth dimension	Patient'southward preference should be asked
	Loftier hazard of recurrence	Infection adventure in puerperium
Hernia repair after childbirth	No exact recommendation for timing	No exact recommendation for timing	A 1-yr interval may be recommended
			Repair can be postponed for another pregnancy
Concomitant diastasis recti	High risk of recurrence	Recommended	Patient should be informed about diastasis

Author Contributions

The author confirms beingness the sole contributor of this work and canonical information technology for publication.

Disharmonize of Involvement Argument

The author declares that the enquiry was conducted in the absenteeism of whatsoever commercial or financial relationships that could be construed as a potential conflict of interest.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796887/

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