Umbilical hernias are a frequent abdominal wall defect where intra-abdominal contents protrude through a weakness at or near the umbilicus. In adults, these hernias are usually acquired and often associated with factors that increase intra-abdominal pressure, such as obesity, pregnancy, chronic cough, or straining. While surgical repair is typically recommended for symptomatic or enlarging hernias, small umbilical hernias (<2 cm) in selected patients can be repaired safely without the use of mesh. Laparoscopic techniques have made even these non-mesh repairs precise, safe, and minimally invasive, with rapid recovery and excellent outcomes.

Introduction

Hernia repair has traditionally involved either open suture closure or mesh reinforcement. Mesh repair is preferred for larger defects due to reduced recurrence rates, but for small defects, primary suture repair remains an effective option, particularly when:

The defect size is less than 2 cm.

Patients have good tissue quality.

There are concerns about mesh-related complications (infection, chronic pain, cost).

Laparoscopic repair without mesh combines the benefits of minimal access surgery—such as smaller incisions, faster recovery, and better visualization—with tissue preservation, avoiding the need for synthetic materials.

Indications

Laparoscopic primary repair of small umbilical hernia is indicated in:

Small defects (<2 cm) with minimal risk of recurrence.

Symptomatic hernias, such as pain or discomfort during activity.

Cosmetic concerns, where minimal scarring is desired.

Patients with contraindications to mesh, including allergy or previous mesh complications.

It is not recommended for large defects (>2 cm), recurrent hernias, or in patients with poor tissue quality, as recurrence risk increases significantly.

Preoperative Evaluation

Careful preoperative preparation ensures optimal outcomes:

Clinical examination to assess defect size, reducibility, and abdominal wall integrity.

Imaging (ultrasound or CT) for atypical presentations or obese patients to delineate anatomy.

Optimization of comorbidities such as diabetes, hypertension, or chronic cough.

Routine laboratory tests and anesthesia assessment.

Patient counseling regarding the procedure, its benefits, limitations, and potential recurrence.

Prophylactic antibiotics are administered before surgery to reduce infection risk.

Surgical Technique

Anesthesia and Positioning

The procedure is performed under general anesthesia.

The patient is placed in a supine position with slight Trendelenburg tilt to improve exposure of the umbilical region.

Port Placement

Pneumoperitoneum is established using a Veress needle or open technique.

A 10 mm camera port is usually placed away from the umbilicus to prevent injury to the hernia sac.

One or two 5 mm working ports are inserted laterally for instrument manipulation.

Reduction of Hernia Contents

The hernia sac is carefully visualized.

Omentum or small bowel loops are gently reduced back into the abdominal cavity.

Adhesiolysis is performed if there are adhesions to the sac wall.

Primary Closure of the Defect

The fascial defect is closed intracorporeally using non-absorbable sutures (e.g., polypropylene).

Suturing may be interrupted or continuous, ensuring tension-free closure.

Proper bite depth and spacing are essential to minimize recurrence.

Completion

Hemostasis is checked, and pneumoperitoneum is released.

Ports are removed, and skin incisions are closed with absorbable sutures or skin glue.

Postoperative Care

Early ambulation is encouraged to prevent thromboembolic complications.

Oral intake can be resumed within a few hours.

Pain is generally mild and managed with oral analgesics.

Hospital stay is typically 24 hours or less.

Patients are advised to avoid heavy lifting or strenuous activity for 4–6 weeks to allow fascial healing.

Advantages

Laparoscopic repair of small umbilical hernia without mesh offers several benefits:

Minimally invasive, resulting in smaller scars and less pain.

No foreign material, avoiding mesh-related complications like infection or chronic pain.

Faster recovery, allowing early return to work and daily activities.

Lower cost compared to mesh repair.

Direct visualization ensures precise defect closure and assessment of surrounding tissue.

Outcomes and Complications

Recurrence rates are low for defects less than 2 cm with proper suture technique.

Complications are rare but may include:

Seroma or hematoma formation

Infection at port or suture sites

Rare bowel injury during dissection

Recurrence if closure is under tension or sutures fail

Careful patient selection and meticulous surgical technique are key to minimizing complications.

Conclusion

Laparoscopic repair of small umbilical hernia without mesh is a safe, effective, and minimally invasive procedure for appropriately selected patients. It avoids the potential complications of mesh, provides excellent cosmetic results, and allows for rapid postoperative recovery. With proper patient evaluation, careful operative technique, and attentive postoperative care, this approach provides durable repair, making it an excellent option for small, uncomplicated umbilical hernias in adults.