Umbilical Hernia
An umbilical hernia occurs when tissue from inside the abdomen pushes through a defect in the abdominal wall at or immediately around the navel. The umbilicus is a natural weak point, since it is the site where the umbilical cord passed through the abdominal wall before birth and where that opening subsequently closed. In infants, umbilical hernias are common, usually painless, and the large majority close on their own without any treatment during the first few years of life. In adults they behave differently: they are acquired rather than congenital, do not resolve spontaneously, tend to enlarge over time, and carry a meaningful risk of tissue becoming trapped. Diagnosis is usually made on physical examination, with ultrasound or CT used when the examination is unclear or a complication is suspected.
What is it?
Before birth, the umbilical cord passes through an opening in the developing abdominal wall, carrying the vessels that connect the fetus to the placenta. After birth, the cord separates and this opening—the umbilical ring—normally closes as the surrounding muscle and fascial layers grow together. The umbilicus remains a site where the abdominal wall has no muscle, only layers of fascia and skin, which makes it an inherent structural weak point for the rest of life.
An umbilical hernia occurs when abdominal contents push through a defect at this site. The contents are most often preperitoneal fat or a portion of the omentum—the fatty apron that hangs from the stomach and transverse colon—and less often a loop of small intestine. The bulge is covered by peritoneum, fascia, and skin, and its prominence varies with position and abdominal pressure.
A closely related term is paraumbilical hernia, describing a defect immediately adjacent to rather than directly through the umbilical ring. In adults, most hernias in this region are technically paraumbilical, and the terms are frequently used interchangeably in practice. The distinction rarely changes management.
Infant and adult umbilical hernias are best understood as different conditions that share a location.
In infants, the hernia reflects incomplete closure of the umbilical ring after birth. It is therefore congenital in origin. It is typically noticed in the first weeks of life as a soft bulge that becomes prominent when the baby cries, strains, or coughs, and flattens easily when the baby is calm or lying down. It is almost always painless, and the crying that makes it protrude is generally the cause of the bulging rather than a sign that the hernia hurts—a point that reassures many parents.
The natural history in infants is favorable and is the central fact for families. The great majority of infant umbilical hernias close spontaneously as the abdominal wall develops, most within the first one to two years and the large bulk by age four to five. Smaller defects close more reliably and more quickly than larger ones. Complications are uncommon in this age group, and incarceration is rare, in contrast to inguinal hernias in infants, where incarceration risk is meaningfully higher and prompt repair is standard.
Certain groups have higher rates. Umbilical hernias are considerably more common in premature and low birth weight infants and in infants of African ancestry. They are also associated with several conditions including congenital hypothyroidism, Beckwith-Wiedemann syndrome, Down syndrome, and mucopolysaccharidoses, though the great majority of infant umbilical hernias occur in otherwise healthy children with no underlying disorder.
In adults, umbilical hernias are acquired. The umbilical fascia weakens or stretches under sustained pressure, and a defect develops or a previously closed one reopens. Unlike in infants, adult umbilical hernias do not close spontaneously. They tend to enlarge gradually, and the contents that pass through them can become trapped.
Risk factors in adults include obesity, which is the most significant single contributor; pregnancy, particularly multiple pregnancies, which stretches the abdominal wall; ascites from cirrhosis or other causes, which produces sustained elevated pressure; chronic cough; chronic constipation with straining; heavy lifting; peritoneal dialysis; prior abdominal surgery; and connective tissue disorders. Diastasis recti—separation of the vertical abdominal muscles, common after pregnancy—frequently coexists and can make the umbilical region appear to bulge even where the hernia defect itself is small.
The terminology describing a hernia’s status is worth understanding, as it appears in reports and consultations and determines urgency.
A reducible hernia is one whose contents can be pushed back into the abdomen, spontaneously on lying down or with gentle pressure. This is the usual state and is not an emergency.
An incarcerated hernia is one whose contents have become trapped and can no longer be reduced. Incarceration does not by itself mean the blood supply is compromised, but it carries a risk of progression and of bowel obstruction if intestine is involved.
A strangulated hernia is one in which blood supply to the trapped tissue has been cut off, leading to ischemia and, without prompt treatment, tissue death. This is a surgical emergency.
Because adult umbilical hernia defects are often small and firm-edged relative to the volume of tissue passing through them, they have a relatively higher tendency to trap contents than their modest size might suggest. This is a common reason surgeons recommend repair of a symptomatic small umbilical hernia rather than continued observation.
Symptoms vary widely. Many adult umbilical hernias are noticed simply as a bulge, sometimes discovered by the patient and sometimes found incidentally on imaging performed for another reason. Where symptoms occur, patients typically describe an aching, dragging, or pressure sensation at the navel, worse after prolonged standing, lifting, or at the end of the day, and relieved by lying down. Larger hernias can cause skin thinning, irritation, or ulceration over the bulge. Pain that is severe, constant, or rapidly worsening is not typical of an uncomplicated hernia.
Signs suggesting incarceration or strangulation include a bulge that has become firm, tender, and irreducible; increasing or severe pain; redness or discoloration of the overlying skin; nausea and vomiting; abdominal distension; and inability to pass gas or stool. These require emergency evaluation.
A specific and serious situation arises in patients with cirrhosis and ascites. Umbilical hernias are common in this group because of the sustained pressure of ascitic fluid combined with abdominal wall thinning and malnutrition. The skin over the hernia can become thin enough to break down and rupture, leaking ascitic fluid—a condition sometimes called Flood syndrome—which carries a high risk of infection and is a medical emergency requiring immediate care.
Diagnosis is primarily clinical.
Physical examination identifies most umbilical hernias. The examiner assesses the size of the defect by palpating its edges, determines whether the contents reduce, and checks for tenderness, skin changes, and signs of incarceration, often with the patient standing and performing a Valsalva maneuver to make the hernia more apparent.
Ultrasound is the usual first-line imaging test when examination is equivocal. It readily demonstrates the fascial defect and its contents, can be performed dynamically with straining, and distinguishes a hernia from other umbilical lesions such as a lipoma, cyst, granuloma, or urachal remnant.
CT of the abdomen and pelvis provides comprehensive anatomical assessment, including precise defect size, contents of the sac, the presence of multiple defects, the state of the surrounding abdominal wall, and the condition of any bowel within the hernia. It is used for large, recurrent, or complex hernias, for surgical planning, and when incarceration, strangulation, or obstruction is suspected. Small umbilical hernias are also identified incidentally on CT with some frequency in patients scanned for unrelated reasons.
MRI is an alternative where detailed soft tissue characterization is needed, and is used less commonly for this indication.
Blood tests do not establish the diagnosis but assess for infection, ischemia, and, in patients with liver disease, the severity of underlying dysfunction relevant to surgical planning.
The differential diagnosis includes epigastric hernia, incisional hernia at a prior periumbilical port site, diastasis recti, lipoma, sebaceous or epidermoid cyst, umbilical granuloma in infants, urachal remnant or cyst, and—rarely but importantly—an umbilical metastatic nodule from an intra-abdominal malignancy, historically known as a Sister Mary Joseph nodule, which is firm, does not reduce, and warrants prompt evaluation.
Important to Know
Management diverges sharply between infants and adults, and understanding which situation applies is the key to making sense of the advice given. Care is typically coordinated by pediatricians and pediatric surgeons in children, and by primary care clinicians and general surgeons in adults.
In infants, observation is standard. Most defects close spontaneously, complications are uncommon, and intervention in the first years of life is rarely warranted. Repair is typically considered from around age four to five for hernias that have not closed, and earlier for hernias that are very large, that are symptomatic, that have incarcerated, or where the defect is enlarging rather than shrinking. Some surgeons individualize timing based on defect size, since larger defects are less likely to close on their own.
Taping the hernia, strapping a coin over it, and using abdominal binders are traditional practices that do not accelerate closure and can cause skin breakdown and irritation. These are not recommended. Parents can be reassured that the hernia bulging when the baby cries is expected and does not indicate pain or harm.
In adults, spontaneous closure does not occur and repair is the only definitive treatment. Elective repair is generally recommended for hernias that cause symptoms, are enlarging, or have skin changes, and is often recommended even for relatively small defects because of their tendency to trap contents. Truly asymptomatic small hernias in patients at high surgical risk may reasonably be observed, but this is an individualized decision rather than a general rule, and the evidence base for watchful waiting is weaker here than it is for inguinal hernias.
Open repair is the most common approach for small and moderate defects. Very small defects may be closed with sutures alone in selected cases, but mesh reinforcement is recommended for most adult repairs—including many defects previously considered small enough for suture repair—because randomized evidence shows it substantially reduces recurrence. Current European and international guidance supports mesh use down to quite small defect sizes.
Minimally invasive repair, laparoscopic or robotic, is used for larger defects, recurrent hernias, patients with obesity, and cases with multiple abdominal wall defects. It places mesh behind the defect and can address several defects through the same access, at the cost of requiring general anesthesia.
Most repairs are performed as day surgery. Recovery typically allows return to light activity within days and most normal activity within two to four weeks, with heavier lifting resumed later according to the surgeon’s guidance.
Weight management before elective repair is frequently recommended, since obesity meaningfully increases both surgical complications and the risk of recurrence. Smoking cessation before surgery is similarly important, as smoking impairs wound healing and increases recurrence. Where possible, addressing chronic cough and constipation before repair reduces early stress on the repair.
Repair in patients with cirrhosis and ascites requires specialized planning and is not a routine operation. Uncontrolled ascites markedly increases the risk of recurrence and complications, so medical optimization—diuretics, dietary sodium restriction, and in some cases paracentesis or a TIPS procedure—generally precedes elective repair. Emergency repair in this setting carries considerably higher risk, which is an argument for planned rather than deferred management in patients with symptomatic hernias and liver disease. Skin breakdown with leaking ascitic fluid requires immediate care.
Repair during pregnancy is generally deferred unless the hernia incarcerates, since the abdominal wall changes throughout pregnancy and recurrence risk is higher if repaired before delivery. Patients planning further pregnancies are often advised to complete their family before elective repair for the same reason, though this is individualized against symptom severity. Elective repair is sometimes coordinated with a planned cesarean delivery in selected cases.
Recurrence after repair occurs in a minority of patients and is more likely with suture-only repair, obesity, smoking, uncontrolled ascites, diabetes, and wound infection. Other complications include seroma, hematoma, wound infection, and, uncommonly, injury to bowel or persistent pain.
Prevention is limited but not absent. Maintaining a healthy weight, treating chronic cough, stopping smoking, managing constipation to avoid straining, and controlling ascites where present all reduce sustained pressure on the abdominal wall. None of these eliminates risk in someone with an underlying predisposition.
Care is typically coordinated by pediatrics or primary care with general or pediatric surgery, and with hepatology involvement when liver disease is present. Imaging and clinical findings are interpreted alongside the patient’s symptoms, examination, and broader clinical context rather than in isolation.
Patient and caregiver education plays an important role. For families, understanding that most infant umbilical hernias close on their own, that bulging with crying is expected, that taping and coins are ineffective, and that surgery is usually deferred for years contributes to appropriate care and avoids unnecessary intervention. For adults, understanding that the hernia will not close on its own, that elective repair is safer than emergency repair, and which symptoms mean a hernia has become trapped is equally important.
Red flag symptoms include a bulge at the navel that has become firm, tender, and cannot be pushed back in; severe or rapidly worsening pain at the site; redness, discoloration, warmth, or skin breakdown over the bulge; leakage of fluid from the skin over the hernia, particularly in someone with liver disease; nausea and vomiting; abdominal distension with inability to pass gas or stool; fever; and signs of systemic illness such as rapid heart rate, low blood pressure, or confusion. These warrant immediate emergency evaluation, as they may indicate incarceration, strangulation, bowel obstruction, bowel ischemia, perforation, or infection.