Surgical Science, 2011, 2, 155-158
doi:10.4236/ss.2011.23033 Published Online May 2011 (
Copyright © 2011 SciRes. SS
A Long-Term Follow-Up: Suture Versus Mesh Repair for
Adult Umbilical Hernia in Saudi Patients. A Single Center
Prospective Study
Ahmed M. Kensarah
Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Received February 23, 2011; revised March 12, 2011; accepted April 3, 2011
Objective: To report results of mesh repair vs. the modified Mayo’s suture overlap in the surgical treatment
of adult umbilical and paraumbilcal hernias in our medical center. Patients & Methods: The study is a Saudi
single center single surgeon trial composed of sixty two patients. It was performed in the Surgical Depart-
ment of King Abdul-Aziz University Hospital at Jeddah. The patients were randomly assigned into 2 groups.
Group A patients underwent onlay mesh repair while modified Mayo’s repair was used in group B patients.
Median follow-up was 28 months, and data were collected regarding size of hernia, type of the operation,
complications, length of follow-up and the recurrence rate. Chi square test was used to compare results at
0.05 levels. Results: Complication was reported in 17% in group A and 8% in group B .There was no dif-
ference in scar pain, cosmetic result, and overall patient satisfaction between both groups. The recurrence
rate was 10% for mesh repair and 18.8% for suture repair. Conclusions: Despite higher complication rate,
mesh repair is superior to suture repair due to lower recurrence rate. Suture repair still has a place under cer-
tain circumstances, also it is simple less costly and has insignificant infection rate.
Keywords: Umbilical Hernia; Paraumbilical; Mesh Repair; Suture Repair
1. Introduction
Umbilical and para-umbilical hernias are common prob-
lems in the Kingdom of Saudi Arabia. Obesity and mul-
tiparity are important predisposing factors not only for
primary, but also for recurrent cases [1-4]. About 10% of
umbilical hernias in adu lts have a congenital etio logy but
manifest later in adulthood. The rest are acquired and
contribute to many abdominal e mergencies with substan-
tial morbidity and mortality. Multiparity, increased ab-
dominal pressure and a single midline decussation are
other predisposing causes [5,6]. The choice of the appro-
priate surgical procedure is still subject to debate. The
simplest and most established is the modified Mayo„s
overlap using non absorbable material without a mesh or
a drain [7,8]. The use of mesh in umbilical hernia repair
resulted in reduction of short term recurrence rates [9],
but the risk of infection increases with prosthesis use.
The use of antimicrobial meshes reduced postoperative
infection risks, as has the adoption of the laparoscopic
approach [10]. Umbilical hernia repair may give rise to
persistent abdominal pain and unsatisfactory esthetic
results [11]. In this study we examined the long term
outcomes of suture versu s mesh repair for adult umbili-
cal hernia in patients electively treated in our medical
center in Jeddah.
2. Patients and Methods
This study was approved by the ethics committee of
King Abdul-Aziz University Hospital, and all patients
provided informed consents to participate in this study.
From January 2006 through May 2009, 62 consecutive
patients were enrolled. Their demographic information
as well as the predisposing facto rs is shown in Tab le 1.
The indication for intervention was cumbersome or un-
sightly hernia and/or the occurrence of complications.
Exclusion criteria were previous recurrence, obesity
(BMI of 30 and above) diabetes mellitus, anti-coagula-
tion and steroid therapy. Patients were randomly chosen
to undergo open onlay mesh repair (Group A) or the
classical Mayo’s suture overlap repair (Group B). For
the mesh group closure of the hernia defect with 00
rolene followed by an onlay polypropylene mesh, p
Table 1. Clinical, operative and postoperative data.
Item Mesh Group A
(n = 30) Overlap Group B
(n = 32)
(1) Age (years) 17-76 (mean 55)
(2) Gender Males 46 Females 16
(3) Predisposing Factors (B ot h G roups)
Item No. %
Ch. Cough
Previous surgery
Lifting Heavy Objects
(4) Mean Hernia Size (cm) 6 5
(5) Hospital Stay (Average in Days) 5.6 4 .6
(6) Percentage of PO Complications (n = 29) 17% 8%
Wound infection
Seroma formation
Chest infection
(7) Period of f ollow up (Mean in months) 28 28
(8) Recurrence (Total = 9 cases) 3 6
while for the suture overlap group the classical steps
were applied with a minor personal modification aiming
to reduce postoperative patient inconvenience. The
modification entails placement of the interrupted mat-
tress stitches so that the knots lie between the two over-
lapping layers and not under the skin. The same staff
surgeon operated on all of the patients and twenty six of
them (42%) were treated in our ambulatory surgical cen-
ter and discharged on the same day of surgery. Com-
parison between the 2 groups was by the Chi-Square test
(x2) at 5% level of significance. Follow-up was per-
formed during return visits, by telephone calls, and by
questionnaire surveys sent by ordinary or e-mail.
3. Results
The age range was 17 - 76 years (mean 42.7, SD 12) and
male to female ratio was 2.8:1 (n = 46 and 16 respec-
tively). Five patients had their hernia since childhood and
in 6 patients the hernia developed following laparoscopic
cholecystectomy. In the remaining 51 patients (>82%)
the hernia developed following different predisposing
factors (Table 1), relative obesity and multiparity being
the commonest (59% and 30% respectively). Other
causes included chronic cough (19%), incisional hernia
(14.5%), prostatic disease (11%), ascites (4.8%), malig-
nant diseases (3%), and work entailing lifting heavy ob-
jects (3%). Within days after surgery th e overall compli-
cation rate was 29% including: superficial woun d infec-
tion (11.3%), seroma formation (8%), chest infection
(4.8%) wound hematoma (3.2%) and deep vein throm-
bosis with a non-fatal pulmonary embolism in 1.6%.
The Average hospital stay ranged from 2 to 17 days
(mean 4, SD 3.78) and the median follow up period was
28 months, the shortest being 12 months during which
there were 9 recurrences(>14.5%). Overall patient sat-
isfaction was built using data collected from a
self-administered questionnaire. Its quality was ensured
by a research fellow, and indicated by 4 proposed items
having the greatest concern by the patients, viz; degree
of late pain (by visual analog scale), subjective umbili-
cal region discomfort, scar quality, and the final cos-
metic result. Surveys were administered during the re-
turn visit or mailed to the patients on the 100th day ap-
proximately following surgery. Chi square test did not
show significant d ifference between the two sets at 0.05
levels. Two patients declined follow up, and contact
was lost with 5 patients, while seven others died of
causes that are unrelated to the surgery, before com-
pleting the follow-up pe ri o d.
4. Discussion
According to local statistics, umbilical hernia accounts
for about 12% of all hernias in adults. Its repair by the
trendy onlay flat mesh is simple, safe and effective with
Copyright © 2011 SciRes. SS
acceptable recurrence rate and a short learning curve [12].
The classical modified Mayo's overlap is less costly and
easier to perform. It is reported to have a higher recur-
rence potential (40% by Halm in 2005) [13]. The lower
recurrence figures reported in some studies are likely due
to underestimation or failure to adopt long term follow
up [11]. In this single surgeon single institution study,
the median follow-up period was 28 months (range 4 -
151) and data were built up by structured interview in
addition to clinical examination, in accordance with the
recommendations of previously published studies [14].
In our series of 62 cases, 9 recurrences were reported
(14.5%) 6 of them are in the suture overlap group and 3
in the onlay mesh group. Though it exceeds the figures
of Kingsnorth et al. [15] at the UK (as low as 3.4%), the
finding of an approximate double recurrence rate in the
suture overlap compared to onlay mesh repair may be
due the longer follow up period that we undertook with
our patients. Ho wever, these findings do not mitig ate the
use of the overlap repair in selected indications. In a re-
cent study by Müller-Riemenschneider et al. in 2007 [16],
much lower recurrence rates and shorter hospital stay
were observed, and if tension is avoided the procedure is
less painful and more convenient to the patient [11]. In
contrast, Aslani (2010) and Arroyo (2001) reported
fewer recurrences with mesh compared to suture repair
for small umbilical hernias [17,18]. In the present work,
as well as in previous studies, there was no difference in
scar quality or scar pain b etween mesh and suture repair.
Reduced mobility of the anterior abdominal wall that
was reported with mesh repair (in up to 50% of cases)
may be a significant drawback of this surgery [19].
Weight loss in obese patien ts may help to improve the
operative conditions and perhaps may reduce the chances
for recurrence, though it may not change the risk of pe-
rioperative complications [20]. Expectation of weight
loss accomplishment and the time necessary for that is to
be balanced with the clinical indication, and a hernia
repair simultaneous with gastric bypass or banding may
be recommended [21,23,24]. Our results are limited by
the small number of patients, and also th e loss of contact
with patients or their death from other causes.
In summary, our resu lts support the view of Halm and
his colleagues for the need to re-evaluate the present
clinical guidelines on mesh placement in umbilical her-
nia repair [13], and under certain circumstances, suture
overlap may be preferable.
5. Conclusions
It may be mandatory to re-evaluate present clinical
guidelines on umbilical hernia repair, and a meshless
suture repair should not be totally disqualified. More
study is needed to understand the effect of such factors
like obesity, hernia size, smoking, diabetes and hyper-
lipidemia in this respect [25].
6. Conflict of Interest
This is a single author single center study. No conflict
of interest with other people or organizations. Study
was neither done un der grant no r fu n di ng.
7. Acknowledgements
From Cairo University, the author is grateful to both
Professor Dr. G. M. SAIED (Faculty of Medicine) and
Professor Dr. Azza Moustafa (Faculty of Engineering)
for statistical assistance.
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