Paraumbilical Hernia: Why a Bulge Near the Navel Needs Special Attention

By Prof. Dr. Zahid Mahmood — General, Laparoscopic & Laser Surgeon, Lahore

A bulge appearing near the navel is one of the most common reasons patients come to see me, and it’s a type of hernia that deserves its own explanation, because it behaves a little differently from hernias elsewhere in the abdomen. The medical terms “umbilical” and “paraumbilical” hernia are often used almost interchangeably today, but understanding what’s actually happening at the belly button — and why these particular hernias carry a somewhat higher risk of becoming a genuine emergency — helps explain why I take them seriously even when they start out small.

What a paraumbilical hernia actually is

Every one of us is born with a natural weak point in the abdominal wall exactly where the umbilical cord once passed through — the navel. In most people this closes firmly within the first week or so of life. A true umbilical hernia occurs when this original opening doesn’t fully close, or reopens later. A paraumbilical hernia, strictly speaking, occurs through a separate weakness in the midline tissue immediately next to the navel — most often just above it — rather than through the belly button opening itself. In everyday practice, and under current medical guidelines, both are now generally just grouped together and called “umbilical hernia,” since the underlying problem, appearance, and treatment are essentially the same.

Two very different situations: children versus adults

This is genuinely one condition that behaves very differently depending on age, and I want to be clear about that distinction because it changes the advice completely.

In infants, umbilical hernias are extremely common — appearing in as many as 1 in 10 babies, more often in those born prematurely. They typically show up as a soft bulge at the navel within the first few weeks of life, becoming more obvious when the baby cries, coughs, or strains, and taking on a characteristic cone-like shape. The reassuring news for parents is that the great majority of these — around 95% — close on their own by the time the child is two years old, without any treatment beyond patience, and serious complications like obstruction or strangulation are extremely rare in this age group. My advice to parents is genuinely simple: if your infant has a small, soft, symptomless umbilical bulge, this is not something to panic about. If it’s still present and significant beyond age two, that’s the point at which a straightforward surgical repair becomes appropriate — a short, well-tolerated procedure through a small, neatly hidden curved incision just below the navel, with the defect closed and the child typically going home the same day.

In adults, the picture is quite different. Here, the hernia typically develops later in life because of stretching and thinning of the strong midline tissue that runs down the centre of the abdomen — this can be caused by obesity, pregnancy, or long-standing liver disease with fluid build-up in the abdomen (ascites). Adult umbilical hernias are seen more often in women than men, frequently in overweight individuals or in women after childbirth, and they present as a bulge that’s often slightly off to one side of the navel, giving the belly button a crescent-shaped, lopsided appearance rather than a perfectly round one.

Don’t confuse it with a stretched tummy muscle

A related but genuinely different condition, called rectus divarication (or diastasis recti), is often mistaken for a hernia, and it’s worth understanding the difference. This is a widening and thinning of the midline tissue itself — the two strap-like muscles running down the front of the abdomen separate further apart than normal, usually as a result of pregnancy or weight gain — without an actual hole or defect for anything to push through. It typically causes a long, vertical bulge or ridge down the middle of the abdomen when straining, rather than a discrete, localised lump at one specific point. Divarication doesn’t carry the strangulation risk of a true hernia and is managed differently — often with targeted core-strengthening exercise rather than surgery, though the two conditions can genuinely coexist in the same patient, particularly after pregnancy, which is exactly why a proper examination matters rather than assuming every midline bulge is the same thing.

Why this type of hernia deserves particular caution

This is the point I most want readers to understand. In an adult, the opening through which a paraumbilical hernia pushes is typically quite narrow compared to the size of the bulge that can develop through it. This narrow-neck-to-sac-size mismatch means these hernias are particularly prone to becoming stuck (irreducible), obstructed, or strangulated — where the blood supply to trapped bowel or fat is cut off — compared to some other types of hernia of a similar size. Most patients experience pain from tension in the tissue, or intermittent symptoms suggesting the bowel is being partially obstructed as it gets briefly caught in the narrow opening. In larger, longstanding hernias, the overlying skin can become very thin and occasionally irritated, though the skin actually splitting open is very rare.

When surgery is needed — and when it can wait

Because of this genuine risk of strangulation, I generally advise surgery for adult umbilical hernias that contain bowel, rather than watching and waiting. Small hernias that are truly symptomless and contain only a little fat can reasonably be left alone for a period, but patients should understand they often continue to slowly enlarge over time, and may need surgery eventually regardless — so “leaving it” is a reasonable short-term choice for a mild case, not a guarantee of never needing treatment.

Special situations that change the approach

Two particular groups of patients need individualised thinking rather than the standard approach, and I want to be upfront about both.

Pregnancy and the postpartum period. Many women develop or notice an umbilical hernia during pregnancy or shortly after delivery, often alongside a related stretching of the abdominal muscles down the midline. My strong advice here is to avoid hernia surgery before or during a pregnancy wherever possible. In the months after delivery, focused abdominal exercise, weight normalisation, and rebuilding core muscle tone often lead to significant, sometimes complete, improvement — so a genuine period of watchful waiting after childbirth, rather than rushing to the operating theatre, is usually the right approach, with surgery reserved for hernias that remain problematic once the body has had a proper chance to recover.

Patients with liver disease and fluid in the abdomen (cirrhosis with ascites). This is a situation I approach with real caution. Patients with significant liver disease face a considerably higher risk of complications from hernia surgery than patients with normal liver function, and this risk rises further with more advanced liver disease. Careful patient selection, working closely with a liver specialist, and specific surgical techniques to reduce the risk of fluid leakage from the repair afterward are all essential in this group — this is very much a case where the decision to operate, and when, needs individualised discussion rather than a standard, one-size-fits-all recommendation.

How the repair is actually done

The right surgical technique depends mainly on the size of the defect.

For very small openings — under about 1 cm — a straightforward stitched repair, without any mesh, is often sufficient, provided the tissue can be brought together without excessive tension.

For defects up to around 2 cm, a well-established technique (sometimes called the “waistcoat-over-trousers” repair) overlaps the two edges of the strong midline tissue like the front of a double-breasted jacket, reinforcing the repair with the body’s own tissue. This remains a popular option for hernias in this size range, though even here, current evidence increasingly favours reinforcing the repair with a small piece of surgical mesh, since this measurably reduces the chance of the hernia coming back.

For anything larger than 2 cm, mesh reinforcement is now considered standard, because the recurrence rate without it is simply too high to justify skipping it. This can be performed as open surgery through a small incision around the navel, or laparoscopically (keyhole surgery), where a mesh is placed on the inside of the abdominal wall through a few small incisions placed away from the hernia itself. The keyhole approach is particularly useful for larger hernias, in patients who are overweight, or where there’s an additional, more generalised stretching of the abdominal wall alongside the hernia itself — it tends to mean fewer wound-related problems afterward, though it does involve mesh placed inside the abdominal cavity, which carries its own specific, if uncommon, considerations that I discuss individually with each patient.

When it becomes a genuine emergency

Because of the narrow-neck problem described earlier, umbilical and paraumbilical hernias are a relatively common source of true surgical emergencies — bowel or fatty tissue becoming trapped, obstructed, or losing its blood supply. This can happen even in a hernia that has previously felt soft and unremarkable, and delay in seeking treatment at this stage risks tissue death requiring more extensive surgery. In this emergency situation, if strangulated tissue is found, I generally avoid using mesh at the time of the emergency operation, since the infection risk in already-compromised tissue is too high — the priority becomes safely dealing with the trapped, damaged tissue, with a more definitive, mesh-reinforced repair planned for later if it’s still needed once everything has settled and healed.

A related hernia worth knowing about: epigastric hernia

A little higher up the midline, between the navel and the lower end of the breastbone, a different but related hernia can occur, called an epigastric hernia. These start as a small split in the strong midline tissue, usually under a centimetre across, and most often contain only a small nub of fatty tissue rather than bowel, gradually spreading outward under the skin into a shape often described as mushroom-like. Despite being small, they can be surprisingly painful, because the fatty tissue can get nipped and briefly lose its blood supply even in a tiny defect. One practical point worth knowing: more than one of these small defects is often present in the same patient along the midline, and missing a second, smaller one at the time of surgery is one of the more common reasons a repair seems to “recur” when in fact a different nearby defect was simply never treated. If you’re found to have one epigastric hernia, it’s worth a careful check for a second.

What to expect from surgery and recovery

For a straightforward, planned repair, this is generally a day-case or overnight-stay procedure. Most patients experience some tenderness around the navel for the first week or two, managed with simple painkillers, and are back to normal light activity within days, with heavier lifting and strenuous exercise usually held off for around four to six weeks to give the repair time to properly integrate. Patients who have laparoscopic mesh repair should be aware that some deep, cramping discomfort in the first day or two after surgery is common and expected with this particular technique, rather than a sign that something has gone wrong. For larger hernias, particularly where the overlying skin has become thin or stretched, I also pay close attention to the cosmetic result — where reasonable, redundant loose skin is trimmed at the time of repair so the navel is left looking as natural as possible, which matters a great deal to many patients even though it’s a secondary consideration to a safe, durable repair.

Warning signs worth getting checked

A bulge at or near the navel, especially one that appears with straining, coughing, or standing and reduces when lying flat
A crescent-shaped or lopsided appearance to the belly button
Pain or discomfort at the site of a known umbilical bulge
A bulge that has become firm, cannot be pushed back in, or is suddenly more painful — these need same-day assessment
Nausea, vomiting, or a swollen, tender abdomen alongside a known umbilical hernia — signs of possible obstruction or strangulation and a genuine emergency
An infant’s umbilical bulge that is still present and significant beyond the age of two

What you should do

For a small, soft, symptomless bulge in an infant, patience and reassurance are genuinely the right approach in the great majority of cases. For an adult with a new or growing bulge near the navel, please don’t assume it’s harmless simply because it’s small — the narrow neck typical of these hernias means size alone isn’t a reliable guide to risk, and a proper assessment will tell you whether watchful waiting or planned surgery is the right path for your specific case. And if a known umbilical hernia suddenly becomes hard, painful, and impossible to push back in, that needs same-day emergency attention, not a wait-and-see approach.

To book a consultation with Prof. Dr. Zahid Mahmood, call 0300 413 0159 or visit professorzahid.com.

This article is for general awareness and does not replace a personal medical consultation.

Paraumbilical Hernia: Why a Bulge Near the Navel Needs Special Attention

Paraumbilical Hernia: Why a Bulge Near the Navel Needs Special Attention

What a paraumbilical hernia actually is

Two very different situations: children versus adults

Don’t confuse it with a stretched tummy muscle

Why this type of hernia deserves particular caution

When surgery is needed — and when it can wait

Special situations that change the approach

How the repair is actually done

When it becomes a genuine emergency

A related hernia worth knowing about: epigastric hernia

What to expect from surgery and recovery

Warning signs worth getting checked

What you should do

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Other conditions we treat

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