Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report

Umbilical hernia is a common type of extra-abdominal hernia in adults. However, chronic granulocytic leukemia in combination with cirrhotic ascites and renal insufficiency is less common. The patient reported here had both indications and contraindications for emergency surgery; therefore, the treatment options were subject to debate. We report the case of a man in his 60s who had a strangulated umbilical hernia, with overlying purple-colored infected and necrotic skin. The area was painful, but his bowel movements were normal. Patients underwent comprehensive conservative management, and remote follow-ups via telephone and video conferencing for a period of 60 days, during which the incarcerated contents of the hernia eventually retracted and his pain was relieved, such that there were no longer indications for emergency surgery. In addition, his skin infection disappeared and his quality of life improved, and therefore the treatment outcomes were good. Thus, we provide evidence that not all incarcerated umbilical hernias require emergency surgery, but may respond well to conservative treatment when the contents do not include intestinal loops or other critical organs.

Suture versus open mesh repair for small umbilical hernia: Results of a propensity-matched cohort study

BACKGROUND

The objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes.

METHODS

This propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11.

RESULTS

Mesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients.

CONCLUSION

Both techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias.

Does Concomitant Umbilical Hernia Repair Increase the Risk of Complications in Abdominoplasty? A Propensity Score Matched Analysis

BACKGROUND

Patients seeking cosmetic abdominoplasty often have umbilical hernias. Optimal management and safety of concomitant umbilical hernia repair with abdominoplasty is not well described.

OBJECTIVES

The goal of this study was to compare complication rates following abdominoplasty with or without umbilical hernia repair.

METHODS

A retrospective propensity score matched cohort study of patients who underwent an abdominoplasty at Massachusetts General Hospital was performed. Direct umbilical hernia repair was performed by making a fascial slit inferior or superior to the umbilical stalk. The fascial edges were approximated with up to three 0-Ethibond sutures (Ethicon, Raritan, NJ) from the preperitoneal or peritoneal space. Propensity score matching was used to adjust for confounding variables.

RESULTS

The authors identified 231 patients with a mean [standard deviation] age of 46.7 [9.7] years and a mean BMI of 25.9 [4.4] kg/m2. Nine (3.9%) had diabetes, 8 (3.5%) were active smokers, and the median number of previous pregnancies was 2. In total, 223 (96%) had a traditional abdominoplasty, whereas 8 (3.5%) underwent a fleur-de-lys approach. Liposuction was performed on 90%, and 45.4% underwent simultaneous breast or body contouring surgery. The overall complication rate was 6.9%. Propensity scores matched 61 pairs in each group (n = 122) with closely aligned covariates. There was no significant difference in total complication rates between abdominoplasty alone vs abdominoplasty with hernia repair. There were no cases of skin necrosis or umbilical necrosis in either group.

CONCLUSIONS

Performing umbilical hernia repair with abdominoplasty is safe when utilizing the technique reported in this series.

LEVEL OF EVIDENCE: 3

Flood Syndrome: Endovascular management of spontaneous rupture of an umbilical hernia due to long-standing ascites - A case report

Umbilical hernias are common in patients with cirrhosis of the liver and ascites; however, spontaneous rupture of the hernia is a rare complication. Flood Syndrome occurs very rarely in cirrhotic patients with massive ascites and refers to the spontaneous rupture of an umbilical hernia followed by leakage of ascites fluid. A literature search shows that patients have been managed both operatively and nonoperatively for this condition. We report a case of a 56-year-old man with a history of alcohol-related liver cirrhosis and massive ascites refractory to medical therapy with sudden and spontaneous perforation of his hernia leading to drainage of ascitic fluid from the abdomen. We performed a transjugular intrahepatic portosystematic shunt to relieve portal pressure and subsequent intraabdominal pressure. The patient had resolution of symptoms and the ascitic fluid outflow was resolved.

Parietex™ Composite Ventral Patch for primary and incisional hernia repair

BACKGROUNDS

Ventral hernia repair with a preformed device is a frequent intervention, but few reports exist with Parietex™ Composite Ventral Patch. The aim was to evaluate the results of this mesh with the open intraperitoneal onlay mesh (open IPOM) technique.

METHODS

Observational retrospective single institution study of all consecutive patients intervened for ventral or incisional hernia with a diameter inferior to 4 cm, from January 2013 to June 2020. The surgical repair was performed according to the open IPOM technique with Parietex™ Composite Ventral Patch.

RESULTS

A total of 146 patients were intervened: 61.6% with umbilical hernias, 8.2% with epigastric hernias, 26.7% with trocar incisional hernias, and 3.4% with other incisional hernias. The global recurrence rate was 7.5% (11/146). Specifically, it was 7.8% in umbilical hernias, 0% in epigastric hernias, 7.7% in trocar incisional hernias and 20% (1/5) in other incisional hernias. The median time for recurrence was 14 months (IQR: 4.4-18.7). The median indirect follow-up was 36.9 months (IQR: 27.2-49.6), and the median presential follow-up was 17.4 months (IQR: 6.5-27.3).

CONCLUSION

The open IPOM technique with a preformed patch offered satisfactory results for the treatment of ventral and incisional hernias.

Outcomes of umbilical hernia repair in cirrhotic veterans: a VASQIP study

PURPOSE

Umbilical hernia repair (UHR) in cirrhotics with ascites is a challenging problem associated with increased morbidity and mortality. This study examines the outcomes of UHR in veterans, comparing those undergoing elective versus emergent repair.

METHODS

VASQIP was queried for all UHRs during the period 2008-2015. Data collection included demographics, operative details, Model for End-stage Liver Disease (MELD) score, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p value of ≤ 0.05 was considered significant.

RESULTS

A total of 383 patients were included in the analysis. Overall, mean age was 58.9, 99.0% were males, mean body mass index (BMI) was 26.7 kg/m2, 98.2% had American Society of Anesthesiologists (ASA) classification ≥ III, and 87.7% had independent functional status. More than 1/3 the patients underwent emergent UHR (37.6%). Compared with the elective UHR group, who underwent emergent repair were older, more likely to be functionally dependent, higher MELD score. Hypoalbuminemia, emergency repair and MELD score were found to be independent predictors of poor outcomes.

CONCLUSION

UHR in cirrhotic veterans has worse outcomes when performed emergently. Diagnosis should be followed by medical optimization and elective repair, rather than waiting for an emergent indication in > 1/3 of patients.

Umbilicus Necrosis During Mesh Repair of Rectus Diastasis for Abdominoplasty: Practical Tips for Prevention and Treatment

Rectus muscles widened by pregnancy are handled in dramatically different ways in standard abdominoplasty and mesh abdominoplasty. Patients with significant abdominal wall laxity and/or umbilical hernia repair are treated with the use of retrorectus mesh placement. In these conditions the risk of damaging the blood supply to the umbilicus might be greater. Despite the fact that it is of no functional significance in adults, the umbilicus is a key esthetic landmark of the anterior abdominal wall. For both patients and surgeons alike, its absence, distortion, or misplacement after surgery can be distressing and can be a source of frequent patient complaint. Umbilical stalk necrosis represents an underreported yet important complication for patients following mesh abdominoplasty. We advance some recommendations for patients undergoing abdominoplasty with mesh repair of rectus diastasis and/or concomitant umbilical hernia mesh repair via the open approach. This information should help influence intraoperative decision-making to prevent the development of this undesirable complication.Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk of Reoperation for Recurrence After Elective Primary Groin and Ventral Hernia Repair by Supervised Residents

Importance

Surgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum.

Objective

To assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists.

Design, Setting, and Participants

This nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority's Online Register via surgeons' unique authorization ID. The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral.

Exposures

Hernia repairs performed by supervised residents vs specialists.

Main Outcomes and Measures

Reoperation for recurrence, analyzed separately for all 4 groups.

Results

A total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048).

Conclusions and Relevance

The findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

Using acellular porcine dermal matrix (XCM Biologic® Tissue Matrix) to repair a giant omphalocele: A case report

RATIONALE

An omphalocele is an abdominal wall birth defect, and a giant omphalocele (GO) is defined as an omphalocele having a diameter >5 cm or containing a herniated liver. GOs are usually treated in stages and in this case, during the silo reduction, dehiscence occurred at the suture site of the axis ring and skin edge, which was repaired using synthetic absorbable mesh.

PATIENT CONCERNS

A girl infant was born at 36 weeks with a GO of 8 cm diameter, and herniated multiple organs such as the small bowel, cecum, appendix, and the entire liver. Even after the staged repair technique for the GO silo, wound dehiscence between the ring of the silo and the edge of the skin occurred and gradual reduction failed.

DIAGNOSIS

A GO of 8 cm diameter, which was found during prenatal ultrasonography.

INTERVENTIONS

Revision was performed to repair the defect. The small bowel and liver were still prolapsed, and there were severe adhesions. After adhesiolysis, the muscle layer of the abdominal wall was repaired using the tissue matrix, but the skin could not be repaired. After the second operation, the defect wound was dressed as sterilely as possible.

OUTCOMES

The abdominal wall defect was repaired completely; there were no residual complications.

LESSONS

Repair of GOs using an acellular porcine dermal matrix can be considered a viable treatment option.

Short-term complications after onlay versus preperitoneal mesh repair of umbilical hernias: a prospective randomized double-blind trial

PURPOSE

To compare the incidence of surgical site occurrences (SSOs) following onlay versus preperitoneal mesh placement in elective open umbilical hernia repairs.

METHODS

This study presents a secondary analysis of a randomized double-blind trial conducted on female patients with primary umbilical hernias admitted to a general hospital, in a residency training program setting. Fifty-six subjects were randomly assigned to either onlay (n=30) or preperitoneal (n=26) mesh repair group. Data on baseline demographics, past medical history, perioperative details, postoperative pain (visual analogue scale (VAS)), wound-related complications, and recurrence were assessed using a standardized protocol.

RESULTS

No statistically significant differences were observed between groups regarding patients' demographics, comorbidities, or defect size. Operative time averaged 67.5 (28-110) min for onlay and 50.5 (31-90) min for preperitoneal repairs, p=.03. The overall rate of SSOs was 21.4% (n=12), mainly in the onlay group (33% vs 7.7%; p=0.02, 95% CI 0.03-0.85) and mostly due to seromas. There were no between-group significant differences in postoperative VAS scores at all timepoints. After a maximum follow-up of 48 months, one recurrence was reported in the onlay group. By logistic regression, the onlay technique was the only independent risk factor for SSOs.

CONCLUSION

The presented data identified a decreased wound morbidity in preperitoneal umbilical hernia repairs, thus contributing to the limited body of evidence regarding mesh place selection in future guidelines. Further cases from this ongoing study and completion of follow-up are expected to also compare both techniques in terms of long-term outcomes.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) UTN code: U1111-1205-0065 (date of registration: March 27, 2018).

Flat patch mesh versus three-dimensional mesh (plug) for open umbilical or epigastric hernia repair. A retrospective study

INTRODUCTION

Hernia repair using prosthetic mesh materials has become the preferred method of repair, as the recurrence rates are much lower than with conventional repair techniques. The aim of this retrospective study was to compare open small- and medium-sized abdominal wall hernia repair with flat patch mesh versus three-dimensional mesh (plug) in terms of recurrence and complication rates.

METHODS

The medical records of 300 patients who underwent abdominal wall hernia repair using flat patch mesh versus three-dimensional mesh between January 2010 to December 2015 were reviewed. All patients were followed up after 1 month, 3 month and 1 year. The rate of recurrence, and short-term postoperative complications such as incidence of Surgical Site Infections (SSIs), hematoma and seroma were evaluated.

RESULTS

Short-term follow-up data were available for all patients. The first group was composed of 150 patients that were treated with a flat polypropylene mesh (68% presened umbilical hernia and 32% presented epigastric hernia). The second group was composed of 150 patients that were treated with a three-dimensional polypropylene mesh (60% presented umbilical hernia and 40% presented epigastric hernia). The majority of postoperative (1-month) complications were wound related, representing superficial SSI or seroma. Our results showed a statistically significant reduction of SSIs [3 (2%) vs 13 (8.6%); p = 0.038] and seroma [2 (1.3%) vs 12 (8%); p = 0.030] in the group of patients treated with plugs compared to flat-mesh group. There was no statistically significant difference in hernia recurrences.

DISCUSSION

Usage three-dimensional mesh for open small- and medium-sized umbilical or epigastric hernia repair represents a feasible and safe technique that significantly lowers the incidence of complications such as SSIs and seroma. Furthermore, compared to flat patch mesh, plugs displayed non-inferiority in terms recurrence. Further, well-designed clinical trials could be realized to investigate possible applications of plugs in treatment of small- and medium-sized umbilical and epigastric hernias.

KEY WORDS

Mesh, Umbilical Hernia.

Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation

PURPOSE

Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm.

METHODS

A retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015-2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient's demographics, comorbidities, intra-and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence.

RESULTS

80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3-50.1) months. The median age was 46 (26-76) years old. The median body mass index was 28 (19-38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence.

CONCLUSIONS

Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.

Hernia-to-neck ratio is associated with emergent ventral hernia repair

BACKGROUND

The ratio of hernia size to fascial defect size, termed the hernia-to-neck ratio (HNR), has been proposed as a novel predictive factor for umbilical hernia complications. HNR ≥ 2.5 has been suggested to warrant surgery due to association with bowel strangulation, incarceration, and necrosis. The aim of this study was to evaluate the association between HNR and emergent ventral hernia repair at our institution.

METHODS

A retrospective cohort study was performed of consecutive patients with ventral hernias evaluated at a large safety-net hospital from 2017 to 2019. Patients who required emergent ventral hernia repair were compared to patients who did not require repair at latest follow-up. HNR was calculated using a previously described method: maximal hernia sac size and maximal fascial defect size (termed "hernia neck size") were measured in the sagittal plane on CT scan. Data are described as mean ± standard deviation and median (interquartile range).

RESULTS

A total of 166 patients were included: 84 (51%) required emergent hernia repair and 82 (49%) did not undergo repair. Median follow-up was 19 (8-27) months. Patient groups were similar except the emergent repair group had more males (50% vs. 34%, p = 0.03), umbilical hernias (93% vs. 56%, p < 0.01), recurrent hernias (31% vs. 15%, p < 0.01), and lower mean BMI (34.3 ± 9.9 vs. 39.1 ± 6.5, p < 0.01). Hernia sac size did not differ between groups (5.8 [3.8-8.4] cm vs. 6.1 [3.5-11.8] cm, p = 0.45). Hernia neck size was significantly smaller in the emergent repair group (1.5 [2.3-3.5] cm vs. 3.4 [1.8-6.2] cm, p < 0.01). Hernia-to-neck ratio was significantly higher in the emergent repair group (2.4 [1.8-3.1] vs. 1.7 [1.1-2.9], p < 0.01).

CONCLUSION

This study demonstrated an association between higher HNR and increased risk of emergent ventral hernia repair. Future studies will evaluate the use of HNR to risk-stratify patients with ventral hernias in a safety-net hospital.

Abdominal Wall Defects: A Review of Current Practice Guidelines

The 2 most common congenital abdominal wall defects are gastroschisis and omphalocele. Gastroschisis is a defect in the abdominal wall with exposed abdominal contents. Mortality rates are low but lengths of stay are often prolonged by bowel dysmotility and other intestinal abnormalities in complicated cases. Omphalocele is a defect through the umbilical cord with herniated abdominal contents covered by a sac. It is associated with other genetic abnormalities and other anomalies that can lead to significant morbidity and mortality. Prenatal diagnosis in both conditions allows for improved prenatal consultation and coordinated perinatal care to improve clinical outcomes.

Effects of Umbilical Preparation Before Trans-umbilical Laparo-endoscopic Single-site Surgery on Umbilical Wounds Healing: a Randomized Controlled Trial

OBJECTIVE

The umbilicus is the only anatomic entrance and incision site for trans-umbilical laparoendoscopic single-site surgery (TU-LESS). Data on incisional surgical site infections (ISSI) and incision healing in TU-LESS are lacking. Therefore, we aimed to observe umbilical incision healing and possible hernia after TU-LESS and explore the efficacy of preoperative umbilicus preparation on ISSI.

SUBJECTS AND METHODS

Consecutive patients aged 18 to 65 years, who were scheduled to undergo TU-LESS at a teaching hospital between March 2020 and November 2021, were enrolled in this prospective study. All patients were randomized to the study group with preoperative umbilicus preparation 30 minutes before patients were sent to the operating room and to the control group without preparation. The umbilical dimple was disinfected twice using povidone-iodine in both groups before the skin incision. The primary outcome was ISSI within 30 days of surgery. Umbilical hernia at 3 months after surgery and perioperative data such as operation time, complications, and incision healing were recorded and compared.

RESULTS

A total of 400 patients were recruited for this study. TU-LESS was performed in all patients without major complications. ISSI occurred in 5 patients in the study group (2.5%) and 3 patients in the control group (1.5%), with no significant differences between both groups ( P =0.479). No umbilical hernia occurred in any patient during the 3 months follow-up. Six patients in the study group (3.1%) and 1 in the control group (0.5%) experienced excessive scarring, a relatively high incidence in the study group, though the difference was not statistically significant ( P =0.067).

CONCLUSIONS

TU-LESS-related umbilical hernias are rare with existing suturing methods. Umbilicus preparation before TU-LESS could not decrease ISSI; however, it increased the nursing workload, which should be avoided.

Cirrhosis and hernia repair in a cohort of 6352 patients in a tertiary hospital: Risk assessment and survival analysis

The prevalence of hernias in patient with cirrhosis can reach up to 40%. The pathophysiology of cirrhosis is closely linked to that of the umbilical hernia, but other types are also common in this population. The aim of this study is to evaluate factors that influence in the prognosis after hernia repair in patients with cirrhosis. A historical cohort of 6419 patients submitted to hernia repair was gathered. Clinical, epidemiological data and hernia characteristics were obtained. For patient with cirrhosis, data from exams, surgery and follow-up outcomes were also analyzed. Survival curves were constructed to assess the impact of clinical and surgical variables on survival. 342 of the 6352 herniated patients were cirrhotic. Patient with cirrhosis had a higher prevalence of umbilical hernia (67.5% × 24.2%, P < .001) and a lower prevalence of epigastric (1.8% × 9.0%, P < .001) and lumbar (0% × 0.18%, P = .022). There were no significant differences in relation to inguinal hernia (P = .609). Ascites was present in 70.1% of patient with cirrhosis and its prevalence was different in relation to the type of hernia (P < .001). The survival curve showed higher mortality for emergency surgery, MELD > 14 and ascites (HR 12.6 [3.79-41.65], 4.5 [2.00-10.34], and 6.1 [1.15-20.70], respectively, P < .05). Hernia correction surgery in patient with cirrhosis has a high mortality, especially when performed under urgent conditions associated with more severe clinical conditions of patients, such as the presence of ascites and elevated MELD.

Comparative Study between Acacia Nilotica versus Povidone Iodine in Topical Treatment of Omphalocele Major

Well established and common practice in conservative management of omphalocele major is escharotics therapy with different topical agents. Among them mercurochrome, alcohol, silver salts, povidone iodine, acacia nilotca paste are commonly used. It is a comparative study between application of acacia nilotica paste and povidone iodine solution as a primary non surgical treatment of omphalocele major regarding efficacy and safety of these two topical agents. A double blind randomized controlled study was conducted at the department of Paediatric Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2019. In this study 20 cases of omphalocele major and randomly divided into two equal groups. Group A and Group B treated with acacia nilotica paste and povidone iodine solution respectively. Gastroschisis, ruptured-omphalocele major or omphalocele minor excluded in this study. The size of the fascial defect in cm, time required for full oral feeding tolerance and duration of hospital stay were evaluating parameters. Patients with Group A tolerated full oral feeding earlier, shorter total hospital stay duration and low mortality rate than those from Group B. Application of acacia nilotica is a safe and effective treatment of omphalocele major regarding rapid full oral feeding tolerance, shorter hospital stay and low mortality rate.

Comparison of rectus sheath block and local anesthetic for analgesia in pediatric umbilical hernia repair: A systematic review and meta-analysis

BACKGROUND

Pediatric umbilical hernia repair could cause considerable postoperative discomfort. This study aimed to compare the analgesia between rectus sheath block and local anesthetic infiltration in child pediatric umbilical hernia repair.

METHODS

The relevant randomized controlled trials were searched from PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases from its inception to October 2020. The random-effects model was used for meta-analysis.

RESULTS

Four randomized controlled trials were included in the meta-analysis. The 4 studies were published between 2006 and 2017, with sample sizes ranging from 13 to 52 and a total of 143 individuals across the 4 studies. The Jadad scores of the 4 included studies ranged from 4 to 5, and all 4 studies were considered high quality based on quality assessment. There was no difference in analgesic effect at 10 minutes (standardized mean difference [SMD] = -0.19; 95% confidence interval [CI] = -1.52 to 1.16; P = .78), 30 minutes (SMD = -0.37; 95% CI = -1.53 to 0.78; P = .52), 1 hour (SMD = -0.73; 95% CI = -2.00 to 0.53; P = .26) after surgery. Besides, there was no significant difference in postoperative nausea (risk ratio = 0.95; 95% CI = 0.18 to 5.02; P = .95) and postoperative morphine use in morphine equivalents (mean difference = -0.95; 95% CI = -0.06 to 0.01; P = .12).

CONCLUSION

Rectus sheath block and local anesthetic are effective methods for analgesia in pediatric umbilical hernia repair.

Frequency of Potentially Avoidable Surgical Referrals for Asymptomatic Umbilical Hernias in Children

INTRODUCTION

The American Association of Pediatrics released guidelines in 2019 recommending delay of surgical referral in children with asymptomatic umbilical hernias until 4-5 y of age. The purpose of this study was to assess contemporary rates of potentially avoidable referrals in this cohort of children, and to assess whether rates have decreased following guideline release.

METHODS

Retrospective analysis of umbilical hernias referrals evaluated at a single pediatric surgery clinic from October 2014 to August 2021. Potentially avoidable referrals (PAR) were defined as asymptomatic, non-enlarging umbilical hernia referrals in a child 3 y of age or younger without a history of incarceration. Referral indication, disposition following clinic visit, and rates of PAR were compared before and after guideline release.

RESULTS

A total of 803 umbilical hernia referrals were evaluated, of which 48% were in children 3 y of age or younger at time of evaluation ("early" referrals). 33% of all referrals and 68% of early referrals were categorized as a PAR, and rates were similar before and after guideline release (all referrals: 32% versus 33%, P = 0.94; early referrals: 68% versus 67%, P = 0.94). Of the 333 early referrals who were managed expectantly per guideline recommendations, 2 (0.6%) developed incarceration which was managed with successful reduction and interval repair.

CONCLUSIONS

One-third of all referrals for umbilical hernia evaluation are potentially avoidable, and this rate did not change following release of American Academy of Pediatrics guidelines. Aligning expectations between surgeons and referring providers through improved education and guideline dissemination may reduce avoidable visits, lost caregiver productivity, and exposure to potentially avoidable surgery.

A Method of Conservative Management of Giant Omphalocele Useful in Preventing Rupture of Sac

BACKGROUND

Omphalocele consists of congenital malformation of anterior abdominal wall defects occurring at the midline with herniation of the viscera through this defect. Giant omphaloceles constitute a challenging situation as such conservative management has been advocated as an effective method of treatment. This study aimed to compare the conventional method of dressing the omphalocele sac using gauze, an escharotic agent, and a crepe bandage to our improvised method of the usage of a sterilization wrap over the escharotic agent with a crepe bandage.

METHODS

This was a retrospective comparative review of 7 babies with giant omphalocele that was treated with topical honey and the non-adherent sterilization wrap covering (group B) and compared with 6 babies that had honey, sofratulle ,and dry gauze covering (group A) that was initially done in our center.

RESULTS

All of the babies who were in group B had an uneventful epithelization of the sac with no rupture; also, no death occurred in this group. However, three in group A had sacs that ruptured before epithelization. Two of these died from complications of sepsis following rupture of the sac, one had a small point on the sac which was ruptured and it healed with a dressing left in place for a week.

CONCLUSION

The use of Kimberley-Clark sterilization wrap prevents rupture of the sac while using the escharotic agent, thereby reducing mortality. We advocate that gauze should not make any contact with the omphalocele sac.

Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients

The goal of this study was to identify risk factors that are associated with mortality in adult and elderly patients who were hospitalized for umbilical hernia. A total of 14,752 adult patients (ages 18−64 years) and 6490 elderly patients (ages 65+), who were admitted emergently for umbilical hernia, were included in this retrospective cohort study. The data were gathered from the National Inpatient Sample (NIS) 2005−2014 database. Predictors of mortality were identified via a multivariable logistic regression, in patients who underwent surgery and those who did not for adult and elderly age groups. The mean (SD) ages for adult males and females were 48.95 (9.61) and 46.59 (11.35) years, respectively. The mean (SD) ages for elderly males and females were 73.62 (6.83) and 77.31 (7.98) years, respectively. The overall mortality was low (113 or 0.8%) in the adult group and in the elderly group (179 or 2.8%). In adult patients who underwent operation, age (OR = 1.066, 95% CI: 1.040−1.093, p < 0.001) and gangrene (OR = 5.635, 95% CI: 2.288−13.874, p < 0.001) were the main risk factors associated with mortality. Within the same population, female sex was found to be a protective factor (OR = 0.547, 95% CI: 0.351−0.854, p = 0.008). Of the total adult sample, 43% used private insurance, while only 18% of patients in the deceased population used private insurance. Conversely, within the entire adult population, only about 48% of patients used Medicare, Medicaid, or self-pay, while these patients made up 75% of the deceased group. In the elderly surgical group, the main risk factors significantly associated with mortality were frailty (OR = 1.284, 95% CI: 1.105−1.491, p = 0.001), gangrene (OR = 13.914, 95% CI: 5.074−38.154, p < 0.001), and age (OR = 1.034, 95% CI: 1.011−1.057, p = 0.003). In the adult non-operation group, hospital length of stay (HLOS) was a significant risk factor associated with mortality (OR = 1.077, 95% CI: 1.004−1.155, p = 0.038). In the elderly non-operation group, obstruction was the main risk factor (OR = 4.534, 95% CI: 1.387−14.819, p = 0.012). Elderly patients experienced a 3.5-fold higher mortality than adult patients who were emergently admitted with umbilical hernia. Increasing age was a significant risk factor of mortality within all patient populations. In the adult surgical group, gangrene, Medicare, Medicaid, and self-pay were significant risk factors of mortality and female sex was a significant protective factor. In the adult non-surgical group, HLOS was the main risk factor of mortality. In the elderly population, frailty and gangrene were the main risk factors of mortality within the surgical group, and obstruction was the main risk factor for the non-surgical group.

eTEP inferior access with tailored retromuscular dissection for small to mid-sized umbilical hernia repair with or without inguinal hernia: early experience

INTRODUCTION

The minimally invasive surgical repair of combined inguinal and ventral hernias often requires shifting from one approach or plane to another. The traditional enhanced-view totally extraperitoneal Rives-Stoppa repair consists of a large retro muscular dissection that is unjustified for small ventral hernias. Here we describe a modification to the minimally invasive Rives-Stoppa repair using a limited retro muscular dissection based on the ventral defect size for small/medium-sized hernias, with or without combined inguinal hernias.

METHODS

From a single surgical team, a retrospective study was performed over a 1-year period. Demographics, hernia characteristics, surgical techniques, intraoperative/postoperative complications, and outcomes were all analyzed and reported. We also included detailed surgical steps, landmarks, pitfalls, and personal tips for this technique.

RESULTS

Twenty-four patients underwent a laparoscopic limited retromuscular dissection ventral hernia repair utilizing the eTEP access technique. Eighteen were primary umbilical hernias and six postoperative incisional hernias, and nine were combined ventral and inguinal hernia repairs. Eight of the primary umbilical hernias were EHS classified as medium size, 11 small, and for the incisional hernias, three were classified as M3W1 and two as M3W2. One procedure was converted to TAPP. There were no intraoperative complications. The mean length of stay was 1.25 days (range 1-3). There was one postoperative retromuscular hematoma and no recurrence during the follow-up period.

CONCLUSION

eTEP with limited dissection offers a good and safe solution for small to medium size hernias; it provides an efficient solution when an inguinal hernia is to be addressed as well.

Sex disparities in the treatment and outcomes of ventral and incisional hernia repair

BACKGROUND

Despite females accounting for nearly half of ventral and incisional hernia repairs performed each year in the United States, shockingly little attention has been paid to sex disparities in hernia treatment and outcomes. We explored sex-based differences in operative approach and outcomes using a population-level hernia registry.

METHODS

We performed a retrospective review of the Michigan Surgical Quality Collaborative Hernia Registry (MSQC-HR) to identify patients undergoing clean ventral or incisional hernia repair between January 1, 2020 to December 31, 2021. The primary outcomes were risk-adjusted rates of laparoscopic/robotic approach, mesh use, and composite 30-day adverse events stratified by sex. Risk adjustment between sex was performed using all patient, clinical, and hernia characteristics.

RESULTS

5269 patients underwent ventral and incisional hernia repair of whom 2295 (43.6%) patients were female. Mean age was 53.9 (14.5) years. Females had slightly larger hernias (3.5 cm vs. 3.0 cm, P < 0.001), fewer umbilical hernias (50.9% vs. 73.0%, P < 0.001), and a higher prevalence of prior hernia repair (17.9% vs. 13.4%, P < 0.001). In a multivariable logistic regression adjusting for differences between males and females, female sex was associated with lower odds of mesh use [aOR 0.62 (95% CI 0.52-0.74)] and higher odds of laparoscopic/robotic repair [aOR 1.26 (95% CI 1.10-1.44)]. In a similar multivariable model, female sex was also associated with significantly higher odds of composite 30-day adverse events [aOR 1.64 (95% CI 1.32-2.02)]. This equates to predicted probabilities of 11.7% (95% CI 10.3-13.0%) vs. 7.6% (95% CI 6.6-8.6%) for adverse events in females compared to males.

CONCLUSIONS

Despite being younger and having fewer comorbidities, women were more likely to experience adverse events after surgery. Moreover, women were less likely to have mesh placed. Additional work is needed to understand the factors that drive these gender disparities in ventral hernia treatment and outcomes.