[The use of prosthesis material in emergency surgery. Comments on a clinical case]

The authors briefly report the case of a patient in whom a double Mersilene graft was used to repair a strangulated umbilical hernia. This report is interesting for various reasons. Firstly, the fact that surgery was performed under emergency conditions and secondly, the position of the graft, which was certainly not ideal--even if obligatory owing to the circumstances under which the operation was performed--in the abdominal wall. In spite of the successful results obtained, the authors feel that graft should preferably be used in elective surgery in which additional operations are not required which may further contaminate the operating field. In particular, special attention should be paid to graft position in relation to the various layers of the abdominal wall.

Spontaneous rupture of infantile umbilical hernia: report of three cases

Three Nigerian infants with spontaneous rupture of an umbilical hernia are described. In two, hernias developed in the neonatal period following umbilical sepsis. Rupture occurred at the ages of 2 and 3 months, respectively, and was probably precipitated by raised intra-abdominal pressure resulting from excessive crying. The third child had a large, ulcerated umbilical hernia which ruptured at 10 months and was precipitated by damage to the overlying skin. The children were treated successfully.

Elective repair of abdominal wall hernias in decompensated cirrhosis

BACKGROUND/AIMS

Abdominal wall hernia is a common feature of decompensated cirrhosis. However, literature on elective hernia repair in these patients is limited. Here we report the experience of our center.

METHODOLOGY

Eleven hernias (seven umbilical, three inguinal and one incisional) in nine patients with decompensated cirrhosis were repaired. The indication for operation was repeated incarceration in two patients and significant pain in four; three patients with umbilical hernias had ulceration and necrosis of the overlying skin. Pre-operatively, medical therapy of ascites was conducted at the hepatology unit. Umbilical hernias were treated with the classic Mayo repair; in all cases but two, this was buttressed with a prolene graft. One inguinal hernia was repaired with the plication-darn technique; the other two and the incisional hernia were repaired with prolene grafts.

RESULTS

There was no mortality. One patient had a scrotal hematoma; two patients had leakage of ascites into the wound. Seven patients were followed up. Four patients died without recurrence after a median period of 12 months (range 6-22). The other patients have no recurrence at 1, 10 and 40 months post-operatively.

CONCLUSIONS

Umbilical and inguinal hernias in patients with decompensated cirrhosis may be repaired safely on an elective basis. Control of ascites is vital for success.

Pediatric umbilical problems

After birth, the normal umbilicus is a relatively simple structure. During the development of the embryo, however, this region is highly complex. Vestigial of the umbilical cord can be responsible for umbilical inflammation and drainage. This article reviews the embryology of the umbilicus and discusses a number of clinical problems seen in this area. The authors' aim is to aid the primary care pediatrician in evaluating, treating, and appropriately referring umbilical problems encountered in office practice.

Mesh plug repair for a small incisional hernia in a cirrhotic patient with ascites: report of a case

We report herein the case of a patient with severe liver ascites due to cirrhosis in whom a small incisional hernia on a midline incision was successfully treated by a mesh plug repair, a method most commonly employed for groin hernia repair. The hernia sac was dissected and inverted into the abdominal cavity by the mesh plug under epidural anesthesia. The patient's recovery was quick and relatively painless, and there has been no recurrence after 1 year of followup. This case report demonstrates that the method of mesh plug repair may be appropriate for small incisional hernias as well as groin hernias, performed under epidural anesthesia.

Delayed external compression reduction of an omphalocele (DECRO): an alternative method of treatment for moderate and large omphaloceles

BACKGROUND/PURPOSE

Standard treatment of large hepatoomphaloceles has been SILASTIC (Dow Corning, Midland, MI) silo placement followed by closure. This requires two operations, and complications from the silo may occur. The authors have looked for a safe and simpler alternate method of closure. Delayed external compression reduction of an omphalocele (DECRO), appears to have a low complication rate and a rapid time to closure.

METHODS

The authors reviewed retrospectively the records of six patients with hepato-omphaloceles treated with DECRO from August 1993 to July 1997. All defects were evaluated by the attending surgeon and could not be closed primarily. All data are expressed as mean +/- SEM.

RESULTS

The average gestational age was 36.5 +/- 0.67 weeks with mean weight of 2,780 +/- 256 g. Two patients had congenital cardiac disease. The mean size of the defects was 6.2 x 5.7 cm. All defects had the liver out of the abdomen. No patients required silo placement. The mean time to reduction and final closure was 5.6 +/- 0.49 days. The average postoperative time on the ventilator was 7.1 +/- 3.5 days. Mean time to full feeds was 18.8 +/- 3.4 days. One patient had superficial necrosis of the skin flap. Mean time to discharge was 30.5 +/- 5.5 days. All patients had DECRO completed without complications.

CONCLUSIONS

This procedure decreases the number of operations needed from two to one. No complications were seen from the procedure and the time of mechanical ventilation required was low. The abdominal compartment syndrome developed in none of the patients. DECRO is a safe and very effective alternative to SILASTIC silo placement in moderate and large omphaloceles that cannot be closed primarily.

Esophageal hiatal hernia after omphalocele repair

Esophageal hiatal hernias (EHH) are probably caused by congenital, traumatic, or iatrogenic factors, although the etiology remains unknown. EHHs may develop after abdominal wall closure for omphalocele or gastroschisis due to the increased intra-abdominal pressure, however, there have been few reports in the literature. We present a case of EHH developing after abdominal wall closure.

Infantile desmoid-type fibromatosis in an Akita puppy

A 10-week-old Akita puppy was evaluated for a reported umbilical hernia. Repair of the hernia had been attempted three times prior to referral. A defect in the ventral abdominal wall with an associated soft-tissue mass was identified on abdominal radiographs. Exploratory surgery was performed; the mass was resected and the abdominal wall defect was repaired. Histopathological evaluation of the mass was consistent with infantile desmoid-type fibromatosis.

Umbilical hernia of stomach

Herniation of the stomach through the umbilicus is exceedingly rare with only one case reported in the international literature in the past 40 years. One case of a reducible gastric umbilical hernia, not diagnosed by endoscopy, is reported. Diagnosis was made by double-contrast barium examination after 5 years of symptoms and ineffective treatment. Herniation of the stomach is difficult to diagnose by endoscopy and radiological studies can be more sensitive and allow a more specific diagnosis.

Cantrell's syndrome: a challenge to the surgeon

We present a case of partial Cantrell's syndrome with ventricular septal defect, left ventricular diverticulum, dextrorotation of the heart, an anterior diaphragmatic defect, and a midline supraumbilical abdominal wall defect with omphalocele. At the age of 20 months, the patient underwent a successful cardiac surgical procedure. To detect risk factors and to define therapeutic strategies, we analyzed the spectrum and the frequency of malformations described in 153 patients with Cantrell's syndrome. Despite modern surgical standards, Cantrell's syndrome represents a challenge to the surgeon because of the wide spectrum of anomalies, the severity of the abdominal and cardiac malformations, and the high mortality.

Videolaparoscopic treatment of Spigelian hernias

Because treatment for Spigelian hernia is rarely discussed in the literature, this report presents two cases observed in a recent 6-month period by the U.O.A. Independent General Surgery Department, Hospital of Este. Both patients had laparoscopic treatment using a polypropylene prosthesis, which confirms the technological validity of the surgical method. The described cases are emblematic, because the intervention permitted a resolution of associated pathologies (gallbladder gallstones and umbilical hernia), which confirms both the efficacy of the surgical technique and of the high diagnostic precision of laparoscopy, as it is described by several sources. The validity of the technique is also confirmed by the quick recovery of patients and by the reduced hospitalization time, especially in elderly patients and in precarious general conditions.

Umbilical hernial defects encountered before and after abdominal laparoscopic procedures

Pre-existing fascial umbilical defects may compound problems faced during laparoscopic surgery. Detection helps in preventing bowel or omental injury and repair can be done at the same time. Postoperative port incisional hernias are not uncommon and require surgical repair.

METHODS

The incidence, clinical features and management of such fascial defects were studied in 2100 patients undergoing abdominal laparoscopy.

RESULTS

The incidence of fascial defects was 18%. The hernias were symptomatic in 56.5% cases, with an overwhelming female preponderance. A supra-umbilical incision above the upper limit of the hernia was used to establish the umbilical port and through this the hernias were repaired with nonabsorbable sutures. Postoperative incisional hernias occurred in 41 patients out of a total follow-up of 1892 cases (2.16%). The common predisposing factors were wound infection, postoperative chest infection and previous existing diseases, like diabetes and connective tissue disorders. Twenty-eight patients underwent mesh plasty and 3 cases had laparoscopic Gortex mesh repair. The remaining 10 cases refused surgery.

CONCLUSIONS

Omental fascial defects should be dealt with at the same sitting through a supra-umbilical port incision avoiding direct entry into the hernia. Use of nonabsorbable sutures is recommended. Prevention of wound infection and postoperative chest infection greatly reduces the chances of an incisional hernia.

Hernia development in CAPD patients and the effect of 2.5 l dialysate volume in selected patients

The aim of this study was to estimate the prevalence of hernia formation in CAPD patients and to study the effect of increased dialysate volume (2.5 l) in selected population of patients who could tolerate it. We reviewed the charts of 454 individuals treated with CAPD in our center during a five-year period (September 1991-September 1996). Out of 404 patients who used 2.0 l dialysate exchange volume forty-nine (11%) developed hernia (umbilical 53%, inguinal 33%, incisional 14%) after having been on CAPD for an average of 10 +/- 11 months, while only one of the 50 patients who would tolerate 2.5 l developed a hernia (inguinal 2%), after having been on CAPD for 12 months. All hernias were repaired surgically and most of the patients returned to CAPD after temporary intermittent peritoneal dialysis. Age, sex, nutritional status, polycystic kidneys, and diabetes do not seem to be predisposing factors for hernia formation, while previous operation for aortic abdominal aneurysm repair, or low body weight (< 60 kg) were risk factors. The use of increased dialysate volume (2.5 l) in patients who could tolerate it, did not result in a higher frequency of hernia development. Surprisingly, patients with hernias seem to have a higher mortality than those without.

[Ways of improvement of surgical results for umbilical hernia in elderly and old patients]

The surgical treatment results of umbilical hernia in 116 patients aged from 60 to 82 years was presented. Operation was done according to Mayo procedure while small hernia presented and middle size (22 patients) with the thinning zone width of aponeurosis up to 2 cm. The original hernioplasty procedure, with duplicature forming of the preliminary doubled aponeurosis edes in the hernia gates, was conducted in 48 patients with middle-size hernia and in 25 with large hernia while the thinning zone of aponeurosis constituted from 2 to 4 cm. While treatment of large and giant hernias with the aponeurosis thinned width over 4 cm was conducted the combined plasty usid autologous tissue (aponeurosis) and the implant (of polyurethane), placed into the duplicature of the hernial sac and fixated to aponeurosis from the abdominal cavity side. Hernia recidive was revealed in 2 (2.8%) of 72 patients followed up in term from 1 year to 5 years. The recurrence was not noted after the combined plasty conduction.

Intraabdominal leg: unique variant of split notochord syndrome

An infant was born with a spectrum of anomalies representing a unique variant of the split notochord syndrome. The major anomalies included giant omphalocele and duplicated lower spine, between which developed a posterior lumbosacral mass that was contiguous with an intraabdominal, skin-covered "leg" within a saccular cecum. Features of this case overlap aspects of fetiform teratoma, fetus-in-fetu, conjoined twins, and caudal duplication, suggesting an etiologic relation between these entities and split notochord syndrome.

Serial lung volume measurements during the perinatal period in infants with abdominal wall defects

METHODS

Daily measurements of lung volume (functional residual capacity, FRC) were made during the perinatal period in eight infants (median gestational age, 37 weeks; range, 34 to 38 weeks) with abdominal wall defects.

RESULTS

On the first day of life and before surgical intervention, four infants had FRCs below the reference range; the occurrence of low lung volumes was not significantly related to gestational age or diagnosis. Lung volume was further, but only temporarily, impaired by surgical closure of the abdominal wall defect, with a reduction in the median FRC from 25 mL/kg (range, 18 to 36) preoperatively to 12 mL/kg (range, 5 to 19) on the first postoperative day (P < .02).

CONCLUSION

These data are consistent with abnormal antenatal lung growth in certain infants with abdominal wall defects.

[Use of a Gore-Tex patch in the primary repair of congenital defects of the anterior abdominal wall]

The surgical treatments for large omphaloceles and gastroschisis have to avoid a dangerous primary fascial closure when it's not feasible, so the pediatric surgeon can use staged surgical procedures that achieve a gradual increase in size of the abdominal cavity. Therefore, a staged approach is mandatory to avoid a complicated reduction and it's the best treatment for large congenital abdominal wall defects. Gore-Tex soft tissue is easy to handle, pliable, soft and well tolerated, so Gore-Tex patch closure is a safe and good alternative to staged repair in large omphaloceles and gastroschisis. The Authors report about five newborns with large congenital abdominal wall defects, in whom primary fascial closure could not be accomplished, so they were successfully treated by primary repair with Gore-Tex patch. The Authors also describe the surgical technique and they reconsider the last surgical techniques for large omphaloceles and gastroschisis.

[Current status of management of omphalocele and gastroschisis]

Forty-five cases of gastroschisis and 85 of omphalocele were reviewed. The survival of gastroschisis has dramatically improved over the past 20 years, however, that of omphalocele still remained in the lower value, because the size of the defect and the presence of associated anomalies are prognostic factors. The primary fascial closure was first employed for the patients with gastroschisis and a silo chimney was used for limited cases. On the other hand, for the patients with omphalocele, primary closure was possible in 34 cases, silo chimney was used in 17, and 45 cases had nonoperative management with epithelialization. Among them, nonoperative management using painting was the most reliable therapeutic for omphalocele.