Abdominal wall hernias in the setting of cirrhosis

In cirrhotic patients, umbilical hernias occur almost exclusively when longstanding ascites is present. Umbilical hernias expose cirrhotic patients to potentially life-threatening complications such as strangulation (which can be precipitated by rapid removal of ascitic fluid) and rupture (which is usually preceded by cutaneous ulcerations on the surface of the hernia). In cirrhotic patients, prevention of umbilical hernias is based on prevention of ascites. When prevention has failed, medical treatment of ascites should be first attempted. In patients in whom medical treatment is effective, and after ascites has disappeared, surgical treatment of umbilical hernia can be safely performed in most cases. In patients in whom medical treatment is ineffective and who develop refractory ascites, treatment strategy for umbilical hernia depends on the presence or absence of indication for liver transplantation. In patients who are candidates for liver transplantation, careful local care with pressure bandage must be performed until transplantation. Herniorrhaphy must be performed at the time of transplantation. In patients with refractory ascites, and who are not candidates for transplantation, portocaval shunt, transjugular intrahepatic portocaval shunt (both followed by surgical herniorrhaphy when ascites has disappeared) or concomitant peritoneo-venous shunt and herniorrhaphy should be considered. In contrast to umbilical hernias, groin hernias are not markedly influenced by ascites. However, ascites is a major risk factor for surgery. Therefore, surgical repair should not be recommended in patients with ascites and poor liver function. In cirrhotic patients with incisional hernia, prosthetic devices should be avoided because of the high risk of bacterial infection.

Pseudoexstrophy of the bladder: case report and literature review

The authors present a case of a boy newborn who had bladder pseudoexstrophy and multiple congenital anomalies. In addition to this unusual variant of the exstrophy-epispadias complex, the patient was found to have a posterior cleft palate, an omphalocele, and an imperforate anus.

[Malignant hyperthermia and sevoflurane--a case report]

The authors report on a course of malignant hyperthermia (MH) in an almost 5-years old boy. In the past, he had been anaesthetized two times with halothane without complications. The causative triggering agent was sevoflurane, a new user-friendly substance for paediatric anaesthesia. Forty five minutes after induction of anaesthesia he developed symptoms of a MH-crisis with increase in endexspiratory CO2 up 87 mmHg and followed by an increase in heart rate up to 160 beats/minute. The blood gas analysis showed a respiratory and metabolic acidosis. The timely administration of dantrolene rapidly reversed the life-threatening signs and prevent progression of the disease. It is apparent that monitoring of endtidal carbon dioxide by means of capnometry is of crucial importance in detecting MH at an early stage, and appropriate treatment is being instituted more promptly. By such early recognition, and treatment with dantrolene, we can reasonably except a further decrease in mortality and morbidity of this enigmatic disorder.

Abdominoplasty in multiparous women with severe musculoaponeurotic laxity

The results and complications of abdominoplasty in 20 consecutive multiparous women with very severe musculoaponeurotic laxity are presented. All patients presented with an abdomen that resembled a full-term pregnancy when the patient was in the erect posture. This very severe laxity was the end result of repeated pregnancies. All patients underwent a standard abdominoplasty with wide longitudinal plication using size 1 prolene sutures. Follow-up averaged 1 year. None of the patients had a major complication. However, all the patients had recurrence of the musculoaponeurotic laxity. Causes and classification of this recurrent laxity are discussed along with possible solutions.

Cantrell's pentalogy. Report of four cases and their management

Four neonates with the uncommon Cantrell's pentalogy seen in our hospital within a 6-month period without any apparent factor in common are described, with a review of the world literature. The first case was diagnosed prenatally at 15 weeks' gestation, the earliest intrauterine finding in the literature. The occurrence of imperforate anus with the syndrome, observed in one of the cases, has not been previously reported. Two were operated upon and only one of the four survived. This high mortality was confirmed by similar cases reported by other authors.

Hernia repair in elderly patients

BACKGROUND

This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population.

METHODS

From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66-93) years). Concomitant diseases were present in 157 patients. A mesh repair was performed with 'tension-free' or 'plug' techniques in all but 23 inguinal and two femoral hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia.

RESULTS

There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotal haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair.

CONCLUSION

Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.

Unusual fate of vesicoallantoic cyst with non-visualization of fetal urinary bladder in a case of patent urachus

We present the sonographic findings of a fetus with a vesicoallantoic cyst. The cyst was first identified at 17 weeks of gestation; it was associated with an omphalocele, and disappeared spontaneously at 29 weeks. The fetal urinary bladder was not visualized thereafter. An omphalocele and exstrophia of the urachus were found at birth and repaired. Non-visualization of the fetal urinary bladder suggested rupture of the covering membrane of the omphalocele and allantois during fetal life. A defect in the wall of the omphalocele supported our hypothesis.

Use of Doppler ultrasonography in the evaluation of liver blood flow during silo reduction of a giant omphalocele

Despite the utility of prosthetic silo reduction techniques, surgical treatment of giant omphaloceles containing herniated liver may result in acute compromise of hepatic vascular flow. The authors report a case of an infant with a giant omphalocele containing liver, in whom hepatic vascular compromise was suspected during the course of prosthetic visceral reduction. Doppler ultrasonography performed on the herniated liver through the prosthetic silo demonstrated triphasic vascular flow in the liver as well as normal hepatic venous flow and vena caval flow, and permitted continued gradual visceral reduction and a safe, delayed primary abdominal wall closure on the seventh day of life. Doppler ultrasonography performed through the silo may be an important diagnostic adjunct during the visceral reduction phase of staged abdominal wall closure in infants with giant omphaloceles.

Laparoscopic cholecystectomy and the umbilicus

BACKGROUND

Pre-existing umbilical defects may present technical problems in patients having laparoscopic surgery. Fascial defects may also occur after operation. Understanding the causes and mechanisms of herniation at laparoscopic port sites may help avoid potentially serious postoperative complications.

METHODS

The incidence, management and potential complications of pre-existing and postoperative umbilical defects were studied in 870 patients undergoing laparoscopic cholecystectomy.

RESULTS

The incidence of umbilical or paraumbilical defects was 12 per cent. The hernias were symptomatic in only 16.3 per cent; the majority of patients were unaware of the defect. The umbilical port was established through, or directly adjacent to, the defect, allowing simple anatomical repair in 90 per cent, using absorbable sutures. The recurrence rate was 3.8 per cent; recurrence was usually caused by wound extension or infection. Incisional hernia occurred in 16 patients after cholecystectomy (1.8 per cent). Only one hernia developed at a port site other than the umbilicus. Risk factors associated with incisional hernia were wound extension in 12 patients, male sex in six, wound infection in five, diabetes in four, pre-existing umbilical hernia in four and acute cholecystitis in three.

CONCLUSION

The significant incidence of umbilical defects in patients undergoing laparoscopic surgery calls for accurate diagnosis and good technique. The incidence of incisional hernia might be reduced by avoiding unnecessary wound extension and the use of non-absorbable sutures for defects larger than 2 cm and in men with umbilical hernia.

Improved survival of infants with omphalocele

BACKGROUND

The surgical management of patients with omphalocele has evolved over the past 4 decades. Despite many improvements in care, the reported mortality has been over 10%.

METHODS

This study reviewed the characteristics, management, and outcome of 31 patients with omphalocele who underwent surgical care between 1980 and 1995 at a single hospital.

RESULTS

Twenty-five patients had additional congenital anomalies. All but 1 patient underwent operative repair; 13 of these patients with large defects had a silo chimney constructed initially. Fourteen patients underwent primary fascial and skin closure at the initial operation. Only 1 patient died perioperatively; another patient died without operation due to other major malformations.

CONCLUSIONS

The results following surgical repair of omphalocele defects depend on the degree of visceroabdominal disproportion and on the severity of associated anomalies. The operative mortality for staged omphalocele repair with limited elevation of intraabdominal pressure is low, and the long-term quality of life of these patients is good.

[Primary abdominal parietorrhaphy and the cure of eventrations with the relon monofilament suture (N.I. 2402/76)]

Primary repair of the abdominal wall and the cure of incisional hernias using the relon mono-filamentous fibres (N.I. 2402/76) Confronted with long lasting parietal suppurations which are entertained by the classic nylon poly-filamentous fibres, suppurations that cannot be avoided unless the above fibres are removed on one hand assuming the risk of a possible subsequent incisional hernias and on the other hand because of the relative elevated price of the mono-filamentous fibres brought from abroad, within the last years (from 1982) we have utilised the relon mono-filamentous fibre (N.I. 2402/76) in abdominal wall reconstruction (initially for the surgical cure of the incisional hernias and there after in primary abdominal wall reconstruction when there were factors predisposing to a possible subsequent parietal for septic contamination, in overweight patients, immune-compromised patients, in patients following steroid therapy, chemotherapy, etc. Our present experience extends over more than 1000 patients who have undertook a surgical procedure.

[Combined laparoscopic surgery]

With minimal and flexible access, combined laparoscopic surgery (CLS) is most suitable to treat several abdominal diseases simultaneously. Among 1000 cases of laparoscopic procedures since 1991, 52 were CLS. They were laparoscopic cholecystectomy (LC) + appendectomy (LA) 24, LC + laparoscopic fenestration of liver cyst (LFLC) 2, LC + laparoscopic herniorraphy (LH) 4, LC + laparoscopic common bile duct exploration (LCBDE) 12, LC + laparoscopic salpingo-ophorectomy 1, LC + laparoscopic removal of leiomyoma of uterus (LRLU) 1, LC + laparoscopic excision of hemangioleiomyolipoma (LEH) in right kidney 1, LH + laparoscopic varicocelectomy (LV) 2, laparoscopic paraesophageal hernia repair + nissen fundoplication 5. CLS was successfully performed laparoscopically without morbidity and mortality. One case of LC + LCBDE and one case of LH + LNF converted to open surgery be cause of unexpected injury of cystic artery and esophageal rupture. Compared with single laparoscopic surgery, CLS did not increase postoperative pain, hospitalization, recovery period, and cost for equipment and instruments. Our results showed that as long as we insist on basic surgical principles, strictly follow operative indications for CLS, more and more patients with multiple abdominal diseases will enjoy minimal access surgery.

[Hernia in children]

Congenital hernia seems to be the right term to define "hernia in childhood". Especially in newborn and infant, it is possible to observe numerous different pathologies which have nothing in common apart their congenital origin. Some as inguinal or umbilical hernia are very commonly encountered and others us omphalocele, gastroschisis or diaphragmatic hernia are quite rare and involved in the field of prenatal diagnosis and neonatal surgery.

A pseudoexstrophy with penile anomaly

Although classical exstrophy of the bladder is not a rare anomaly, variants of exstrophy are extremely uncommon. We report a male pseudoexstrophy case with appearance of a low set umbilicus associated with umbilical hernia and penile anomaly. Although this mild exstrophy variant does not normally require surgical management, penile reconstruction was necessary in our patient.

Fetiform teratoma arising from a tubular intestinal duplication. A probable cause of ruptured exomphalos

A neonate who had a ruptured exomphalos with a fetiform teratoma arising from the end of a long intestinal tubular duplication and a short gut is presented. The management is discussed and the literature is reviewed.

[Incisional hernia after surgical laparoscopy: a case of hepatic ligament incarceration and review of the literature]

The authors report a case of incisonal hernia occurring 5 years after laparoscopic treatment of extra-uterine pregnancy. This involved incarceration of the hepatic suspensor ligament during insertion of a 10 mm umbilical trocard. Laparoscopy permitted diagnosis and treatment of the hernia. Parietal complications after laparoscopy usually concern epigastric vascular lesions, infections at trocard sites, and residual abdominal wall pain. Incisonal umbilical and extra-umbilical hernias, described for the first time in 1968, are highly unusual complications, with an incidence of 21/100,000 in the Mintz study. The hernia sac usually contains omentum or small intestine. The present observation alems to be the first case of incarceration of the hepatic suspensor ligament in an umbilical trocard. This observation is remarkable not only for the hernia sac contents but also for the delay between laparoscopy and the occurrence of the umbilical hernia.

Para-umbilical block: a new concept for regional anaesthesia in children

This preliminary study describes a new technique to provide analgesia in children undergoing umbilical hernia repair. The para-umbilical block consists of infiltrating the anterior cutaneous branches of the two tenth spinal roots over and under the rectus sheath far from the operative field. Intra and postoperative analgesia as well as operative conditions were assessed in 11 children 16.7 +/- 31 months old, weighing 8421 +/- 6941 g, the block being performed before surgery under light general anaesthesia. Intraoperative analgesia, operative conditions and recovery were good in all patients. Analgesia was adequate one h after surgery in ten patients, six h after surgery in eight. The block proved to be safe and on the whole effective in this short series. The study should proceed on a multi-centre basis if possible. Indications can be extended.

Incarcerated umbilical hernia in children

Over a period of 5 years, four cases of incarcerated (one strangulated) umbilical hernia (UH) in children were observed and treated in Saint-Denis, France. In a review of the literature, only 45 descriptions of complicated UHs in children were found worldwide. Incarceration of UHs is considered to be very rare in children, however, it appears to occur more frequently than it is generally believed. Therefore, a more active therapeutic approach is recommended even in smaller hernias, from more than an aesthetic point of view.

Antibiotic prophylaxis in umbilical and incisional hernia repair: a prospective randomised study

OBJECTIVE

To find out if preoperative prophylaxis would reduce infection rates after umbilical and incisional hernia repair.

DESIGN

Randomised controlled trial.

SETTING

Teaching hospital, Israel.

SUBJECTS

35 Patients who presented with umbilical (n = 19) or incisional (n = 16) hernias during a period of 8 months.

INTERVENTIONS

Cefonicid 1 g was given by intravenous infusion to alternate patients 30 minutes before the operation.

MAIN OUTCOME MEASURES

Wound infection.

RESULTS

The groups were comparable for age, body mass index, grade of surgeon, operating time, and size of hernial ring. The wound infection rates were 0/8 compared with 4/8 for incisional hernia repairs (p = 0.08) and 1/9 compared with 4/10 for umbilical hernia repairs (p = 0.3). The overall rate was 1/17 compared with 8/18 (p = 0.02).

CONCLUSIONS

Single dose antibiotic puphylaxis seems to exert a beneficial effect on the wound infection rate after umbilical and incisional hernia repair.

Successful endoscopic balloon dilatation for hypertrophic pyloric stenosis

The authors successfully applied endoscopic balloon dilatation for the treatment of hypertrophic pyloric stenosis (HPS). The patient was an infant girl who had undergone repair of a giant omphalocele. Endoscopic balloon dilatation was performed using a 9-mm endoscope and an 8-mm polyethylene terephthalate (PET) balloon dilator. Dilatation was performed three times for 10 minutes. Vomiting continued after the dilatation. At the second session, dilatation was performed using a 12-mm PET balloon dilator. The 9-mm endoscope then passed through the pylorus. The patient has had no episodes of vomiting since the second treatment. This procedure is an important therapeutic option for selected patients with HPS.

Thrombolytic therapy for treatment of pulmonary embolism in the postoperative period: case report and review of the literature

A patient with morbid obesity and insulin-dependent diabetes was admitted to the surgical intensive care unit, four days status postsurgical repair of an umbilical hernia. A pulmonary embolus (PE) was diagnosed by ventilation/perfusion scan and confirmed by transthoracic echocardiogram. A right ventricular ejection fraction/volumetric/oximetry pulmonary artery catheter revealed a very low ejection fraction and cardiac index. Systemic urokinase therapy was initiated and the patient improved considerably over the ensuing 12 hours. Anesthesiologists must be able to diagnose the signs and symptoms of PE and should be familiar with treatment modalities to reverse right ventricular dysfunction. Review of the literature regarding thrombolytic therapy in the perioperative period indicates potential benefit in select patients.