Ultrasound-Guided Epigastric Hernia Repair in the Pediatric Population: One Institution's Experience and Outcomes

Introduction: Epigastric hernia repair is a common procedure performed on pediatric patients. These hernias have been demonstrated to be readily identified by ultrasound. This manuscript describes and assesses a novel technique in which ultrasound is used to identify and repair the hernias in a minimally invasive manner. Methods: A retrospective chart review evaluates all the ultrasound-guided epigastric hernia repairs done with prolene suture at one institution over 20 months. Operative details and postoperative complications were compared to patients who underwent traditional open epigastric hernia repair at the same institution during the same time frame. Results: Thirty-two pediatric patients underwent epigastric hernia repair between May 2021 and December 2022. Thirteen (41%) underwent the ultrasound-guided technique with prolene suture and using only a meniscus needle and no incision. Nineteen (59%) underwent standard open repair. There were no recurrences or postoperative complications in either group. The average operative time for the ultrasound hernia repair was 24.4 minutes, which was shorter than the average operative time of 33.6 minutes for the open repair (P = .08). In 3 ultrasound cases (23%), an additional epigastric hernia that had not been clinically apparent was identified and simultaneously repaired. Conclusions: Ultrasound-guided epigastria hernia repair is a feasible alternative to traditional open repair. It has a comparable safety and efficacy profile, has a short operative time, and has the advantages of being minimally invasive and having the ability to identify and repair concurrent epigastric hernias.

Peritoneal Bridging Versus Nonclosure in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial

Introduction

Postoperative seroma and pain are common problems following laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernias. These adverse outcomes may be avoided by dissecting and using the peritoneum in the hernial sac to bridge the hernia defect.

Methods

This was a patient- and outcome assessor-blinded, parallel-design, randomized controlled trial comparing nonclosure and peritoneal bridging approaches in patients scheduled for elective midline ventral hernia repair. The primary endpoint was seroma volume on ultrasonography. The secondary endpoints were postoperative pain, recurrence, and complications.

Results

Between November 2018 and December 2020, 112 patients were randomized, of whom 60 were in the nonclosure group and 52 were in the peritoneal bridging group. The seroma volume in the nonclosure and peritoneal bridging groups were 17 cm3 (6-53 cm3) versus 0 cm3 (0-26 cm3) at 1-month follow-up (P = 0.013). The median volume was zero at the 3-, 6-, and 12-month follow-ups in both groups. No significant differences were observed in early postoperative pain (P = 0.447) and in recurrence rate (P = 0.684). There were 4 (7%) and 1 (2%) perioperative complications that lead to reoperations in simple IPOM (sIPOM) and IPOM with peritoneal bridging (IPOM-pb), respectively.

Conclusions

Seroma was less prevalent after IPOM-pb at 1-month follow-up compared with sIPOM, with similar postoperative pain 1 week after index surgery in both groups. At subsequent follow-ups, the differences in seroma were not statistically significant. Further studies are required to confirm these results. Trial registration (NCT04229940).

An incarcerated epigastric hernia containing stomach

Most epigastric hernia contains preperitoneal fat or the omentum. Intraabdominal organ herniation is rare and, if present, contains mostly small bowel. Incarcerated epigastric hernia having the stomach as content is infrequent, and only one case has been reported in the literature so far. Herein, we report a rare case of incarcerated epigastric hernia that contains the stomach and was managed with emergency hernioplasty.

Are Surgeons of the Abdominal Core Health Quality Collaborative Following Guidelines in Umbilical and Epigastric Hernia Repair?

BACKGROUND

Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement.

METHOD

Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance.

RESULTS

Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met.

DISCUSSION

Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost.

Usefulness of dynamic ultrasound in the diagnosis of epigastric herniation of stomach

Introduction

Abdominal wall hernia contents usually consist of omental or mesenteric fat or loops of small or large bowel. Gastric involvement has been only rarely reported.

Case report

We present a case of a 62-year-old woman who was admitted to our hospital due to epigastric pain and vomiting. On physical examination, the only observed abnormality was a soft, painless, epigastric bulge located in the upper midline. Based on the clinical presentation, the patient was diagnosed with a probable epigastric hernia. Dynamic ultrasound evaluation of the palpable bulge confirmed the presence of epigastric hernia demonstrating the movement of abdominal contents through a large wall defect. Surprisingly, the herniated contents were found to contain also the anterior wall of the distal stomach together with omental fat and vessels. The patient opted for surgery, which confirmed the presence of an epigastric hernia containing the distal portion of stomach.

Discussion

In this case, dynamic ultrasound provided added value over computed tomography by clearly demonstrating stomach passing from the abdominal cavity to enter into the hernia sac and it is therefore reported for both its rarity and interest. To our knowledge, this is the first such ultrasound-based case report presented in literature and certainly the best sonographically documented.

Conclusion

We anticiapte that this case report will promote the use of dynamic ultrasound in current practice as an effective imaging tool to recognise unusual types of hernias.

Strangulated Epigastric Hernia: A Rare Occurrence

An epigastric hernia is a rare type of abdominal hernia, described in the literature mostly as small, containing only preperitoneal fat. A large true epigastric hernia with herniation of the abdominal viscera is even rarer. Only a few case reports have given an account of strangulation in such an epigastric hernia. This case report describes a middle-aged, morbidly obese man with a big epigastric hernia presenting with incarceration and acute abdominal pain. Emergency surgical exploration revealed a 7 cm midline defect in the rectus sheath and a 30 cm segment of the jejunum and a 6 cm segment of the transverse colon were gangrenous. The gangrenous bowel segments were resected, and an end-to-end jejuno-jejunal and colo-colic anastomosis were done. The patient had an uneventful postoperative recovery.

Pre-operative ultrasound diagnosis and successful surgery of a stomach incarcerated in epigastric hernia: a rare case report

An incarcerated epigastric hernia (localized in linea alba) is a very rare observation. Here, we present a case of a 66-year-old white male who was admitted to the emergency department due to vomiting and epigastric pain. On physical examination, the only observed abnormality was a painless soft epigastric tumor located in the upper midline, measuring about 12 cm in diameter. The patient claimed that he had the tumor for more than 30 years and it never changed in diameter nor caused him any discomfort. A lipoma was initially suspected. However, an ultrasound of the abdomen revealed an incarcerated stomach, trapped due to the defect in the epigastric abdominal wall. The patient was sent for surgery and the presence of an incarcerated epigastric hernia of the linea alba, which contained the anterior wall of the stomach was confirmed. The presented case confirms that the use of ultrasonography may be an effective method to recognize unusual types of hernias, and that ultrasonography should be routinely used in emergency departments.

Single-incision laparoscopic approach for linea alba hernia in children

Objective:

The aim of this study is to describe the technique and to evaluate the outcome of single-incision laparoscopic (SILC) approach for linea alba hernia in children.

Materials and Methods:

A 2 cm vertical umbilical incision was made and stretched horizontally. A 5-mm trocar was inserted through middle port for the telescope. Another extra-long 5-mm 30° trocar was inserted through the lateral port, 5 mm beside the middle port. The extraperitoneal fat was removed, and the defect of linea alba was repaired after hernial sac was excised. The peritoneum was reconstructed with interrupted suture.

Results:

From May 2014 to May 2015, eight children with linea alba hernia underwent SILC. Pre-operative abdominal ultrasound showed the average diameter of hernia ring was 3.2 ± 0.7 cm. Mean operation time was 32.5 min (range = 30–45 min). Oral intake was resumed during anaesthesia recovery period. All could endure pain and discharge on the post-operative 12 h. There was no post-operative wound infection. The follow-up period was 1–12 months, no recurrence and other complications occurred.

Conclusions:

SILC approach for linea alba hernia is a safe and effective, minimally invasive new technology. The linea alba hernia could be repaired with a cosmetic outcome.

A multicenter prospective study of patients undergoing open ventral hernia repair with intraperitoneal positioning using the monofilament polyester composite ventral patch: interim results of the PANACEA study

Purpose

This study assessed the recurrence rate and other safety and efficacy parameters following ventral hernia repair with a polyester composite prosthesis (Parietex™ Composite Ventral Patch [PCO-VP]).

Patients and methods

A single-arm, multicenter prospective study of 126 patients undergoing open ventral hernia repair with the PCO-VP was performed. Patient outcomes were assessed at discharge and at 10 days, 1, 6, 12, and 24 months postoperative.

Results

All patients had hernioplasty for umbilical (n = 110, 87.3%) or epigastric hernia (n = 16, 12.7%). Mean hernia diameter was 1.8 ± 0.8 cm. Mean operative time was 36.2 ±15.6 minutes, with a mean mesh positioning time of 8.1 ± 3.4 minutes. Surgeons reported satisfaction with mesh ease of use in 95% of surgeries. The cumulative hernia recurrence rate at 1 year was 2.8% (3/106). Numeric Rating Scale (NRS) pain scores showed improvement from 2.1 ± 2.0 at preoperative baseline to 0.5 ± 0.7 at 1 month postoperative (P < 0.001), and this low pain level was maintained at 12 months postsurgery (P < 0.001). The mean global Carolina’s Comfort Scale^® (CCS) score improved postoperatively from 3.8 ± 6.2 at 1 month to 1.6 ± 3.5 at 6 months (P < 0.001). One patient was unsatisfied with the procedure.

Conclusion

This 1-year interim analysis using PCO-VP for primary umbilical and epigastric defects shows promising results in terms of mesh ease of use, postoperative pain, and patient satisfaction. Recurrence rate is low, but, as laparoscopic evaluation shows a need for patch repositioning in some cases, an accurate surgical technique remains of utmost importance.

Isolated congenital cardiac diverticulum originating from the left ventricular apex: Report of a pediatric case

Congenital ventricular diverticulum is a rare cardiac anomaly defined as a localized protrusion of the ventricular free wall. Although, it is usually asymptomatic, complications such as embolism, infective endocarditis, and arrhythmias can occur. The diagnosis can be made by echocardiography, cardiac magnetic resonance imaging, or catheter angiography. Surgical resection is the treatment of choice in symptomatic patients, whereas the management of asymptomatic patients often represents a therapeutic dilemma. We report here, a 9-month-old patient with asymptomatic congenital left ventricular (LV) diverticulum associated with epigastric hernia.

Endoscopic-Assisted Linea Alba Reconstruction plus Mesh Augmentation for Treatment of Umbilical and/or Epigastric Hernias and Rectus Abdominis Diastasis - Early Results

INTRODUCTION

Symptomatic umbilical and/or epigastric hernias are often seen concomitantly with rectus abdominis diastasis (RAD), and suture repair of such defects has a high recurrence rate. In the literature, there are reports of both endoscopic and open techniques for repair of symptomatic umbilical and/or epigastric hernias in association with RAD. This paper now reports on the early results of a hybrid technique used for reconstruction of the linea alba and mesh augmentation [endoscopic-assisted linea alba reconstruction plus mesh augmentation (ELAR plus)].

MATERIALS AND METHODS

Between 15 June 2015 and 31 January 2016, 40 patients with symptomatic umbilical and/or epigastric hernia and concomitant RAD underwent reconstruction of the linea alba using a hybrid technique involving a small umbilical incision and the use of video-endoscopic equipment. The patients comprised 29 men and 11 women with a mean age of 53.6 years and mean BMI of 32.6. The mean operating time was 120 min. The mesh had a mean longitudinal extension of 18.6 cm and transverse extension of 9.1 cm.

RESULTS

Thirty-day follow-up results are available for all patients. Thirty-seven out of 40 patients (92.5%) experienced no postoperative complication. Two cases of discrete impaired umbilical wound healing and one seroma were successfully managed with conservative treatment. On 30-day follow-up, 3 out of 40 patients (7.5%) complained of intermittent pain on exertion, and 2 out of 40 patients (5%) still took painkillers when required.

CONCLUSION

ELAR plus is a novel minimally invasive procedure for repair of symptomatic umbilical and/or epigastric hernias with concomitant RAD. Reconstruction of the linea alba via a minimally invasive access route is able to restore the normal anatomy of the abdominal wall.

Is pooled data analysis of ventral and incisional hernia repair acceptable?

PURPOSE

In meta-analyses and systematic reviews comparing laparoscopic with open repair of ventral hernias, data on umbilical, epigastric, and incisional hernias are pooled. Based on data from the Herniamed Hernia Registry, we aimed to investigate whether the differences in the therapy and treatment results justified such an approach.

METHODS

Between 1st September 2009 and 31st August 2013, 31,664 patients with a ventral hernia were enrolled in the Herniamed Hernia Registry. The implicated hernias included 16,206 umbilical hernias, 3,757 epigastric hernias, and 11,701 incisional hernias. Data on the surgical techniques, postoperative complication rates, and 1-year follow-up results were subjected to statistical analysis to identify any significant differences between the various hernia types.

RESULTS

The laparoscopic IPOM technique was used significantly more often for incisional hernia than for epigastric hernia, 31.3 vs. 24.0%, respectively, and was used for 12.9% of umbilical hernias (p < 0.0001). Likewise, the open technique with suturing of defect was used significantly more often for umbilical hernia than for epigastric hernia, 56.1 vs. 35.4%, respectively, and was used for 12.5% of incisional hernias (p < 0.0001). The postoperative complication rates of 3.2% for umbilical hernia and 3.5% for epigastric hernia were significantly lower than for incisional hernia, at 9.2% (p < 0.0001). That was also true for the reoperation rates due to postoperative complications, of 1.0 vs. 1.2 vs. 4.2% (p < 0.0001). The 1-year follow-up revealed significantly higher recurrence rates as well as rates of chronic pain needing treatment of 6.3 and 7.9%, respectively, for incisional hernia, compared with 4.1 and 4.3%, respectively, for epigastric hernia, and 2 and 1.9%, respectively, for umbilical hernia (p < 0.0001).

CONCLUSION

Since significant differences were identified in the therapy and treatment results between umbilical hernia, epigastric hernia, and incisional hernia, scientific studies should be conducted comparing the various surgical techniques only for a single hernia type.

Shared and nonshared familial susceptibility to surgically treated inguinal hernia, femoral hernia, incisional hernia, epigastric hernia, and umbilical hernia

BACKGROUND

The familial risk of abdominal wall hernia (AWH) is largely unknown. In addition, it is unknown whether inguinal hernia (IH), femoral hernia (FH), incisional hernia (INH), epigastric hernia (EH), and umbilical hernia (UH) share familial susceptibility. The aim of this nationwide study was to determine the familial risks of concordant AWH (same disease in proband and exposed relative) and discordant AWH (different disease in proband and exposed relative).

STUDY DESIGN

Data from the Swedish Multigeneration Register on individuals aged 0 to 78 years were linked to the Swedish hospital discharge register and the Swedish outpatient register for the period from 1964 to 2010. Standardized incidence ratios (SIRs) and 95% CIs for surgically treated IH (n = 209,814 cases), FH (n = 4,576), INH (n = 19,494), EH (n = 8,257), and UH (n = 22,761) were calculated for siblings of individuals with hernia compared with the siblings of unaffected individuals. The procedure was repeated for spouses.

RESULTS

All concordant and most discordant familial sibling risks were increased. Familial concordant SIRs for siblings were IH = 1.97 (95% CI, 1.94-1.99), FH = 3.40 (95% CI, 2.44-4.62), INH = 2.24 (95% CI, 2.04-2.46), EH = 5.57 (95% CI, 4.64-6.64), and UH = 3.61 (95% CI, 3.33-3.91). Concordant familial risks were higher than discordant risks. For example, when the proband sibling had IH, the discordant SIRs were FH = 1.74 (95% CI, 1.61-1.88), INH = 1.22 (95% CI, 1.16-1.28), EH = 1.30 (95% CI, 1.20-1.40), and UH = 1.35 (95% CI, 1.29-1.41). Concordant SIRs for spouses were lower: IH = 1.23 (95% CI, 1.20-1.26), FH = 0.97 (95% CI, 0.64-1.36), INH = 1.56 (95% CI, 1.41-1.71), EH = 1.70 (95% CI, 1.09-2.45), and UH = 1.31 (95% CI, 1.09-1.56).

CONCLUSIONS

Family history of surgically treated AWH is an important risk factor for surgical treatment of AWH. The 5 forms of AWH studied share familial susceptibility, but site-specific familial factors might exist. Several spouse risks were increased, suggesting the possibility of a nongenetic contribution to familial risks.

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair

BACKGROUND

Although the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult.

MATERIALS AND METHODS

Under the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry.

RESULTS

A set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database.

CONCLUSION

An online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.

Seroma and recurrence in laparoscopic ventral hernioplasty

BACKGROUND

Recurrence after laparoscopic ventral hernioplasty is a severe problem despite surgeons' increased experience in recent years. It is well known that the main reasons for recurrences are lack of experience, bad technique, infection, and seroma. The aim of this study was to investigate the events, what caused recurrences, and the technique to prevent recurrence in laparoscopic ventral hernioplasty.

METHODS

From May 1996 through December 2005, 78 patients who underwent 80 laparoscopic ventral hernioplasties (67 incisional hernias, 8 large epigastric, 5 large umbilical) were separated into 2 groups. Group A (n=28): ePTFE dual mesh patch secured intraperitoneally by full-thickness stitches and endoscopic tacks to cover the hernia defect and to overlap healthy margins by at least 2.5 cm (n=17, subgroup A1) or 4 cm (n=11, subgroup A2). In subgroup A2, a full-thickness suture was placed in the center of the hernia defect to reduce the "dead space." Group B (n=52): The same technique as in group A, but the hernia sac was cauterized by monopolar cautery (n=5) or Harmonic scalpel (n=47). The overlapping healthy margins were at least 2.5 cm (n=16, subgroup B1) or 4 cm (n=36, subgroup B2). In subgroup B2, a full-thickness suture was placed in the center of the hernia defect to reduce the dead space. Postoperatively, CT-scans were used to confirm complications or recurrences.

RESULTS

In group A, 7 seromas [4 clinical (A1) and 3 subclinical (A1=1, A2=2)], 3 hematomas (A1=2, A2=1), 2 infections (A1), and 3 recurrences (10.7%) were observed (A1=2 or 11.8%, A2=1 or 9%). Two recurrences were observed in symptomatic seromas (subgroup A1) and 1 in a patient without seroma (subgroup A2). In group B, 1 subclinical seroma, 1 hematoma, and 1 recurrence (6.2%) were noted in subgroup B1. In subgroup B2, no recurrence was observed. Significantly fewer total seromas occurred in group B compared with group A (P=0.004). The total recurrence rate in group B was 1.95% (NS vs group A), but a significant difference was observed between subgroups A1 and B2 (P=0.036).

CONCLUSION

Cauterization of the hernia sac and a central full-thickness suture to reduce dead space seems to prevent seroma. This technique combined with a large patch to cover at least 4 cm of healthy margins and the surgeon's experience may be sufficient to prevent recurrences in laparoscopic ventral hernioplasty.