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.

The analgesic efficacy of transversus abdominis plane block vs. wound infiltration after inguinal and infra-umbilical hernia repairs: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Both transversus abdominis plane (TAP) block and wound infiltration with local anaesthetic have been used to relieve pain after inguinal or infra-umbilical hernia repair.

OBJECTIVES

To determine whether TAP block or local anaesthetic infiltration is the best analgesic option after inguinal or infra-umbilical hernia repair.

DESIGN

Systematic review and meta-analysis with trial sequential analysis.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science, up to June, 2020.

ELIGIBILITY CRITERIA

We retrieved randomised controlled trials comparing TAP block with wound infiltration after inguinal or infra-umbilical hernia repair. Primary outcome was rest pain score (analogue scale 0 to 10) at 2 postoperative hours. Secondary pain-related outcomes included rest pain score at 12 and 24 h, and intravenous morphine consumption at 2, 12 and 24 h. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, haematoma, visceral injury and systemic toxicity of local anaesthetic.

RESULTS

Seven trials including 420 patients were identified. There was a significant difference in rest pain score at 2 postoperative hours in favour of TAP block compared with wound infiltration, with a mean (95% confidence interval) difference of -0.8 (-1.3 to -0.2); I2  = 85%; P   =  0.01. Most secondary pain-related outcomes were also significantly improved following TAP block. No complication was reported. The overall quality of evidence was moderate.

CONCLUSION

There is moderate level evidence that TAP block provides superior analgesia compared with wound infiltration following inguinal or infra-umbilical hernia repair.

TRIAL REGISTRY NUMBER

PROSPERO CRD42020208053.

Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum

Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.

A novel technique to treat ruptured umbilical hernias in patients with liver cirrhosis and severe ascites

The full-thickness skin erosion (rupture) of an umbilical hernia in a patient with end-stage liver disease can lead to significant morbidity and mortality. Here, we present a case report of the use of a novel technique to treat a patient with this condition. The use of a fibrin-based tissue adhesive provides a means of managing such patients medically.

Management of ventral hernia after giant exomphalos with external pressure compression using helmet device

PURPOSE

The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele.

METHODS

The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation.

RESULTS

The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia.

CONCLUSIONS

The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.

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.

Use of mercurochrome in the management of the large exomphalos

The topical application of solutions containing mercury has remained popular in the conservative management of the large exomphalos, despite recent reports of high organ mercury levels occurring in neonates who have died following this type of treatment. There are few reports of mercury poisoning being recognized in survivors. This report records blood and urine mercury levels in four patients with no apparent sequelae after treatment with Mercurochrome and provides guidelines for the safer use of mercurial solutions in the conservative management of exomphalos: one thin application of 1% Mercurochrome be applied to the intact sac; thereafter, Mercurochrome be applied sparingly only to areas that remain moist; blood and urine levels of mercury be monitored routinely; and applications ceased whenever mercury levels exceed the minimum toxic level. Only with this sparing and judicious use of mercurial solutions is the hazard to the infant kept to a minimum.

[Omphalocele: 10-year-experience]

We review our experience of 32 cases of omphalocele treated in the last ten years. Improved neonatal intensive care unit, as well as other support care measures, allowed to extend even to the large defects the indication to radical primary repair. Our experience has supported that this is the method of choice in almost all cases. At present the surgical success depend on associated anomalies, cardiac especially (25% in our series), and on development of sepsis. Analysis of the results shows an overall mortality rate of 41% in the period 1973/1982, significantly decreased to 33% in the last five years.

[Suggestion for treatment of primarily inoperable omphalocele (author's transl)]

Bending primarily inoperable omphalocele can be avoided by simply using Stülpa tube-dressing together with a spongering. Epithelising under the employment of tannin or Betaisodona becomes much easier if this method is used.

Mercury poisoning from mercurochrome therapy of an infected omphalocele

A neonate with an infected omphalocele was treated locally with merbromin (mercurochrome) for five days. Extensive skin peeling with bullous lesions, edema, and fever developed three days after mercurochrome therapy. The infant died on the ninth day. Autopsy revealed evidence of heavy metal poisoning of the kidney, excessive mercury levels in the blood, and in tissues of the brain, kidney, and liver.

Organ mercury levels in infants with omphaloceles treated with organic mercurial antiseptic

Samples of fresh and fixed tissues from infants with exomphalos treated by thiomersal application were analysed for mercury content. The results showed that thiomersal can induce blood and organ levels of organic mercury which are well in excess of the minimum toxic level in adults and fetuses. The analysis of fresh and fixed tissues must be carefully controlled against normal tissues in order to interpret mercury levels accurately.