Tension-free mesh repair of umbilical hernia as a day case using local anaesthesia

Persistent low rates of same-day umbilical hernia repair in Australia over the past 20 years: is there a need to change?

BACKGROUND

Several recent reports have identified significant variations in discharge practices following umbilical hernia repair (UHR). The primary aim of this paper is to determine Australian UHR same day discharge (SDD) rates over the past two decades. Secondary aims are to analyse factors which may contribute to variation in discharge practices, compare Australian UHR SDD rates internationally and determine LOS trends.

METHODS

A retrospective, population-based cohort study was conducted using de-identified data from the Australian Institute of Health and Welfare (1 July 1998 to 30 June 2019). SDD rates and LOS were calculated for age, gender and complexity. Negative binomial models were used to investigate associations between characteristics.

RESULTS

The overall mean UHR SDD rate was 41.2% with a modest improvement over the study period (36.5% to 44.4%, P < 0.0001). The mean LOS was 3.4 days, and this decreased over the study period (P = 0.01). Males had a higher rate of SDD (42.1% vs. 39.4%, P < 0.0001) and shorter LOS (3.0 vs. 3.7 days, P < 0.0001) compared with females. Increased age was associated with decreased SDD (P < 0.0001) and increased LOS (P < 0.0001). Australia's SDD rate was lower than in both New Zealand and the United Kingdom.

CONCLUSION

While SDD and LOS following UHR improved across the study period, SDD rates remain below the RACS recommendation and compare unfavourably internationally. Advancing age and female gender were associated with decreased SDD and increased LOS demonstrating potential areas for improvement. Multiple strategies are discussed to address the persistently low rates of SDD after UHR.

Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital

BACKGROUND

Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population.

METHODS

From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance.

RESULTS

The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m²) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair.

CONCLUSION

Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.

Umbilical Hernia Repair in Cirrhotic Patients With Ascites: A Systemic Review of Literature

BACKGROUND

Umbilical hernia is a common abdominal complication in cirrhotic patients. The incidence of umbilical hernias can be up to 20% in the presence of ascites. However, there is no consensus regarding the optimal management of umbilical hernias in cirrhotic patients. The purpose of this study is to review the management of umbilical hernias in cirrhotic patients with ascites.

METHODS

A search of the available literature in English since 1980 was performed using PubMed, the Cochrane Library, and a search of relevant journals and reference lists. The search terms included "umbilical hernia," "ascites," "cirrhosis," and any derivatives of these terms, and the literature search identified all the relevant publications.

RESULTS

Thirty-three relevant articles published in the language of English were identified. Fourteen studies involved the management of refractory ascites in cirrhotic patients. Twenty-four studies included cirrhotic patients receiving elective or emergency surgery. Because of much lower morbidity and mortality in elective surgery than in emergency surgery, many authors advocated early elective repair of uncomplicated umbilical hernias in cirrhotic patients. Of these, 2 studies described laparoscopic umbilical hernioplasty, with a significant lower morbidity and hernia recurrence than open repair. Fifteen studies described the use of prosthetic mesh umbilical hernia repair in cirrhotic patients, which was associated with minimal wound-related morbidity and markedly lower recurrences.

CONCLUSIONS

Our results indicate that early elective repair of uncomplicated umbilical hernias is recommended in cirrhotic patients with tolerable hepatic functional reserve or when the expected time for liver transplantation is >3 months. Umbilical hernias are supposed to be corrected in the process of liver transplantation, provided that patients could have a better prospect to be transplanted within 3 months. Control of ascites is a crucial part to successful outcomes of umbilical hernia repair. Large volume paracentesis, concomitant peritoneovenous shunting with herniorrhaphy and transjugular intrahepatic portosystemic shunting can be applied to control refractory ascites. Emergency repair of umbilical hernias is indicated in cirrhotic patients with ascites when complications develop.

Repair of a medium-sized ventral hernia with the UltraPro Hernia System

Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.

Local anaesthetic repair of paraumbilical hernia as a safe option across a range of body mass indices

INTRODUCTION

Local anaesthetic repair of paraumbilical hernia (PUH) is a commonly performed operation. The aim of this study was to investigate whether local anaesthesia (LA) repair of PUH was feasible in patients with a high body mass index (BMI) and whether BMI had an impact on patient reported pain scores.

METHODS

Patients undergoing PUH repair under the care of single consultant in a district general hospital between March 2010 and January 2018 were recruited. Patient demographics, BMI, duration of operation, volume of LA infiltrated and grade of operating surgeon were available from the consultant's database. The database also included prospectively recorded patient reported pain scores based on a numerical scale (0-100) and overall patient satisfaction measured as a percentage. Patients were divided into three BMI categories: <25kg/m², 25-30kg/m² and >30 kg/m².

RESULTS

A total of 123 patients underwent PUH repair under LA during the study period. Six patients had no recorded BMI and were excluded from the analysis. Of the remaining 117 patients, 36 (31%) were in the normal BMI range, 35 (30%) in the overweight range and 46 (39%) in the obese range. There was no statistically significant difference between the BMI groups in terms of volume of LA used, duration of operation, postoperative pain scores or patient satisfaction.

CONCLUSIONS

LA repair of PUH is feasible for patients with a raised BMI and does not result in higher postoperative pain scores or the need for higher doses of LA.

Tentacle-shaped mesh for fixation-free repair of umbilical hernias

Purpose

Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique.

Methods

A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect.

Results

In a mean follow-up of 48 months (range 10–62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported.

Conclusions

The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Mesh repair of paraumblical hernia, outcome of 58 cases

Background

According to the literature, defects in para-umbilical hernias up to 2 cm in diameter could be sutured primarily. For defects larger than 2 cm in dimeters, mesh repair is recommended. The aim of this study is to evaluate the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Methods

In this retrospective study, patients with para-umbilical hernia, who were managed by onlay mesh placement were presented, and followed for 1–6 years. Several variables were studied including patients' socio-demographic data, post-operative complications, morbidity and mortality.

Results

The series includes 58 patients, the age ranged from 18 to 85 years with median age of 44 years and inter-quartile range of 13.5 years. Mean body mass index was (30.9 ± 4.2). From 49 female patients; 43 (87.8%) were multipara. Forty seven cases (81%) presented for the first time, and 11 cases (19%) had recurrent hernias. Twenty patients (34.5%) had hernia defect ≤2 cm, while 38 patients (65.5%) had hernia size >2 cm. Superficial surgical site infection was found in 6 patients (10.34%). Seroma was found in one female patient (1.72%). One patient (1.72%) had recurrent hernia after 19 months.

Conclusion

Mesh onlay repair by open surgery can be applied to all sizes of para umbilical hernias, it has low recurrence rate and the rates of morbidity and recurrence are comparable with international standard.

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Defect in para-umbilical hernias up to 2 cm in diameter may be sutured primarily. For defects larger than 2 cm, mesh repair is recommended.

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A retrospective study of 58 paraumblical hernias that were treated with onlay mesh.

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The aim of this study is to confirm the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Incarceration of a pedunculated uterine fibroid in an umbilical hernia

Uterine fibroids are common benign tumors that may cause an umbilical hernia in patients with increased intra-abdominal pressure due to pregnancy, obesity, ascites, and intra-abdominal tumors. However, the simultaneous occurrence of uterine fibroids and umbilical hernias, or fibroids and an associated umbilical hernia, during pregnancy has rarely been reported. Here, we present the case of a fibroid presenting as an incarcerated umbilical hernia in a menopausal patient.

The feasibility of local anesthesia for the surgical treatment of umbilical hernia: a systematic review of the literature

Background

Yearly approximately 4500 umbilical hernias are repaired in The Netherlands, mostly under general anesthesia. The use of local anesthesia has shown several advantages in groin hernia surgery. Local anesthesia might be useful in the treatment of umbilical hernia as well. However, convincing evidence is lacking. We have conducted a systematic review on safety, feasibility, and advantages of local anesthesia for umbilical hernia repair.

Methods

A systematic review was conducted according to the PRISMA guidelines. Outcome parameters were duration of surgery, surgical site infection, perioperative and postoperative complications, postoperative pain, hernia recurrence, time before discharge, and patient satisfaction.

Results

The systematic review resulted in nine included articles. Various anesthetic agents were used, varying from short acting to longer acting agents. There was no consensus regarding the injection technique and no conversions to general anesthesia were described. The most common postoperative complication was surgical site infection, with an overall percentage of 3.4%. There were no postoperative deaths and no allergic reactions described for local anesthesia. The hernia recurrence rate varied from 2 to 7.4%. Almost 90% of umbilical hernia patients treated with local anesthesia were discharged within 24 h, compared with 47% of patients treated with general anesthesia. The overall patient satisfaction rate varied from 89 to 97%.

Conclusion

Local anesthesia for umbilical hernia seems safe and feasible. However, the advantages of local anesthesia are not sufficiently demonstrated, due to the heterogeneity of included studies. We, therefore, propose a randomized controlled trial comparing general versus local anesthesia for umbilical hernia repair.

Current options in umbilical hernia repair in adult patients

Umbilical hernia is a rather common surgical problem. Elective repair after diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh can be placed through either an open or laparoscopic approach with good clinical results. Standard polypropylene mesh is suitable for the open onlay technique; however, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may result in recurrence. Obesity, ascites, and excessive weight gain following repair are obviously potential risk factors. Moreover, smoking may create a risk for recurrence.

Local anaesthetic repair of uncomplicated paraumbilical hernia without sedation: peri-operative pain and patient satisfaction

PURPOSE

Paraumbilical hernia (PUH) is a common condition that usually requires surgical repair. However, there is a dearth of literature on this surgery performed under local anaesthesia (LA) without the use of sedation. The aims of this study were to assess peri-operative pain and patient satisfaction in patients undergoing PUH repair using LA without sedation.

METHODS

All patients having PUH repair under a single consultant between January 2010 and December 2011 were eligible to participate. If eligible for both, patients chose either general anaesthetic (GA) or LA repair. If only eligible for either LA or GA, they were offered this anaesthetic modality. Visual analogue scales were used to report peri-operative pain (10 point score) and satisfaction (%). Results were compared by grade of surgeon (higher surgical trainee (HST) versus consultant).

RESULTS

A total of 63 patients underwent PUH repair (31 GA; 32 LA). Of them, only 28/32 of LA repair patients agreed to participate. LA and GA patients had equivalent age and sex distribution. LA patients had a lower body mass index (BMI) than GA [27.1 (3.7) versus 30.3 (5.1), p = 0.007]. The median length of LA procedure was 24 (17.5-30) minutes. The median LA solution infiltrated was 25 (20-32) ml. Peri-operative pain scores were low [1.1 (0.3-2.9) %] and patient satisfaction was high [96 (91-99) %]. There were no differences in pain, patient satisfaction, duration of procedure and amount of LA infiltrated with increasing BMI. Comparing HST to consultant, the former took longer [30 (25-36) versus 20 (16-24) minutes, p = 0.0007], infiltrated more LA [34.5 (26-47) versus 20 (19-25.5) ml, p = 0.0039], and patients reported more pain [2.75 (1.0-4.95) versus 0.4 (0.2-1.7) %, p = 0.029], but overall satisfaction was equivalent [95.5 (89-99.25) versus 96.3 (92.25-99) %, p = 0.684].

CONCLUSION

Open mesh PUH repair using LA without sedation is associated with low peri-operative pain and very high satisfaction when either a higher surgical trainee or a consultant grade is operating.

Incisions do not simply sum

BACKGROUND

Critics of minimally invasive methods sometimes argue that the summed lengths of all trocar sites have a morbidity similar to that for an open incision of equal length. This argument assumes correctly that pain and scarring are proportional to the total tension normal to a linear incision. But the argument also assumes that total tension sums linearly with incision length. This report demonstrates why that premise is not valid.

METHODS

Wounds of various sizes are compared using a simple mathematical model. The closing tension perpendicular to any linear incision is a function of the incision's length, varying symmetrically together with a maximum at the midpoint of length. If tension rises linearly across an incision, integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length. In this report, incisions of various lengths are modeled, and plausible alternative incision scenarios for various procedures (e.g., Nissen, appendectomy) are compared.

RESULTS

Total tension rises nonlinearly with increasing wound length. Thus, total tension across multiple incisions is always less than the total tension for an incision of the same total length. For example, an open appendectomy creates 2.7-fold more wound tension than a laparoscopic appendectomy. Similarly, two 3-mm trocars create less total tension than a single 5-mm trocar.

CONCLUSION

Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length. This inequality yields three clinically relevant corollaries. First, it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar. Second, addition of a trocar in difficult cases adds relatively little morbidity. Finally, using two small trocars is better than using a single larger trocar.

Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial

PURPOSE

The optimal management of complicated umbilical hernia in patients with liver cirrhosis is still undefined. The purpose of this study is to evaluate the use of polypropylene mesh to treat complicated umbilical hernia in cirrhotic patients.

METHODS

In the period from January 2005 to May 2008, 80 patients with complicated umbilical hernia combined with liver cirrhosis underwent hernia repair. The patients were randomly divided into two groups; each group consisted of 40 patients. Hernia repair was carried out by conventional fascial repair in group I and by mesh hernioplasty in group II.

RESULTS

The male/female ratio, Child-Pugh class, and mode of hernia complication were almost matched in both groups. Hernia recurrence was significantly less in the mesh hernioplasty group. No mesh exposure or fistulae were experienced. There was no need to remove any of the meshes.

CONCLUSIONS

Permanent mesh can be used in complicated hernias in cirrhotic patients with minimal wound-related morbidity and a significantly lower rate of recurrence.

Incarceration of umbilical hernia during pregnancy due to a sessile fibroid

The incidence of both umbilical hernias and fibroids during pregnancy is reported to be rare. Another rare entity is the incarceration of fibroids in pregnancy. We report here the case of a 30-year-old woman in her 32nd gestational week with an incarcerated umbilical hernia. She was operated on an emergency basis, the sessile fibroid was mobilized and the hernia defect was repaired with the Mayo technique. No complications were observed during the post-operative period. She gave birth to a baby girl during the 38th gestational week by means of a cesarean section. The possibility of a fibroid entrapped in the hernial sac should always be taken into consideration at the evaluation of incarcerated hernias during pregnancy. If the contents of the hernial sac cannot be pushed into the abdominal cavity easily, an emergency operation should be considered as a means to prevent further complications related to pregnancy.

Ambulatory surgery of umbilical, epigastric and small incisional hernias: open preperitoneal flat mesh technique in local anaesthesia

Introduction. The dilemma whether to use the mesh or non mesh technique in the management of umbilical, epigastric and small incisional hernia is slowly fading away. The open preperitoneal "flat mesh" technique performed as ambulatory surgery may be one of the solutions. The Aim. The aim of this retrospective study is to present the results of open preperitoneal "flat mesh" technique in the management of umbilical, epigastric and small incisional hernia within Material and methods. This study included 34 patients (11 of them with umbilical, 13 with epigastric and 8 of them with small incisional hernia) operated by one surgeon in the period January 2004 - January 2006. Results. The median operative time was 52 minutes for umbilical hernia?s, 43 minutes for epgastric and 54 minutes for incisional hernia?s. The ambulatory surgery was performed at 91% of patients. The median hospitalization was 4h for patients with umbilical hernia?s, 3,7h for patients with epigastric and, 7,7h for patients with small incisional hernia. The follow up is 10,5 months. Apart of one superficial infection other complications were absent. Conclusion. The open preperitoneal "flat mesh" technique performed in local anesthesia as an ambulatory surgery provides good results in the management of umbilical, epigastric and small incisional hernia.

Prospective study on the presentation and outcome of patients with an acute hernia

Recent advances in hernia surgery should help to make operation more acceptable to patients and their doctors. The aim of this study was to prospectively assess the presentation and management of patients with an acute hernia in light of these changes. Data on all patients admitted with an acute hernia between March 2001 and February 2004 was entered on a prospective database. During the 3 year study period, of the 91 patients admitted with an acute hernia, 41 were ventral, 24 femoral, 24 inguinal and 2 parastomal. Forty-six had a previous medical assessment, 18 of these had been declared unfit for operation at that assessment; ten were ASA4 (ASA, American Society of Anaesthesiology), five ASA3 and three ASA2. Eleven patients were on the waiting list for operation, three of whom had a previous acute hospital admission. For 30 patients this hospital admission was the first indication that they had a hernia while the remaining were aware that they had a hernia but did not seek medical advice. Of the five patients who died, two while being assessed for operation and three postoperatively, three were ASA4 and had a ventral hernia while two were ASA3 with a femoral hernia. Despite advances in hernia surgery there is still room for improvement in preoperative assessment of patients presenting with an acute hernia.

Long-term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and mesh repair

Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n = 37). In 12 patients (11%) umbilical hernia repair was achieved with mesh implantation. Fourteen umbilical hernia recurrences were noted (13%); none had been repaired using mesh. No relationship was found between wound infection or obesity and umbilical hernia recurrence. In the light of these results it is necessary to re-evaluate our clinical "guidelines" on mesh placement in umbilical hernia repair: apparently not every umbilical fascial defect needs mesh repair. Research should focus on establishing risk factors for hernia recurrence.

Retrospective comparison of mesh and sutured repair for adult umbilical hernias

Adult umbilical and paraumbilical hernia repair is associated with a high recurrence rate of 10-30%. Mesh repair has been reported to be associated with low recurrence rates. This study aims to compare sutured repair with prosthetic mesh repair to evaluate recurrence and infection rates. A retrospective study was conducted over an 8-year period including all the umbilical and paraumbilical hernia repairs performed by one consultant surgeon. The hernias were repaired using interrupted suture, Mayo overlap, flat mesh and mesh plug techniques. The study was based on case-note review, telephone and postal questionnaire survey. A total of 100 patients were studied, of which 70 had paraumbilical hernias, 28 had umbilical hernias and 2 had both types of hernia. Median age was 56 years (range 19-90 years). A total of 61 patients had suture repair (50 interrupted suture repair, 11 Mayo) and 39 had prosthetic mesh repair (33 mesh plug, 6 flat mesh). The median body mass index (BMI) was 31.2 (range 23.4-44.5) in the suture repair group and 33.3 (range 24.1-59.1) in the mesh group, with no significant statistical difference in BMI between the two groups (P>0.05). Median follow-up was 4.5 years (range 1-8 years). Recurrence rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Infection rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Our data suggest that prosthetic mesh repair is ideal for managing primary and recurrent umbilical hernias in both obese and non-obese patients.