Prosthetic repair of umbilical hernias in adults with local anesthesia in a day-case setting: a comprehensive report from a specialized hernia center

The feasibility and safety of ventral hernia repairs under local anaesthesia: a systematic review

BACKGROUND

Ventral hernias represent a significant global healthcare burden. Repair under local anaesthesia (LA) provides benefits to patients, hospitals and economies. While inguinal hernia repair under LA has been established, this has not translated to other abdominal wall hernias. This systematic review evaluates the feasibility, safety, and efficacy of performing these repairs under LA.

METHODS

A systematic review was conducted using OVID® EMBASE and MEDLINE to review articles published between 1966 and 2023. Thirty-three papers were included examining variables such as type of hernia, complications, cost-effectiveness, LA used and length of stay. All papers were quality assessed using the ROBINS-I tool. Papers assessing inguinal hernias were excluded.

RESULTS

13,491 patients underwent ventral hernia repair under LA. Complication rates for LA repairs are low, with wound infections and hematomas ranging from 0.3 to 2%. Recurrence rates were also low (0.3-2.5%). Early mobilisation and same-day discharge were notable benefits, with over 97% of patients ambulatory within hours. Postoperative pain was minimal, contributing to high patient satisfaction rates (90-97%). LA repairs proved especially beneficial for high-risk groups, including elderly and frail patients. However, these findings were only seen in hernia defects less than 5 cm. Heterogeneity among study populations, small sample sizes, and lack of standardisation in LA administration were noted.

CONCLUSION

This review supports the broader implementation of LA for ventral hernia repairs in small defects (< 5 cm), demonstrating its safety, feasibility, and patient acceptability. Careful patient selection for standardisation of best practices for LA hernia repairs offers the potential for significant cost-savings with overall favourable outcomes.

Laparoscopic subcutaneous onlay mesh repair for ventral hernia: Our early experience

Introduction

Repair of the ventral hernia is an ongoing challenge in surgery, and a number of surgical techniques have been developed ranging from direct suturing techniques to the use of various mesh types in different planes of the abdominal wall to close the defect and strengthen the musculofascial tissue. Laparoscopic subcutaneous onlay mesh (SCOM) repair is a novel procedure developed recently for ventral hernia repair. We would like to share our experience with laparoscopic SCOM repair.

Patients and Methods

This is a prospective observational study of patients who have undergone ventral hernia repair at Bangalore Endoscopic Surgery Training Institute and Research Centre from June 2020 to June 2022. A total of 20 patients are included in this study.

Statistical Analysis Used

The data were entered into MS Excel and analysed.

Results

A total of 20 patients underwent SCOM repair with a defect size measuring up to 8 cm × 8 cm and a mean operative time of 117 min. Three patients had seroma formation and one patient had surgical site infection. No recurrence is seen after 1-year 2-month follow-up.

Conclusion

SCOM repair is the newer approach to ventral hernia repair with the advantage over open onlay mesh repair in terms of less pain and better cosmesis. SCOM repair avoids intraperitoneal dissection which may lead to visceral injuries as well as subsequent intraperitoneal adhesions. The acceptance of such surgeries would depend on further long-term studies.

Ventral Hernia Repair Using Ventralex® ST Patch: A Single-Center Study of Clinical Outcomes and Complications

Background

Ventralex® ST (Bard Davol Inc, Warwick, RI) patch is a composite self-expanding and non-absorbable mesh used to reinforce ventral hernia repair. This study was conducted to assess the efficacy, post-operative clinical outcomes, the duration of operation, and complications deciding the post-operative duration/need of hospitalization in patients of small ventral hernia after their open surgical repair using Ventralex ST hernia patch.

Materials and methods

We included 36 patients diagnosed with a small (<2 cm defect size) ventral hernia who underwent open mesh repair following strict surgical methodology using Ventralex® ST hernia patch between September 2018 and April 2020. It was a prospective observational study. Clinically relevant characteristics, along with operative and post-operative data collected through direct interview, clinical examination, and a pretested proforma, were analyzed prospectively.

Results

Thirty-four patients (94.5%) were observed to have an operative time of fewer than 60 minutes, with an average duration of 30-40 minutes. Thirty-one patients (86%) were discharged within 48 hours of surgery, out of which 17 patients (47.2%) were discharged within 24 hours of surgery and 14 patients (38.8%) within 48 hours. Only five patients (13.88%) had a prolonged hospital stay for more than 48 hours due to post-operative complications. Three patients (8.33%) acquired post-surgical wound infection, whereas two (5.55%) developed seroma. Nevertheless, just one patient (2.7%) reportedly developed both infection and seroma after surgery. No cases of mesh infection or recurrences were noted.

Conclusion

This study demonstrates that open repair of small (<2 cm defect size) ventral hernia using the Ventralex® ST hernia patch can be an extremely safe and effective method. Furthermore, it has excellent clinical outcomes when meticulously used with an easily reproducible surgical technique, which requires less intra-operative time, has minimal post-operative complications and negligible recurrence rate, along with reduced post-op hospital stay (86% of patients being discharged within 48 hours).

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.

Management of epigastric, umbilical, spigelian and small incisional hernia as a day case procedure: results of long-term follow-up after open preperitoneal flat mesh technique

PURPOSE

To investigate short and long-term outcome after the open preperitoneal flat mesh technique (OPFMT) for umbilical, epigastric, spigelian, small incisional and "port-site" hernia performed as a day case procedure.

METHODS

We retrospectively analyzed records of patients who underwent OPFMT for umbilical, epigastric, Spigelian, small incisional and "port-site" hernia in ambulatory settings between 2004 and 2020 at Clinical Center of Serbia. Demographic and clinical characteristics, operative data and postoperative complications were compared between the groups. Univariate and multivariate analyses were performed to identify predictive factors for mesh infection and recurrence.

RESULTS

Overall, 476 patients were divided according to the type of hernia. Early postoperative complications were similar in all study groups. Mesh infection, chronic pain and recurrence were different between groups (p = 0.013, p = 0.019 and p = 0.011, respectively). Overall recurrence rate after OPFMT was 2.5%. Hernia defect, hematoma and length of postoperative stay at the Day Surgery Unit were identified as potential predictors of mesh infection (Odds ratio 6.449, 22.143 and 1.546, respectively; p = 0.027, p = 0.011 and p = 0.038, respectively) while mesh infection was the only potential predictor of recurrence in univariate analysis. Hematoma was an independent predictor of recurrence (Odds ratio 27.068; 95% Confidence interval 2.355-311.073; p = 0.008).

CONCLUSION

The OPFMT performed under local anesthesia as a day case procedure is a safe technique associated with favorable long-term outcome. Hematoma is an independent predictor of mesh infection occurrence.

Local Anesthesia is Associated with Fewer Complications in Umbilical Hernia Repair in Frail Veterans

BACKGROUND

The optimal anesthesia modality for umbilical hernia repair is unclear. We hypothesized that using local rather than general anesthesia would be associated with improved outcomes, especially for frail patients.

METHODS

We utilized the 1998-2018 Veterans Affairs Surgical Quality Improvement Program to identify patients who underwent elective, open umbilical hernia repair under general or local anesthesia. We used the Risk Analysis Index to measure frailty. Outcomes included complications and operative time.

RESULTS

There were 4958 Veterans (13%) whose hernias were repaired under local anesthesia. Compared to general anesthesia, local was associated with a 12%-24% faster operative time for all patients, and an 86% lower (OR 0.14, 95%CI 0.03-0.72) complication rate for frail patients.

CONCLUSIONS

Local anesthesia may reduce the operative time for all patients and complications for frail patients having umbilical hernia repair.

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.

Enhanced ambulatory male urethral surgery: a pathway to successful outpatient urethroplasty

Background

Length of stay following anterior urethroplasty (AU) surgery has progressively shortened over the past two decades with most patients discharging the day of surgery or following overnight observation. We sought to assess overall analgesia and patient satisfaction with same-day discharge after AU surgery.

Methods

Our prospectively maintained anterior urethroplasty database was reviewed. Men were identified who underwent anterior urethroplasty surgery by a single surgeon (B.R.V.) with the Enhanced Ambulatory Male Urethral Surgery (EAMUS) protocol followed by same-day discharge. Patients were contacted within 3 weeks of surgery and completed validated assessment tools to characterize satisfaction with the outpatient experience and with analgesia management. A statistical analysis was performed to assess predictors of overall satisfaction with same-day discharge following AU surgery.

Results

Fifty-seven patients with median age 52.2 years underwent same-day AU surgery between August 2017 and October 2018. In total, 46 patients (80.7%) responded to post-discharge surveys assessing overall outpatient satisfaction and satisfaction with analgesia. Median satisfaction with outpatient experience (scale 1-5) was 5 (IQR 4, 5) with 93.4% of patients indicating they were satisfied to very satisfied (4 or 5). Median patient satisfaction with analgesia (scale 1-6) was 6 (IQR 5, 6) with 93.4% of patients indicating a satisfaction with analgesia score of ≥5 (satisfied to very satisfied). Median number of 5 mg oxycodone tablets used following discharge was 3 (IQR 0.75, 5). Postoperative complications occurred in 14 patients (25%) with 12 (86%) being low grade complications (Clavien-Dindo Classification ≤ II).

Conclusions

With appropriate preoperative education and peri-operative analgesia, anterior urethroplasty surgery can be performed with same-day discharge with comparable postoperative complication rates while maintaining excellent patient satisfaction. Additional high volume, prospectively collected studies are necessary to verify short-term satisfaction rates while confirming long-term urethroplasty success rates remain comparable to AU surgery performed with next day discharge.

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.

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.

Day case hernia repair: weak evidence or practice gap?

BACKGROUND

Analysis of a private insurer's administrative data set revealed significant variation in the length of hospital stay following hernia surgery.

OBJECTIVES

This review examined factors influencing the performance of day surgery for inguinal, femoral and umbilical hernia repair in adults.

DATA SOURCES

A systematic literature search was conducted in the PubMed, Embase and Cochrane Library databases to identify studies and clinical practice guidelines (CPGs) comparing same day hernia surgery to surgery followed by an overnight stay.

REVIEW METHODS

Screening of studies by abstract and full text was completed by a single researcher and checked by a second. Studies were selected for inclusion based on a step-wise approach across three phases.

RESULTS

Limited evidence from one systematic review, and three case series studies including 3213 patients found that same day hernia surgery was as safe and effective as an overnight stay. All identified CPGs recommended a same day procedure for most patients. Two case series studies reported that 3-8% of patients were ineligible for day procedures due to medical reasons; however, the characteristics of patients, in general, which are not suitable, have not been adequately investigated.

CONCLUSIONS

Day surgery for groin hernia repair is safe and effective for most patients. However, evidence-based support is only one of many factors that may contribute to the uptake of day surgery in Australia. There is an opportunity for key stakeholders across the private healthcare system to deliver an equally effective but more sustainable and affordable hernia care by increasing the day surgery rates.

Prospective Analysis of Epigastric, Umbilical, and Small Incisional Hernia Repair Using the Modified Kugel Oval Patch

The study was performed to determine the complication and recurrence rate using the modified Kugel oval patch for small ventral hernia repair. Another aim of the study was to find risk factors for recurrence in patients with this repair. Seventy-three patients underwent ventral hernia repair with the modified Kugel oval patch between April 2013 and February 2015. Prospective follow-up data (18 months postoperative) were collected and evaluated. A total of 58 primary (18 epigastric/40 umbilical) and 15 incisional ventral hernias were repaired with the modified Kugel oval patch (7.6/10.2 cm/8 x 12 cm). We found three patients suffered superficial wound infection and two participants got hernia recurrence. Placement of mesh was found to be a significant risk factor for hernia recurrence. Small ventral hernia repair using the modified Kugel oval patch is a novel and useful approach and we recommend placing the patch preperitoneally.

Preventive Effects of Pre- and Intra-operative Marcaine, Lidocaine, and Marcaine Plus Lidocaine on Pain Relief in Lumbar Disc Herination Open Surgery

BACKGROUND

As marcaine is administered to a great extent due to minor complications and reasonable expenses and as discectomy is prevalently used in Iran, this study makes a comparison between effect of marcaine alone, lidocaine alone, and marcaine plus lidocaine on pain relief of patients undergoing lumbar disc open surgery.

MATERIALS AND METHODS

In a clinical trial study, 192 patients were selected and randomly divided into four groups. Patients in Groups 1-4 received 0.5 ml marcaine during surgery, 5 ml lidocaine 2% before incision, 5 ml lidocaine 2% before incision plus 5 ml marcaine during surgey and normal saline, respectively. After patients gained knowledge of visual analog scale (VAS) criteria, their severity of pain was measured and was recorded in their profiles, along with demographic details and history of diseases. After surgery and their transfer to their rooms, their severity of pain was measured and recorded again by using VAS criteria. Finally, difference between the four groups was compared by SPSS software.

RESULTS

The mean (±standard deviation) of postoperative pain in marcaine + lidocaine, marcaine, lidocaine, and normal saline was 3.5 ± 1.3, 3.5 ± 1.6, 36.1.9, and 4.2 ± 1.8, respectively, and we did not observe any significant difference in severity of pain after surgery in these groups (P = 0.15). The highest and lowest degree of satisfaction occurred in marcaine-lidocaine group and control group, respectively, (40 patients [83.3%] vs. 25 patients [52.1%]).

CONCLUSION

Lidocaine-marcaine treatment reduces the need to opiates in cases of postoperative pain relief of discectomy and provides patients with great satisfaction.

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 Trends in Laparoscopic Ventral Hernia Repair

Background and Objectives:

The purpose of this study was to analyze the surgical technique, postoperative complications, and possible recurrence after laparoscopic ventral hernia repair (LVHR) in comparison with open ventral hernia repair (OVHR), based on the international literature.

Database:

A Medline search of the current English literature was performed using the terms laparoscopic ventral hernia repair and incisional hernia repair.

Conclusions:

LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. Incidental enterotomy can be avoided by using a meticulous technique and sharp dissection to avoid thermal injury.

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.

Laparoscopic tension-free abdominal wall repair: impact of mesh size and of different fixation devices in a consecutive series of 120 patients

PURPOSE

To assess the impact of mesh size and fixation devices on short-term outcomes in a consecutive series of tension-free laparoscopic abdominal wall repairs.

METHODS

Data for 120 consecutive, unselected patients undergoing tension-free laparoscopic incisional (n=63) or umbilical (n=57) hernia repair were prospectively collected. A multivariate analysis was performed to evaluate variables influencing outcomes.

RESULTS

Persistent seromas were observed in 13 patients (10.83%) and 2 recurrences (1.98%) occurred. Mesh size >300 cm was associated with increased hospital stay [odds ratio (OR) 4.83; 95% confidence interval (CI), 1.5-15.53; P=0.008], increased postoperative day 1 (POD1) pain assessed with visual analog scale (OR 5.51; 95% CI, 1.76-17.2; P=0.003), and the presence of complications (OR 10.4; 95% CI, 1.85-58.96; P=0.007). Body mass index >30 resulted in increased hospital stay (OR 3.05; 95% CI, 1.23-7.57; P=0.01) and increased POD1 visual analog scale (OR 2.28; 95% CI, 1-5.18; P=0.04).

CONCLUSIONS

Mesh size and obesity were the main factors influencing postoperative outcomes.

Changes in the frequencies of abdominal wall hernias and the preferences for their repair: a multicenter national study from Turkey

Abdominal wall hernias are a common problem in the general population. A Western estimate reveals that the lifetime risk of developing a hernia is about 2%. As a result, hernia repairs likely comprise the most frequent general surgery operations. More than 20 million hernias are estimated to be repaired every year around the world. Numerous repair techniques have been described to date however tension-free mesh repairs are widely used today because of their low hernia recurrence rates. Nevertheless, there are some ongoing debates regarding the ideal approach (open or laparoscopic), the ideal anesthesia (general, local, or regional), and the ideal mesh (standard polypropylene or newer meshes).

Repair of umbilical and epigastric hernias

Umbilical and epigastric hernias are primary midline defects that are present in up to 50% of the population. In the United States, only about 1% of the population carries this specific diagnosis, and only about 11% of these are repaired. Repair is aimed at symptoms relief or prevention, and the patient's goals and expectations should be explicitly identified and aligned with the health care team. This article details some relevant and interesting anatomic issues, reviews existing data, and highlights some common and important surgical techniques. Emphasis is placed on a patient-centered approach to the repair of umbilical and epigastric hernias.

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17-384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0-33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.

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.