Dwell time and bloodstream infection incidence of umbilical venous catheterization in China

Importance

Central line-associated bloodstream infection (CLABSI) is one of the most serious complications of central venous access devices. Reducing the risk of CLABSI is of utmost significance in efforts to improve neonatal mortality rates and enhance long-term prognosis.

Objective

To determine the dwell time and incidence of CLABSI of umbilical venous catheterization (UVC) for preterm infants in China.

Methods

Preterm infants with UVC admitted to 44 tertiary neonatal intensive care units in 24 provinces in China were enrolled. Study period was from November 2019 to August 2021. The end point of observations was 48 h after umbilical venous (UV) catheter removal. The primary outcomes were dwell time of UV catheter and UVC-associated CLABSI. Data between infants with UV catheter dwell time ≤7 days and >7 days, and with birth weight (BW) ≤1000 g and >1000 g were compared.

Results

In total, 2172 neonates were enrolled (gestational age 30.0 ± 2.4 weeks, BW 1258.5 ± 392.8 g). The median UV catheter dwell time was 7 (6-10) days. The incidence of UVC-associated CLABSI was 3.03/1000 UV catheter days. For infants with UV catheter dwell time ≤7 days and >7 days, the UVC-associated CLABSI incidence was 3.71 and 2.65 per 1000 UV catheter days, respectively, P = 0.23. For infants with UVC dwell times of 3-6, 7-12, and 13-15 days, the UVC-associated CLABSI rates were 0.14%, 0.68%, and 2.48% (P < 0.01). The Kaplan-Meier plot of UV catheter dwell time to CLABSI showed no difference between infants with BW ≤1000 g and >1000 g (P = 0.60).

Interpretation

The median dwell time of UV catheter was 7 days, and the incidence of UVC-associated CLABSI was 3.03/1000 catheter days in China. The daily risk of UVC-associated CLABSI and other complications increased with the dwell time.

Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs

Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.

Foetal death due to extensive extra-abdominal umbilical vein Varix with umbilical vein thrombosis: a case report

BACKGROUND

Foetal anaemia and umbilical vein thrombosis are rare pregnancy complications that can increase the risk of perinatal adverse events, which, in severe cases, can lead to foetal death. During pregnancy, umbilical vein varix (UVV) commonly occurs in the intra-abdominal part of the umbilical vein and is associated with an increased risk of foetal anaemia and umbilical vein thrombosis. However, UVV occurring in the extra-abdominal part of the umbilical vein is rare, especially when accompanied by thrombosis. In this case report, we describe a rare case of an extensive extra-abdominal umbilical vein varix (EAUVV), which ultimately resulted in foetal death due to umbilical vein thrombosis.

CASE PRESENTATION

In this report, we describe a rare case of an extensive EAUVV that was discovered at 25 weeks and 3 days of gestation. During the examination, there were no abnormalities in foetal haemodynamics. The estimated weight of the foetus was only 709 g. In addition to refusing to be hospitalized, the patient refused close monitoring of the foetus. As a result, we were limited to choosing an expectant therapy. The foetus died 2 weeks after diagnosis and was confirmed to have EAUVV with thrombosis after the induction of labour.

CONCLUSION

In the case of EAUVV, lesions are extremely rare, and it is very easy for thrombosis to form, which may result in the death of the child. When determining the next step in the treatment of the condition, the degree of UVV, possible complications, gestational age, foetal haemodynamics, and other relevant factors are strongly connected to the clinical therapy decision, and these factors should be considered comprehensively when making a clinical decision. We recommend close monitoring with hospital admission (to facilities capable of handling extremely preterm foetuses) after variability in delivery for worsening haemodynamic status.

Urachal sinus: An atypical case and review of the literature

Urachal sinus is a rare type of urachal abnormality. It happens because of blind focal dilation at the umbilical end and has increased risk of infection. We report the case of a 23-year-old female with abdominal pain and umbilical discharge. Ultrasound detected a possible infected urachal sinus which was initially treated with antibiotic therapy. Urachal sinus excision and laparoscopic bladder raffia was later performed with no recurrence at present. Diagnosis of this pathology is essential given that surgery is curative and avoids complications such as neoplastic transformation.

Short-term complications after onlay versus preperitoneal mesh repair of umbilical hernias: a prospective randomized double-blind trial

PURPOSE

To compare the incidence of surgical site occurrences (SSOs) following onlay versus preperitoneal mesh placement in elective open umbilical hernia repairs.

METHODS

This study presents a secondary analysis of a randomized double-blind trial conducted on female patients with primary umbilical hernias admitted to a general hospital, in a residency training program setting. Fifty-six subjects were randomly assigned to either onlay (n=30) or preperitoneal (n=26) mesh repair group. Data on baseline demographics, past medical history, perioperative details, postoperative pain (visual analogue scale (VAS)), wound-related complications, and recurrence were assessed using a standardized protocol.

RESULTS

No statistically significant differences were observed between groups regarding patients' demographics, comorbidities, or defect size. Operative time averaged 67.5 (28-110) min for onlay and 50.5 (31-90) min for preperitoneal repairs, p=.03. The overall rate of SSOs was 21.4% (n=12), mainly in the onlay group (33% vs 7.7%; p=0.02, 95% CI 0.03-0.85) and mostly due to seromas. There were no between-group significant differences in postoperative VAS scores at all timepoints. After a maximum follow-up of 48 months, one recurrence was reported in the onlay group. By logistic regression, the onlay technique was the only independent risk factor for SSOs.

CONCLUSION

The presented data identified a decreased wound morbidity in preperitoneal umbilical hernia repairs, thus contributing to the limited body of evidence regarding mesh place selection in future guidelines. Further cases from this ongoing study and completion of follow-up are expected to also compare both techniques in terms of long-term outcomes.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) UTN code: U1111-1205-0065 (date of registration: March 27, 2018).

Operative time tracking for umbilical hernia patients

BACKGROUND

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms.

METHODS

This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018.

RESULTS

A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant.

CONCLUSION

This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

The effects of aging and gestational month on uteroplacental vascular perfusion, and umbilical artery hemodynamics in pregnant jennies

This study aimed to correlate the pulsed wave spectral indices of the middle uterine artery at both sides with placental development in jenny within mid-late pregnancies, and establish umbilical Doppler values for different ages and different gestational months. Twenty Equus Asinus pregnant jennies 260-450 kg (average, 320 ± 10 kg) were examined from 5 to 9 months of pregnancy with different ages (4-14 years). Monthly B-mode ultrasound examination was performed on both the combined thickness of the uterus and placenta (CTUP; mm) and umbilical artery cross-sectional diameter, and Doppler mode examination was performed on both the middle uterine (MUA at right [R] and left [L] sides) and umbilical arteries to measure both Doppler indices that expressed by resistance (RI) and pulsatility indices (PI), and blood flow rate. CTUP was elevated within pregnancy time at different ages (P < 0.05). L. PI was significantly declined throughout different ages (P < 0.05), but this declining trend was not observed in L. RI. The L. blood flow rate (R; bpm) was elevated among different ages and different months (P < 0.05). Both RI and PI were significantly decreased from 5 to 9 month of gestation period in jennies (P < 0.05).. The umbilical arteries cross-sectional diameter (Umb A; mm), was elevated among different ages and different months, while both Doppler indices were declined. A positive correlation was found (between both Doppler indices of both umbilical and uterine arteries P < 0.001). There was elevated vascular perfusion in uterine and umbilical arteries associated with reduced both Doppler indices along the course of pregnancy at different ages.

Robotic transabdominal retromuscular rectus diastasis (r-TARRD) repair: a new approach

PURPOSE

The aim of this study is to present our innovative robotic approach for the treatment of rectus diastasis with concurrent primary or incisional ventral hernias.

METHODS

We performed 45 r-TARRD repairs for symptomatic rectus diastasis with concomitant associated ventral/incisional umbilical and/or epigastric hernias between January 2019 and January 2020. Data on patient demographics, type of hernia, operative time, complications, recurrence rate, and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1, 6 months, and 1 year after surgery.

RESULTS

45 patients (13 M, 32 F) underwent r-TARRD repair. Mean age was 54.8 years (range 31-68) and mean BMI was 26.74 kg/m² (range 21.1-31). Mean ASA was 2.2 (range 1-3). In all patients we used a polypropylene mesh 25 × 15 cm, properly shaped. Mean operative time was 192 min (range 115-260). Mean hospital stay 4.2 days (range 2-7). No conversion to laparoscopy or open surgery and no major complications occurred. At 1-month follow-up one mesh infection (2.22%) was observed and it was treated conservatively. Four recurrences (8.88%) were reported at 1-year follow-up.

CONCLUSIONS

Robot-assisted TARRD repair is conceived as a novel alternative minimally invasive procedure for RD with concurrent midline defects ensuring a primary fascial defect closure and mesh implantation in a sublay position with a wide overlap. It is important to better evaluate the suture that should be used to perform the repair, and multicenter studies with standardization of patient's demographics, RD characteristics, and long-term follow-up outcomes are mandatory to assess the effectiveness and durability of r-TARDD repair.

Therapeutic Potential of Mesenchymal Stromal Stem Cells in Rheumatoid Arthritis: a Systematic Review of In Vivo Studies

Standard treatment options for rheumatoid arthritis (RA) often fail to deliver a long-term therapeutic outcome and in many cases cause intractable adverse events leading to treatment discontinuation or readjustment. Treatment with mesenchymal stem cells (MSCs) has been recently studied in RA due to its immunomodulatory and anti-inflammatory capacities. Thus, this study aims at systematically search and review the literature for randomized or non-randomized clinical trials comparing interventions of MSCs with placebo in RA patients. Electronic searches were conducted on PubMed, SCOPUS, Cochrane-CENTRAL, registries of clinical trials and grey literature. Selected studies were estimated for risk of bias with the Cochrane RoB tool 2 or the ROBINS-I tool. Four trials met the eligibility criteria and entered the review process. Identified MSCs treatments varied from allogeneic to autologous or umbilical cord-derived cells. Enrolled patients had an active RA and had poor responses to previous standard medications. In general, the safety evaluation revealed that treatment with MSCs was safe and well tolerated. Regarding the efficacy measurements, modest improvements were found in RA symptoms and RA-related indices. Significant decreases were found in inflammatory molecules such as C-reactive protein, tumor necrosis factor alpha and interleukin 6. However, clinical response criteria related to RA were achieved by a low-to-moderate percentage of patients. In conclusion, treatment of RA with MSCs appears to have a short-term therapeutic effect. Better-designed randomized trials with sufficient follow-up periods are needed so that the long-term safety and efficacy interventions with MSCs would be elucidated.

Estimating umbilical cord flow resistance from measurements of the whole cord

Measuring umbilical blood pressure in utero is challenging and for this reason non-invasive methods are required. However, the total vessel blood pressure drop can be estimated using numerical and empirical results by studying the mechanics of fluids in coiled and straight tubes. Two key findings emerge from such an analysis. Firstly, the total pressure drop along a vessel at a given blood flow-rate depends on both the tightness of the coils and the total cord length. Relatively short and straight cords exhibit low pressure, while long, tightly coiled cords with large width exhibit high pressure. It follows that an estimate of the pressure requires three measurements: the full cord length, its average width and number of coils. Using this result we propose two prototype indices for clinical testing that estimate umbilical cord flow resistance. The umbilical pressure index (P_X) and flow index (Q_X) quantify the deviation of a cord geometry from defined typical conditions by considering the steady pressure drop and flow-rate, respectively. These indices can be quickly calculated, and require only a single additional measurement to the conventional umbilical coiling index (UCI); namely the cord coiling width. Unlike the UCI, these indices are derived from blood-flow properties and provide a measure of the relative flow-resistance inherent to a cord geometry. Furthermore, the pressure index can be applied to irregularities, including loose true knots, which we show must be accounted for.

Portal gas in neonates; is it always surgical? A case report

BACKGROUND

Hepatic portal venous gas in infants is frequently due to late presentation of necrotizing enterocolitis which is considered a relative indicator for surgical intervention.

CASE SUMMARY

A preterm baby underwent an umbilical catheter placement and discovered in abdominal radiograph to have air in the portal venous system due to malpositioning of the umbilical catheter.

CONCLUSION

Hepatic portal venous gas in infants without signs of necrotizing enterocolitis could result from malposition of umbilical venous catheter, and in that case, should be managed medically, with no need for surgical intervention.

Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study

Purpose

A retrospective analysis was carried out to compare the results of patch repair using ready-made, synthetic mesh (PR) and sutured repair (SR) based on standard protocols. The accumulated recurrence rate was accepted as the primary outcome. Pain at rest and during exercise, cosmetic effect and treatment satisfaction were chosen as the secondary endpoints.

Methods

Adult patients after elective, open surgical repair of a single, primary umbilical hernia < 2 cm in diameter were included. Patients with incarceration or strangulation, after previous umbilical hernia repair or other abdominal surgical interventions were excluded. In the SR group, single-layer sutures were placed using the short-stitch technique. In PR group, a 6.3-mm ready-made Parietene Ventral Patch (Medtronic) was used.

Results

161 patients (104 in PR and 57 in SR groups) were included in the study (22 months follow-up). Nine recurrences were observed [six in PR (5.8%) and three in SR group (5.2%)]. In PR group, three patients (2.9%) reported complaints at rest and none in SR group, while 18 patients (17.3%) in PR group reported pain during exercises and 7 (12.3%) in SR group.

Conclusion

For the smallest umbilical hernias, the use of dense fascia suturing (short-stitch technique) may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. The mesh patch repair method is associated with a significantly higher risk of postsurgical pain. Diastasis recti is a factor favoring umbilical hernia recurrence after both pure tissue repair and patch repair.

Current practice patterns for initial umbilical hernia repair in the United States

PURPOSE

The approach to repairing an initial umbilical hernia (IUH) varies substantially, and this likely depends on hernia size, patient age, sex, BMI, comorbidities including diabetes mellitus, and surgeon preference. Of these, only hernia size has been widely studied. This cross-sectional study aims to look at the practice pattern of umbilical hernia repair in the United States.

METHODS

A retrospective study was performed using data from the America Hernia Society Quality Collaborative. Patient characteristics included age, sex, hernia width, BMI, smoking status, and diabetes. Outcomes were use of mesh for repair, as well as surgical approach (open vs minimally invasive). Multivariate logistic regression was performed to assess the independent effect of age, sex, hernia width, BMI, smoking status, and diabetes on use of mesh and approach to repair.

RESULTS

3475 patients were included. 74% were men. Mesh use was more common in men (67% vs 60%, P < 0.001). Mesh was used in 33% of repairs ≤ 1 cm, and 82% of repairs > 1 cm (P < 0.001). Younger patients were less likely to receive a mesh repair (54% if age ≤ 35 vs 67% for age > 35, P < 0.001). However, on multivariate analysis, mesh use was associated with increasing hernia width (OR 5.474, 95% CI 4.7-6.3) as well as BMI (OR 1.8, 95% CI 1.5-2.1) but not with age or sex.

CONCLUSION

The majority of IUH are performed open. Patient BMI and hernia defect size contribute to choice of surgical technique including use of mesh. The use of mesh in 33% of hernias below 1 cm demonstrates a gap between evidence and practice. Patient factors including patient age and sex had no impact on operative approach or use of mesh.

Enterocutaneous fistula occurring 10 years after an open umbilical hernia repair with placement of an onlay polypropylene mesh: A case report

•

An enterocutaneous fistula is a rare complication that can arise many years after an umbilical hernia repair.

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Recurrence of the hernia may be a predisposing factor leading to mesh erosion into the underlying structures.

•

Modification of repair technique and mesh type and location may aid in reducing the incidence of an enterocutaneous fistula.

Introduction

Ventral hernia repair is a common surgical procedure performed within the specialty of general surgery. Short and long term complications can arise after this procedure. Although rare, an enterocutaneous fistula may occur, leading to a significant morbidity and the possible need for surgical intervention.

Presentation of case

We present a rare case of a 76 years old female, who presented with the sudden occurrence of an enterocutaneous fistula arising ten years after a primary umbilical hernia repair with placement of a polypropylene onlay mesh. She was also found to have a large recurrent umbilical hernia. She underwent a laparotomy with the identification of a mesh eroding into the small bowel lumen, causing an enterocutaneous fistula. An enterectomy was performed to remove the fistula with the mesh, and a small bowel anastomosis was created.

Discussion

Ventral hernia recurrence is associated with risk factors including old age, obesity, wound infection as well as the type and location of the mesh used. As in this case, enterocutaneous fistula after hernia repair can occur due to multiple factors including mesh migration and erosion into near-by structures including bowel. These risk factors can perhaps be modified to possibly reduce the incidence of complications like an enterocutaneous fistula.

Conclusion

The case highlights a rare but serious complication associated with a ventral hernia repair. It also addresses key aspects with regards to the possible mechanisms involved in the occurrence of an enterocutaneous fistula following a hernia repair with the use of a synthetic mesh.

Primary non-complicated midline ventral hernia: overview of approaches and controversies

Umbilical hernias and epigastric hernias are some of the most common hernias in the world. Umbilical and epigastric hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Repair techniques include open, laparoscopic, and robotics options, each with advantages and disadvantages. A mesh-based repair is indicated in most cases due to having fewer associated recurrences. Overall outcomes are favorable following umbilical and epigastric hernia repairs; however, some patients have chronic complaints mostly related to recurrences. This report is an overview of available techniques for repair of umbilical and epigastric hernias. It also discusses ongoing controversies related to umbilical and epigastric hernia repairs, the limitations of available literature, and the need for future research.

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.

Genome-wide association study reveals a QTL and strong candidate genes for umbilical hernia in pigs on SSC14

Background

Umbilical hernia is one of the most prevalent congenital defect in pigs, causing economic losses and substantial animal welfare problems. Identification and implementation of genomic regions controlling umbilical hernia in breeding is of great interest to reduce incidences of hernia in commercial pig production. The aim of this study was to identify such regions and possibly identify causative variation affecting umbilical hernia in pigs. A case/control material consisting of 739 Norwegian Landrace pigs was collected and applied in a GWAS study with a genome-wide distributed panel of 60 K SNPs. Additionally candidate genes were sequenced to detect additional polymorphisms that were used for single SNP and haplotype association analyses in 453 of the pigs.

Results

The GWAS in this report detected a highly significant region affecting umbilical hernia around 50 Mb on SSC14 (P < 0.0001) explaining up to 8.6% of the phenotypic variance of the trait. The region is rather broad and includes 62 significant SNPs in high linkage disequilibrium with each other. Targeted sequencing of candidate genes within the region revealed polymorphisms within the Leukemia inhibitory factor (LIF) and Oncostatin M (OSM) that were significantly associated with umbilical hernia (P < 0.001).

Conclusions

A highly significant QTL for umbilical hernia in Norwegian Landrace pigs was detected around 50 Mb on SSC14. Resequencing of candidate genes within the region revealed SNPs within LIF and OSM highly associated with the trait. However, because of extended LD within the region, studies in other populations and functional studies are needed to determine whether these variants are causal or not. Still without this knowledge, SNPs within the region can be used as genetic markers to reduce incidences of umbilical hernia in Norwegian Landrace pigs.

Umbilical Hernia Repair: Overview of Approaches and Review of Literature

Umbilical hernias are ubiquitous, and surgery is indicated in symptomatic patients. Umbilical hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Open, laparoscopic, and robotic options exist for repair, with each having its advantages and disadvantages. In general, mesh should be used for repair, because it has been shown to decrease recurrence rates, even in small hernias. Although outcomes are generally favorable after umbilical hernia repairs, some patients have chronic complaints that are mostly related to recurrences.

Incisional Outcomes of Umbilical vs Suprapubic Mini-laparotomy for Tissue Extraction: A Retrospective Cohort Study

STUDY OBJECTIVE

To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction.

DESIGN CLASSIFICATION

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Two large academic medical centers.

PATIENTS

Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016.

INTERVENTIONS

Umbilical or suprapubic minilaparotomy for tissue extraction.

MEASUREMENTS AND MAIN RESULTS

A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia.

CONCLUSION

There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.

Fifteen-minute consultation: stabilisation of the high-risk newborn infant beside the mother

Paediatric and adult resuscitation is often performed with family present. Current guidelines recommend deferred umbilical cord clamping as part of immediate neonatal care, requiring neonatal assessment next to the mother. This paper describes strategies for providing care beside the mother using both standard resuscitation equipment and a trolley designed for this purpose.

A case report of spontaneous umbilical enterocutaneous fistula resulting from an incarcerated Richter's hernia, with a brief literature review

BACKGROUND

Richter's hernia is a high-risk ischaemic gastrointestinal disorder that is typically diagnosed in a delayed manner due to a lack of obvious symptoms. Spontaneous umbilical enterocutaneous fistula (ECF) resulting from an incarcerated Richter's hernia is extremely rare.

CASE PRESENTATION

A 62-year-old female presented with a chief complaint of recurrent umbilical region infection for the preceding 20 months with no symptoms of ileus. Preoperative CT and fistulography revealed an incarcerated Richter's hernia complicated by an ECF. Exploratory laparotomy revealed a loop of the distal ileum adherent to the umbilical region that was retrieved back into the abdominal cavity. Side-to-side ileo-ileal anastomosis was performed using a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed using plication sutures instead of via mesh repair due to the patient's small defect and infection risk.

CONCLUSION

Richter's hernia can be observed at any age but is particularly common in frail, elderly patients. This nonspecific clinical and laboratory findings of this condition are associated with a high misdiagnosis rate, resulting inrelatively high mortality. Abdominal CT and gastrointestinal imaging are recommended if Richter's hernia is suspected. Timely surgical intervention is crucial for reducing mortality and improving prognosis.

Outcomes of robot-assisted versus laparoscopic repair of small-sized ventral hernias

INTRODUCTION

The aim of the study is to investigate the outcomes of the da Vinci robot-assisted laparoscopic hernia repair of small-sized ventral hernias with circumferential suturing of the mesh compared to the traditional laparoscopic repair with trans-fascial suturing.

METHODS

A retrospective review was conducted of all robot-assisted umbilical, epigastric and incisional hernia repairs performed at our institution between 2013 and 2015 compared to laparoscopic umbilical or epigastric hernia repairs. Patient characteristics, operative details and postoperative complications were collected and analyzed using univariate analysis. Three primary minimally invasive fellowship trained surgeons performed all of the procedures included in the analysis.

RESULTS

72 patients were identified during the study period. 39 patients underwent robot- assisted repair (21 umbilical, 14 epigastric, 4 incisional), and 33 patients laparoscopic repair (27 umbilical, 6 epigastric). Seven had recurrent hernias (robot: 4, laparoscopic: 3). There were no significant differences in preoperative characteristics between the two groups. Average operative time was 156 min for robot-assisted repair and 65 min for laparoscopic repair (p < 0.0001). The average defect size was significantly larger for the robot group [3.07 cm (1-9 cm)] than that for the laparoscopic group [2.02 cm (0.5-5 cm)] (p < 0.0001), although there was no significant difference in the average size of mesh used (13 vs. 13 cm). There was no difference in patients requiring postoperative admission or length of stay between the two groups. The mean duration of follow-up was 47 days. There was no difference in complication rate during this time, and no recurrences were reported.

CONCLUSION

There are no significant differences in terms of safety and early efficacy when comparing small-sized ventral hernias repaired using the robot-assisted technique versus the standard laparoscopic repair.

Incarceration of umbilical hernia: a rare complication of large volume paracentesis

We present two cases of umbilical hernia incarceration following large volume paracentesis (LVP) in patients with cirrhotic ascites. Both patients became symptomatic within 48 hours after the LVP. Although being rare, given the significantly higher mortality rate of cirrhotic patients undergoing emergent herniorrhaphy, this complication of LVP is potentially serious. Therefore, it is recommended that patients be examined closely for the presence of umbilical hernias before removal of ascitic fluid and an attempt should be made for external reduction of easily reducible hernias, if a hernia is present.

Functional differences between the arteries perfusing gas exchange and nutritional membranes in the late chicken embryo

The chicken extraembryonic arterial system comprises the allantoic arteries, which irrigate the gas exchange organ (the chorioallantoic membrane, CAM) and the yolk sac (YS) artery, which irrigates the nutritional organ (the YS membrane). We compared, using wire myography, the reactivity of allantoic and YS arteries from 19-day chicken embryos (total incubation 21 days). The contractions induced by KCl, the adrenergic agonists norepinephrine (NE, nonselective), phenylephrine (α1), and oxymetazoline (α2), electric field stimulation (EFS), serotonin, U46619 (TP receptor agonist), and endothelin (ET)-1 and the relaxations induced by acetylcholine (ACh), sodium nitroprusside (SNP, NO donor), forskolin (adenylate cyclase activator), and isoproterenol (β-adrenergic agonist) were investigated. Extraembryonic allantoic arteries did not show α-adrenergic-mediated contraction (either elicited by exogenous agonists or EFS) or ACh-induced (endothelium-dependent) relaxation, whereas these responses were present in YS arteries. Interestingly, the intraembryonic segment of the allantoic artery showed EFS- and α-adrenergic-induced contraction and ACh-mediated relaxation. Moreover, glyoxylic acid staining showed the presence of catecholamine-containing nerves in the YS and the intraembryonic allantoic artery, but not in the extraembryonic allantoic artery. Isoproterenol- and forskolin-induced relaxation and ET-1-induced contraction were higher in YS than in allantoic arteries, whereas serotonin- and U46619-induced contraction and SNP-induced relaxation did not significantly differ between the two arteries. In conclusion, our study demonstrates a different pattern of reactivity in the arteries perfusing the gas exchange and the nutritional membranes of the chicken embryo.

Cardiopulmonary changes with aeration of the newborn lung

The newborn's transition from fetal to neonatal life includes aeration of the lungs, establishment of pulmonary gas exchange and changing the fetal circulation into the adult phenotype. This review summarizes the latest research findings, which show that lung aeration, airway liquid clearance and cardiovascular changes are directly interconnected at birth. The mechanisms of airway liquid clearance at birth are reviewed and the particular importance of the transpulmonary pressure gradient during lung aeration is discussed. Further, we summarize research findings which prove that lung aeration triggers the increase in pulmonary blood flow (PBF) at birth, and how the increase in PBF secures the preload for left ventricular output. Consequently, we review animal experiments which suggest that delaying umbilical cord clamping until breathing commences facilitates hemodynamic stability during transition. These data are reviewed with respect to the clinical applicability: As lung aeration is the key to successful transition to newborn life, providing adequate respiratory support at birth must be the primary objective of neonatal staff attending to the newborn infant. Clinical studies are needed to demonstrate whether the obvious benefits of delaying cord clamping until breathing commences hold true in human babies.

Comprehensive study of hydrostatic pressure treated human umbilical cord blood cells via response surface method

Amelioration of the survival parameters of cryopreserved samples after thawing has already been addressed through several techniques including vitrification to avoid the formation of ice cores. However, this approach cannot be followed in the case of samples with higher volumes. Hydrostatic pressure (HP) treatment has been proven to increase some qualifying parameters (e.g., motility, insemination efficiency) of certain biological samples. Accordingly, the preparation of umbilical cord blood (UCB) samples through an active (mechanical) pre-stressing process to increase the survival rate of cryopreserved samples can be regarded as a novel strategy that calls for basic experimental studies. The goal of our study was to assess the effects of HP treatment on the qualifying parameters (DNA fragmentation by agarose gel electrophoresis and capillary electrophoresis, Total Nucleotide Cell (TNC) count, CD34+/CD45+ count, and superoxide dismutase activity (SOD) of human umbilical cord blood (UCB) derived cells). The experimental arrangement was set to provide data for response-surface analysis to take into account the common effects of the individual variables of pressure and time exposure. 3D visualization of experimental data revealed that 50-min long HP treatment at 12.5 MPa can significantly (α = 0.05) enhance white blood cell (WBC) and CD34+/CD45+ cell counts. However no DNA fragmentation was observed even at higher pressures, SOD activity was triggered over 15.0 MPa. As a conclusion, HP treatment may contribute to the optimal cryopreservation of UCB cells by significantly increasing WBC and CD34+/CD45+ cell counts without adverse effects neither on DNA stability nor on triggering SOD activity.

The human umbilical cord: a model for microsurgical training

Microsurgery continues to be a fundamental technique in many surgical subspecialties. In the past, many models have been utilized for microsurgery training. We are proposing the human umbilical cord as a training model, which is cheap, available and practical. This model can be used both for junior trainees to achieve good microsurgical skills before operating on human being and it can also help surgeons to maintain their skills.

Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh

BACKGROUND

This study sought to identify the incidence, indications, and predictors of abdominal reoperation and mesh explantation following open ventral hernia repair with mesh (OVHR).

METHODS

A retrospective cohort study of all patients at a single institution who underwent an OVHR from 2000 to 2010 was performed. Patients who required subsequent abdominal reoperation or mesh explantation were compared with those who did not. Reasons for reoperation were recorded. The 2 groups were compared using univariate and multivariate analysis (MVA).

RESULTS

A total of 407 patients were followed for a median (range) of 57 (1 to 143) months. Subsequent abdominal reoperation was required in 69 (17%) patients. The most common reasons for reoperation were recurrence and surgical site infection. Only the number of prior abdominal surgeries was associated with abdominal reoperation on MVA. Twenty-eight patients (6.9%) underwent subsequent mesh explantation. Only the Ventral Hernia Working Group grade was associated with mesh explantation on MVA.

CONCLUSIONS

Abdominal reoperation and mesh explantation following OVHR are common. Overwhelmingly, surgical complications are themost common causes for reoperation and mesh explantation.

Urachus fistula: a rare first presentation of diverticulitis

Urachus fistulas are rare, especially in adulthood. In grown-ups urachus fistulas are usually a reflection of Crohn's disease. We present a patient in whom an urachus fistula was the first presentation of diverticulitis of the sigmoid colon. The need for proper preoperative diagnostic imaging is discussed.