Provincial Review of Adherence to Age-specific Guidelines for Umbilical Hernia Repair and Trends in Management

BACKGROUND

Umbilical hernia (UH) is a common pediatric condition, for which delaying surgical repair for asymptomatic UH until after age 3 is recommended due to a high incidence of spontaneous closure. We aimed to determine the adherence to guidelines, rate of urgent surgical repair, outcomes, cost, and interinstitutional referral patterns of UH repair in the province of Quebec (Canada).

METHODS

This was a population-based retrospective cohort study of children 28 days to 17 years old who underwent UH repair between 2010 and 2020 using health administrative databases. Children who had multiple procedures, or prolonged peri-operative stays were excluded. Early repair was defined as elective surgery at or under age 3.

RESULTS

Of the 3215 children, 1744 (54.2%) were female, and 1872 (58.2%) were treated in a tertiary children's hospital. Guidelines were respected for 2853 out of 3215 children (89.7%). Patients living over 75 km from their treating hospitals (OR 2.36, 95% CI 1.33-4.16, P < 0.01), with pre-existing comorbidities (OR, 2.82; 95% CI, 1.96-4.05; P < 0.001), or being treated in a tertiary center (OR 2.10, 95% CI 1.45-3.03, P < 0.001) had a higher risk of early repair. Repair at or under age 3 and urgent surgery were associated with significant cost increases of 411$ (P < 0.001) and 558$ (P < 0.001), respectively.

CONCLUSION

Quebec has a high rate of adherence to age-specific guidelines for UH repair. Future research should explore factors that explain transfers into tertiary centers, and the extent to which these reflect efficient use of resources.

LEVEL OF EVIDENCE

level III.

TYPE OF STUDY

Retrospective comparative study.

Spontaneous bowel evisceration through umbilical hernia in an adult non-cirrhotic patient

Few cases of spontaneous bowel evisceration (SBE) through umbilical hernias (UHs) in adult patients have been reported in the literature. Interestingly, the spontaneous rupture of the hernia sac is a rare complication usually seen in adult cirrhotic patients with persistent ascites or in patients with congenital wall defects. A man in his early 50s was admitted to our emergency department with SBE through a long-standing acquired UH. He was not clinically cirrhotic, although being HCV positive. Surgeons performed an urgent laparotomy with ileal resection, latero-lateral ileal anastomosis and direct hernioplasty without mesh. Given the rarity of this presentation, we reported it and reviewed the available literature on this subject. Elective hernioplasty is currently suggested to lower the risk of complications. Mesh placement should be preferred, but only if comorbidities and infectious risks do not contraindicate its use. In emergency situations, a direct hernia repair is preferred.

Incarcerated Littre's Umbilical Hernia: A Case Report

Littre's hernia is an extremely rare type of hernia which has Meckel's diverticulum as its content. A 63-year-old male, presented to the emergency department with chief complaints of swelling and pain around the umbilicus. The patient was diagnosed with an incarcerated umbilical hernia. Following the emergency laparotomy, the intraoperative finding depicted an umbilical Littre's hernia. The patient underwent open Meckel's diverticulectomy with mesh repair. Preoperative diagnosis of Littre's hernia is unlikely due to its low incidence and lack of specific radiological and clinical findings, but the role of computed tomography scan and ultrasound are important in differentiating between strangulated or incarcerated bowel and omentum and in guiding the urgency of operative management.

Keywords

case reports; hernia; Meckel diverticulum.

Use of Bilateral Rectus Sheath Blocks in Open Umbilical Hernia Repair

BACKGROUND

In recent years, the rectus sheath block (RSB) has become increasingly prevalent in laparoscopic surgery. However, there is currently no definitive research on its use in the open repair of umbilical hernias with cirrhotic ascites.

OBJECTIVE

In this study, we assessed the safety and clinical efficacy of ultrasound-guided (US-guided) bilateral RSBs in open umbilical hernia repair for patients diagnosed with cirrhotic ascites.

STUDY DESIGN

Seventy-two patients diagnosed with umbilical hernias that presented with cirrhotic ascites and who were admitted to our hospital were randomly divided into 2 groups. These categories were labeled the RSB group (Group R) and the local infiltration group (Group L); we used US-guided RSBs in Group R and local infiltration in Group L.

SETTING

The clinical outcomes of the patients in each group were compared to one another. Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were recorded at various time points in both groups.

METHODS

Measurements of the patients' outcomes were taken before anesthesia (T0), at the beginning of surgery (T1), at the time of the separation of the hernia sac (T2), at the end of surgery (T3), 6 hours postoperatively (T4), and 24 hours postoperatively (T5). On the Visual Analog Scale (VAS), pain scores at rest (T1-T3) and during activity (T4-T5) were recorded, as were the incidence of perioperative remedial analgesia and adverse effects.

RESULTS

Compared to T0, both groups' HR was significantly higher at T1-T3 (P < 0.05). The SBP and DBP were also significantly higher (P < 0.05). At T1-T3, the HR of Group R was significantly slower than that of Group L (P < 0.05), and at T4-T5, the VAS score for activity in Group R was significantly lower than that of Group L (P < 0.05). Group R had a significantly lower incidence of intraoperative remedial analgesia and postoperative nausea and vomiting than did Group L (P < 0.05). Neither group required postoperative remedial analgesia, and no patient experienced adverse reactions during the perioperative period.

LIMITATIONS

This study has limitations in its sample size, lack of blood ammonia levels, and absence of data on patient satisfaction, necessitating future studies to address these issues.

CONCLUSION

US-guided RSBs are an efficient method of anesthesia for open umbilical hernia repair in patients diagnosed with cirrhosis. This technique not only provides precise anesthesia and appropriate analgesia but also results in a low incidence of postoperative nausea and vomiting.

The impact of urgency of umbilical hernia repair on adverse outcomes in patients with cirrhosis: a population-based cohort study from England

INTRODUCTION

Umbilical hernia is common in patients with cirrhosis; however, there is a paucity of dedicated studies on postoperative outcomes in this group of patients. This population-based cohort study aimed to determine the outcomes after emergency and elective umbilical hernia repair in patients with cirrhosis.

METHODS

Two linked electronic healthcare databases from England were used to identify all patients undergoing umbilical hernia repair between January 2000 and December 2017. Patients were grouped into those with and without cirrhosis and stratified by severity into compensated and decompensated cirrhosis. Length of stay, readmission, 90-day case fatality rate and the odds ratio of 90-day postoperative mortality were defined using logistic regression.

RESULTS

In total, 22,163 patients who underwent an umbilical hernia repair were included and 297 (1.34%) had cirrhosis. More patients without cirrhosis had an elective procedure, 86% compared with 51% of those with cirrhosis (P < 0.001). In both the elective and emergency settings, patients with cirrhosis had longer hospital length of stay (elective: 0 vs 1 day, emergency: 2 vs 4 days, P < 0.0001) and higher readmission rates (elective: 4.87% vs 11.33%, emergency:11.39% vs 29.25%, P < 0.0001) than those without cirrhosis. The 90-day case fatality rates were 2% and 0.16% in the elective setting, and 19% and 2.96% in the emergency setting in patients with and without cirrhosis respectively.

CONCLUSION

Emergency umbilical hernia repair in patients with cirrhosis is associated with poorer outcomes in terms of length of stay, readmissions and mortality at 90 days.

Predictive value of hematological parameters in cirrhotic patients with open umbilical hernia repair

PURPOSE

Patients with liver cirrhosis sometimes suffer from high recurrence rates and postoperative complications. We previously reported that platelet-related hematological parameters are associated with the outcomes after incisional herniorrhaphy, and aim to evaluate the predictive value of these criteria in cirrhotic patients undergoing open umbilical herniorrhaphy.

METHODS

This is a retrospective study. The data of 95 cirrhotic patients undergoing open umbilical herniorrhaphy were analyzed. Patients were grouped based on the recurrence and defined hematological values. Platelet-multiple-lymphocyte index (PLM), neutrophil-leukocyte ratio, lymphocyte-monocyte ratio, platelet-neutrophil ratio, systemic immune-inflammation index, and aspartate aminotransferase-leukocyte ratio values were calculated based on preoperative blood analyses. The outcomes were obtained from hospital records and follow-up calls to patients.

RESULTS

Using cutoff values acquired by the Youden Index, we found a PLM value < 27.9, and the history of inguinal herniorrhaphy were revealed to be statistically significant in the recurrence based on univariant and multivariant analyses (p < 0.05). We further divided patients into two groups based on the cutoff value of PLM and found that a PLM value < 27.9 was significantly associated with the recurrence of incisional hernias (p = 0.018) and the occurrence of postoperative foreign sensation (p = 0.044), and tended to result in other postoperative complications such as cardiopathy, respiratory infection, hypoproteinemia, and hepatic diseases (p = 0.089).

CONCLUSION

The preoperative hematological values, especially PLM, may indicate the outcomes in cirrhotic patients after open umbilical herniorrhaphy. Accurate identification of risks may alert the intraoperative and postoperative care for patients.

Leaking Umbilical Hernias in Cirrhotic Patients, Repair or Observe?

BACKGROUND

Umbilical hernias (UHs) in cirrhotic patients are common, can be quite complicated and are associated with significant morbidity and mortality. Leakage of ascites is a challenging entity and poses significant risks.

METHODS

This is a retrospective study of patients with cirrhosis and UHs with ascitic leakage. Patients were divided into two groups: patients managed operatively during index admission (Group 1) and those managed non-surgically during index admission (Group 2). Group 2 was further divided into those that subsequently underwent repair of UH and those managed medically.

RESULTS

Of 47 cirrhotic patients with leaking UHs, 19 patients were managed surgically during index admission (Group 1). In Group 2, 15 patients were managed non-surgically and 13 subsequently underwent surgery. The groups had comparable demographics, MELD-Na and Child-Pugh class. Group 2 had a higher rate of emergency surgery (92% vs 58%, P = .04) and higher rate of recurrence (31 vs. 0%, P = .02). The non-surgical patients in Group 2 had higher 1-year mortality (67%) compared to Group 1 (21%) and surgical patients in Group 2 (31%, P = .007). Multi-variable logistic regression for 1-year mortality demonstrated MELD-Na as the most significant risk factor (OR = 1.2, P = .05) and undergoing UH repair as the most significant protective factor (OR = .16, P = .02).

CONCLUSIONS

Cirrhotic patients with leaking UHs should undergo urgent repair. Non-operative management confers high risk of continued or increased ascitic leakage necessitating more emergent surgery. Despite high rate of post-operative complications related to cirrhosis, there is a clear mortality benefit to the repair of leaking UHs in cirrhotic patients.

An analysis of factors affecting survival in prenatally diagnosed omphalocele

OBJECTIVES

To estimate factors affecting survival in prenatally diagnosed omphalocele, factors predicting genetic abnormalities, and association of omphalocele and specific groups of anomalies.

METHODS

A retrospective observational study was performed, analyzing data of all omphalocele cases diagnosed prenatally in the perinatology clinic of a referral center. Demographic data, characteristics of the omphalocele (size, content, associated anomalies), results of genetic testing, pregnancy outcomes and postnatal outcomes were analyzed.

RESULTS

Sixty-nine fetuses with omphalocele were included. The prevalence of omphalocele in livebirth was 0.007 %. Overall survival during the study period was 73.9 %. Twenty-eight (71.7 %) out of 39 cases with associated anomalies who were born live, survived, whereas survival was 85.7 % in the isolated cases. The most common anomaly associated with omphalocele were cardiac defects with 42 %; followed by placental or umbilical cord anomalies (28.9 %), skeletal defects (27.5), genitourinary anomalies (20.2 %), central nervous system (18.8 %) and facial anomalies (7.2 %), respectively. Eighty-five percent of the fetuses had at least one additional anomaly or ultrasound finding. Skeletal abnormalities and staged surgical repair of omphalocele were associated with survival. Associated skeletal anomalies and staged repair significantly increase the risk of postnatal death (OR: 4.6 95 % CI (1.1-19.5) and (OR: 10.3 95 % CI (1.6-63.9), respectively).

CONCLUSIONS

Associated skeletal abnormalities and staged surgical repair are negatively associated with postnatal survival.

Fetal lung volumes measured by MRI predict pulmonary morbidity among infants with giant omphaloceles

OBJECTIVE

Giant omphaloceles (GO) have associated pulmonary hypoplasia and respiratory complications. Total lung volumes (TLV) on fetal MRI can prognosticate congenital diaphragmatic hernia outcomes; however, its applicability to GO is unknown. We hypothesize that late gestation TLV and observed-to-expected TLV (O/E TLV) on fetal MRI correlate with postnatal pulmonary morbidity in GO.

METHOD

A single-institution retrospective review of GO evaluated between 2012 and 2022 was performed. Fetal MRI TLV between 32 and 36 weeks' gestation and O/E TLV throughout gestation were calculated and correlated with postnatal outcomes.

RESULTS

86 fetuses with omphaloceles were evaluated; however, only 26 met strict inclusion criteria. MRIs occurred between 18 and 36 weeks' gestation. Those requiring delivery room intubation had significantly lower late gestation TLV and O/E TLV. O/E TLV predicted tracheostomy placement and survival. Neither TLV nor O/E TLV predicted the length of hospitalization or supplemental oxygen after discharge. Three fetuses had a TLV less than 35 mL: one died of respiratory failure, and the other two required tracheostomy.

CONCLUSIONS

Fetal MRI TLV measured between 32 and 36 weeks' gestation and O/E TLV predict the need for delivery room intubation and tracheostomy. O/E TLV correlated with survival. These data support fetal MRI as a prognostic tool to predict GO associated pulmonary morbidity.

Après Moi, Le Deluge: The identification and management of flood syndrome in the emergency department

Umbilical hernias develop in approximately 20% of patients with liver cirrhosis and ascites. Flood Syndrome is an eponym describing the spontaneous rupture of these umbilical hernias due to the elevated intrabdominal pressure associated with large-volume ascites. Though rare, Flood Syndrome is associated with several life-threatening sequela including infection, organ failure, and hypovolemic shock, leading to mortality or transplant in over 30% of patients. The following case is a single patient encounter describing an 80-year-old female with long-standing ascites who presented to the Emergency Department shortly after experiencing a spontaneous extravasation of fluid from her umbilical hernia.

Flood Syndrome: Endovascular management of spontaneous rupture of an umbilical hernia due to long-standing ascites - A case report

Umbilical hernias are common in patients with cirrhosis of the liver and ascites; however, spontaneous rupture of the hernia is a rare complication. Flood Syndrome occurs very rarely in cirrhotic patients with massive ascites and refers to the spontaneous rupture of an umbilical hernia followed by leakage of ascites fluid. A literature search shows that patients have been managed both operatively and nonoperatively for this condition. We report a case of a 56-year-old man with a history of alcohol-related liver cirrhosis and massive ascites refractory to medical therapy with sudden and spontaneous perforation of his hernia leading to drainage of ascitic fluid from the abdomen. We performed a transjugular intrahepatic portosystematic shunt to relieve portal pressure and subsequent intraabdominal pressure. The patient had resolution of symptoms and the ascitic fluid outflow was resolved.

Three-Dimensional Ultrasound Evaluation of Lung Volume in Fetuses with Abdominal Wall Defect

INTRODUCTION

Abdominal wall defects (AWDs) interfere with postnatal respiratory parameters. We aimed to evaluate lung volume (LV) in fetuses with AWD using three-dimensional (3D) ultrasound (US) and to correlate AWD with the type (omphalocele and gastroschisis) and size of the defect and neonatal morbidity and mortality.

METHODS

This prospective observational study included 72 pregnant women with fetuses with AWD and a gestational age <25 weeks. The data on abdominal volume, 3D US LV, and herniated volume were acquired every 4 weeks up to 33 weeks. LV was compared with normal reference curves and correlated with abdominal and herniated volumes.

RESULTS

Omphalocele (p < 0.001) and gastroschisis (p < 0.001) fetuses had smaller LV than normal fetuses. LV was positively correlated with abdominal volume (omphalocele, r = 0.86; gastroschisis, r = 0.88), whereas LV was negatively correlated with omphalocele-herniated volume/abdominal volume (p < 0.001, r = -0.51). LV was smaller in omphalocele fetuses that died (p = 0.002), were intubated (p = 0.02), or had secondary closure (p < 0.001). In gastroschisis, a smaller LV was observed in fetuses discharged using oxygen (p = 0.002).

CONCLUSION

Fetuses with AWD had smaller 3D LV than normal fetuses. Fetal abdominal volume was inversely correlated with LV. In omphalocele fetuses, a smaller LV was associated with neonatal mortality and morbidity.

Outcomes of umbilical hernia repair in cirrhotic veterans: a VASQIP study

PURPOSE

Umbilical hernia repair (UHR) in cirrhotics with ascites is a challenging problem associated with increased morbidity and mortality. This study examines the outcomes of UHR in veterans, comparing those undergoing elective versus emergent repair.

METHODS

VASQIP was queried for all UHRs during the period 2008-2015. Data collection included demographics, operative details, Model for End-stage Liver Disease (MELD) score, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p value of ≤ 0.05 was considered significant.

RESULTS

A total of 383 patients were included in the analysis. Overall, mean age was 58.9, 99.0% were males, mean body mass index (BMI) was 26.7 kg/m2, 98.2% had American Society of Anesthesiologists (ASA) classification ≥ III, and 87.7% had independent functional status. More than 1/3 the patients underwent emergent UHR (37.6%). Compared with the elective UHR group, who underwent emergent repair were older, more likely to be functionally dependent, higher MELD score. Hypoalbuminemia, emergency repair and MELD score were found to be independent predictors of poor outcomes.

CONCLUSION

UHR in cirrhotic veterans has worse outcomes when performed emergently. Diagnosis should be followed by medical optimization and elective repair, rather than waiting for an emergent indication in > 1/3 of patients.

eTEP inferior access with tailored retromuscular dissection for small to mid-sized umbilical hernia repair with or without inguinal hernia: early experience

INTRODUCTION

The minimally invasive surgical repair of combined inguinal and ventral hernias often requires shifting from one approach or plane to another. The traditional enhanced-view totally extraperitoneal Rives-Stoppa repair consists of a large retro muscular dissection that is unjustified for small ventral hernias. Here we describe a modification to the minimally invasive Rives-Stoppa repair using a limited retro muscular dissection based on the ventral defect size for small/medium-sized hernias, with or without combined inguinal hernias.

METHODS

From a single surgical team, a retrospective study was performed over a 1-year period. Demographics, hernia characteristics, surgical techniques, intraoperative/postoperative complications, and outcomes were all analyzed and reported. We also included detailed surgical steps, landmarks, pitfalls, and personal tips for this technique.

RESULTS

Twenty-four patients underwent a laparoscopic limited retromuscular dissection ventral hernia repair utilizing the eTEP access technique. Eighteen were primary umbilical hernias and six postoperative incisional hernias, and nine were combined ventral and inguinal hernia repairs. Eight of the primary umbilical hernias were EHS classified as medium size, 11 small, and for the incisional hernias, three were classified as M3W1 and two as M3W2. One procedure was converted to TAPP. There were no intraoperative complications. The mean length of stay was 1.25 days (range 1-3). There was one postoperative retromuscular hematoma and no recurrence during the follow-up period.

CONCLUSION

eTEP with limited dissection offers a good and safe solution for small to medium size hernias; it provides an efficient solution when an inguinal hernia is to be addressed as well.

Correlation between estimated fetal weight and weight at birth in infants with gastroschisis and omphalocele

BACKGROUND

An accurate estimated fetal weight (EFW) calculated with traditional formulae in cases of abdominal wall defects (AWDs) can be challenging. As a result of reduced abdominal circumference, fetal weight may be underestimated, which could affect prenatal management. Siemer et al. proposed a formula without the use of abdominal circumference, but it is not used in our protocols yet.

OBJECTIVES

Our aim was to evaluate the correlation of EFW and birth weight in fetuses with AWD by using Hadlock 1, Hadlock 2, and Siemer et al.'s formulae. Our secondary goal was to evaluate how often fetuses classified as small for gestational age (SGA) were in fact SGA at birth.

STUDY DESIGN

This was a retrospective cohort study of gestations complicated by gastroschisis and omphalocele at two tertiary-care centers in Brazil and Italy during an 8-year period. Of a total of 114 cases, 85 (44 cases of gastroschisis and 41 cases of omphalocele) met our criteria.

RESULTS

The last prenatal scan was performed 5.2 (±4.1) days before birth. The mean gestational age at birth was 37.2 (±1.8) weeks. Correlation of EFW with birth weight was calculated with the three formulae with and without adjustment for weight gain between scan and birth, with the use of the Spearman coefficient. The correlation between EFW and weight at birth was positive according to all three formulae for the infants with gastroschisis. This finding was not confirmed in the infants with omphalocele. All formulae overestimated the number of SGA cases: although only 17.6% of fetuses were actually SGA at birth, the Hadlock formulae had classified nearly 35% of them as SGA, and Siemer et al.'s formula, 15.3%.

CONCLUSION

All three formulae yielded a good correlation between EFW in the last scan and birth weight in the infants with gastroschisis but not for those with omphalocele. Cases of SGA were overestimated.

[The treatment of umbilical hernia in patients with cirrhosis]

Patients with cirrhosis undergoing emergency umbilical hernia repair have increased risk of fatal complications. Of all patients with cirrhosis and umbilical hernia, 43% undergo emergency hernia repair, and thus the feasibility of elective procedures in this patient group was examined. This review found that medical and wound-related complications were the most frequent after umbilical hernia repair in patients with cirrhosis. Accordingly, additional evidence is needed to evaluate methods allowing for elective umbilical hernia repair in patients with cirrhosis.

Persistent omphalomesenteric duct and urachus presenting as an umbilical hernia

Vitellointestinal duct anomalies, although one of the most frequent malformations to be found (2%-3% in population), they are most unlikely to cause symptoms. A persistent Vitellointestinal duct can induce abdominal pain, bowel obstruction, intestinal haemorrhage and umbilical sinus, fistula or hernia which commonly occurs in children. Patent vitellointestinal duct or persistent omphalomesenteric duct is a very unusual congenital anomaly which occurs in 2% of the population related to the embryonic yolk stalk. Similarly, urachal anomalies remain a rare finding, with the most common being a cyst or sinus followed by patent urachus and rarely a urachal diverticulum. Presenting symptoms include periumbilical discharge, pain and a palpable mass.Here, we report a case of an adult patient with patent vitellointestinal duct and urachus identified intraoperatively on diagnostic laparoscopy when being operated for umbilical hernia repair.

Effect of Laparoscopic Total Extraperitoneal Umbilical Hernia Repair on Incision Infection, Complication Rate, and Recurrence Rate in Patients with Umbilical Hernia

The aim of this study is to clarify the influence of laparoscopic total extraperitoneal umbilical hernia repair on incision infection, complication rate, and recurrence rate in patients with an umbilical hernia (UH). Sixty-seven UH patients referred to our hospital from June 2017 to June 2019 were selected as the research participants. Thirty-six patients in the research group (RG) were treated with laparoscopic total extraperitoneal umbilical hernia repair, and the other 31 cases in the control group (CG) were treated with traditional umbilical hernia repair. The two cohorts of patients were compared with respect to the curative effect after treatment; intraoperative blood loss, operation time, postoperative pain time, ambulation time, and hospital stay; incidence of complications; pain severity (VAS) before and after operation; sleep quality (PSQI) before and after operation; patient satisfaction after treatment; and recurrence half a year after discharge. The RG presented a higher effective treatment rate (P < 0.05), less intraoperative blood loss, operation time, postoperative pain time, ambulation time, and hospital stay, as well as lower incidence of complications than the CG (P < 0.05). VAS and PSQI scores differed insignificantly between the two cohorts of patients before treatment (P > 0.05) but reduced after treatment, with lower VAS and PSQI scores in the RG than in the CG (P < 0.05). The number of people who were highly satisfied, as investigated by the satisfaction survey, was higher in the RG than in the CG, while the recurrence rate of prognosis was lower than that in the CG (P < 0.05). Laparoscopic total extraperitoneal umbilical hernia repair is effective for UH patients and can validly reduce the incidence of complications and recurrence rate, which has huge clinical application value.

Spontaneous rupture of umbilical hernia in end stage liver disease patient: injection of fibrin glue as a temporary solution

BACKGROUND

Umbilical hernia is a common disease, which occurs in 20% of cirrhotic patients in the presence of persistent ascites. A rare but dangerous complication of this disease in end stage liver patient is a spontaneous rupture of umbilical hernia with ascitic fluid leaking. Up to date there is no general consensus on its most appropriate treatment.

CASE REPORT

A 60 years-old male patient, with Child Pugh C and Meld score of 18 end stage liver disease, came to our observation for a spontaneous minimal rupture of his long lasting 5 cm umbilical hernia with ascitic fluid leaking. A medical therapy was undertaken aiming to manage the ascites and a temporary conservative therapy, with fibrin glue injection, was performed to solve the hernia ulceration, delaying the surgical repair after 20 days, when he underwent to a surgical repair with the positioning of a on lay mesh. At 12 month follow up we did not observe any recurrence.

CONCLUSIONS

Spontaneous rupture of umbilical hernia is a rare but life threatening complication of umbilical hernia in cirrhotic patient with refractory ascites. Even if a general consensus on its management is lacking, a conservative therapy with glue injection, appears feasible and effective, with low risk and representing a bridge therapy to surgery, to treat the ascitic leak and allow the clinical optimization of the patient.

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.

Prenatal sonography of extracorporeal ductus venosus in association with large fetal gastroschisis

Liver herniation commonly associated with omphalocele occurs in only approximately 2.3% to 16% of fetuses with gastroschisis. Liver herniation in such cases is associated with considerably decreased survival rates (43% vs 97% with or without liver herniation, respectively). Rarely, abnormally positioned fetal hepatic vasculature has been reported mainly in association with congenital diaphragmatic hernia. In these rare cases, intrathoracic depiction of hepatic venous vasculature has assisted in confirming intrathoracic displacement of the fetal liver. We present a case of a large gastroschisis with complete herniation of the fetal liver in which prenatal sonography depicted an extracorporeal ductus venosus.

Umbilical hernioplasty in cirrhotic patients with ascites A case control study

OBJECTIVE

Umbilical hernia is a very frequent pathology, and plastic with prosthetic material is the most frequently used surgical procedure currently used for its repair. In patients with cirrhosis in asciic phase, this pathology is particularly frequent, with a tendency to rapidly increase in size and to become symptomatic. In the past treatment with traditional surgery in cirrhotic patients was considered problematic and was viewed with reserve, and only recently is the surgical approach recommended also in these patients. This study is aimed to evaluate the feasibility and safety of open umbilical hernia plastic with prosthetic material in cirrhotic and ascitic patients.

MATERIALS AND METHODS

Our case-control study was conducted on 35 male patients with ascitic phase liver cirrhosis and an equal number of non-cirrhotic patients, all suffering from uncomplicated but symptomatic umbilical hernia, treated surgically consecutively from March 2005 to March 2015. All patients underwent open umbilical hernioplasty with placement of a retromuscular pre-aponeurotic mesh.

RESULTS

Of the 35 patients with liver cirrhosis, 20% were classified in Class C, according to Child-Pugh, 28.5% had a MELD score> 15. We have not shown any post-operative mortality. In general, minor complications were observed, more frequent in cirrhotic patients than in healthy controls (p = 0.0315). Among the aforementioned complications the most frequent were hematomas and wound infections, more frequent in cirrhotic patients in Class C according to Child- Pugh and with MELD score> 15 (p <0.005).

CONCLUSIONS

Our study shows that umbilical hernia pathology in ascitic cirrhotic patients can be treated surgically with satisfactory results especially in Child-Pugh class A and B patients. The surgical approach of choice must, preferably, be the preferred prosthetic plastic after pre-operative optimization of the coagulation, nutritional and ascitic state.

KEY WORDS

Ascites, Hernioplasty ,Liver cirrhosis; Umbilical hernia.

Giant inguinoscrotal hernia repair

Giant inguinoscrotal hernia is defined as an inguinal hernia extending below the midpoint of inner thigh in standing position. The authors describe giant inguinoscrotal hernia and small umbilical hernia with 12 years history of this uncommon disease. After preoperative evaluation, US and CT examination he was operated on. It was very difficult to return the hernia sac contents back to the abdomen and additional infraumbilical incision was needed. Hernioplasty suo modo without mesh was done. Patient recovered uneventfully. In the discussion the authors present the newer classification of giant inguinal hernia, the current treatment options and known serious complications of surgery. Finally, it indicates that good treatment results can only be achieved by close cooperation of concerned professionals in the treatment and intensive intraoperative and postoperative patient monitoring (Fig. 9, Ref. 31).

Locally advanced colon cancer with cutaneous invasion: case report

BACKGROUND

Locally advanced colon cancer with direct abdominal wall and skin invasion is an extremely rare finding with most data being derived from case reports, historical autopsy-based or single-center retrospective studies. We present a unique case of a colon cancer with direct cutaneous invasion and colocutaneous fistulization.

CASE PRESENTATION

Eighty-six year old Caucasian female with multiple comorbidities, referred to Surgical Consultation due to ulcerated skin lesion in the abdomen. She had a long-standing large umbilical hernia but with no previous episodes of incarceration or occlusive symptoms. She denied any digestive or constitutional symptoms. Physical examination showed a large non-reducible umbilical hernia, with an associated painless firm mass within the hernia sac and cutaneous ulcerated growth. Colonoscopy revealed transverse colon cancer (endoscopic biopsy of the tumor and skin punch biopsy confirmed adenocarcinoma of the colon). Computed tomography showed a tumoral mass within the umbilical hernia, with cutaneous infiltration and enlarged regional lymph nodes. Rapid local progression led to colocutaneous fistula with total fecal diversion. We performed an extended right hemicolectomy with en bloc excision of the hernia sac and infiltrating cutaneous mass.

CONCLUSIONS

In the current era of widespread use of screening colonoscopies, initial diagnosis of locally advanced colon cancer is decreasing. However, this unique case presented an opportunity to recall the advantages of multivisceral resections.

Male breast cancer originating in an ectopic breast tissue in the umbilicus A Case Report

INTRODUCTION

Accessory breast tissue is a rare finding in the general population with an incidence of 1-2%. Carcinomas of accessory breast tissue account for ∼0.3% of breast cancers, 5% of which are arising within a supernumerary breast. They are usually diagnosed at a later stage compared with breast cancer, due to their rarity and low clinical suspicion.

CASE PRESENTATION

We present the case of a 58 years old male who was admitted to our hospital for an umbilical hernia, surgical repair. During surgery a small skin biopsy was excised and sent for pathological examination as routine procedure. The histological report revealed the presence of a poorly differentiated carcinoma. Immunochemical analysis confirmed adenocarcinoma of breast origin.

CONCLUSION

Carcinomas of accessory breast tissue are rare and therefore they are usually of advanced stage in time of diagnosis. Few cases have been reported in literature of accessory breast tissue carcinomas in men. To the best of our knowledge, this is the only case in the literature, of ectopic breast tissue cancer in the umbilicus.

KEY WORDS

Ectopic breast, Male breast cancer, Umbilicus.

A giant inguinoscrotal hernia associated with other abdominal wall defects A case report

INTRODUCTION

Giant inguinoscrotal hernias are unusual in developed countries and rarely associated with other wall hernias, such as controlateral inguinal hernia, umbilical hernia. The presence of more parietal defects can facilitate reinstatement of giant hernia content without respiratory and circulatory compromise, but the risk of occlusion and bowel strangulation results increased.

CASE REPORT

Here, we report an unusual case of an asymptomatic giant inguinal hernia associated with controlateral inguinal and umbilical hernia in a 60 years old Caucasian male treated with sequential surgical approach. In particular, the Lichtenstein's technique under spinal anesthesia was performed and it could be considered the gold standard for this disease.

CONCLUSION

Giant inguinal hernia and abdomen wall defects should not be repaired at the same time. It is more useful to be less aggressive, monitoring the progressive and natural adaptation of the viscera into the abdomen. Anyway, thereby literature results very poor and additional reports are required.

KEY WORDS

Giant inguinoscrotal hernia, Hernia, Hernia treatment, Wall defects.

[ANESTHESIA DURING THE SEPARATION OF THE FETUS IN FETU IN A 2 DAYS-LIFE CHILD WITH ACCOMPANYING NON-CORRECTED CRITICAL CONGENITAL HEART DISEASE (CHD)]

The article describes a clinical case of treating a few- hours-life child with birth body weight--2900 g, length--50 cm, who had been extremely rare complex congenital malformations: fetus in fetu in the epigastrium with satisfactorily formed the lower half of the body of the failed twin, omphalocele and severe CHD. The surgical treatment was in terms of multicomponent endotracheal anesthesia. At the end of surgery puncture and catheterization of the epidural space at the level of L1/L2 holding the catheter up to Th9/Th10 for postoperative analgesia was made. Cardiotonic therapy and mechanical ventilation was performed after the operation. There have been signs of high pulmonary hypertension. On the 6th day of life the child was transferred to the Department of cardiac surgery and intensive care for the correction of complex combined CHD. At the age of 8 days of life performed the operation. Clamping of the aorta lasted for 21 minutes. On the 24th day of life has been deteriorating due to increasing renal failure and development of multiorgan failure, disseminated intravascular coagulation syndrome. After repeated resuscitations the child died at the age of 25 days of life.

Button hole hernioplasty: A new technique for treatment of umblical hernia in cirrhotic patients. A prospective follow up study

BACKGROUND

Surgical treatment of umbilical hernia in cirrhotic patients is still an interesting topic in many studies to achieve the best method of treatment. These patients are liable to many surgical and medical risks.

AIMS

to evaluate the surgical outcome as well as the postoperative course of Button hole hernioplasty as a simple, safe, and effective new technique for hernia repair in cirrhotic patients.

METHODS

Forty cirrhotic patients with uncomplicated umbilical hernia were included in this study through collaboration between Departments of General Surgery and Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut, during one year period. Patients were categorized according to the severity of liver cirrhosis into three groups (A, B, and C). Patients were subjected to an elective hernioplasty after adjustment of the disturbed medical and biochemical factors.

RESULTS

There was a significant difference in operative time, hospital stay, and prothrombine (time and concentration) among the three groups (p < 0.05). The three parameters were longest in group C when compared to the other two groups. No severe complications were recorded except in only one case. Also, no recurrence, no morbidities or deaths were recorded after 6 months follow-up.

CONCLUSIONS

Button hole hernioplasty is a new simple surgical technique for treatment of umbilical hernia in cirrhotic patients with no significant complications.

Gastroesophageal reflux and congenital gastrointestinal malformations

Although the outcome of newborns with surgical congenital diseases (e.g., diaphragmatic hernia; esophageal atresia; omphalocele; gastroschisis) has improved rapidly with recent advances in perinatal intensive care and surgery, infant survivors often require intensive treatment after birth, have prolonged hospitalizations, and, after discharge, may have long-term sequelae including gastro-intestinal comorbidities, above all, gastroesophageal reflux (GER). This condition involves the involuntary retrograde passage of gastric contents into the esophagus, with or without regurgitation or vomiting. It is a well-recognized condition, typical of infants, with an incidence of 85%, which usually resolves after physiological maturation of the lower esophageal sphincter and lengthening of the intra-abdominal esophagus, in the first few months after birth. Although the exact cause of abnormal esophageal function in congenital defects is not clearly understood, it has been hypothesized that common (increased intra-abdominal pressure after closure of the abdominal defect) and/or specific (e.g., motility disturbance of the upper gastrointestinal tract, damage of esophageal peristaltic pump) pathological mechanisms may play a role in the etiology of GER in patients with birth defects. Improvement of knowledge could positively impact the long-term prognosis of patients with surgical congenital diseases. The present manuscript provides a literature review focused on pathological and clinical characteristics of GER in patients who have undergone surgical treatment for congenital abdominal malformations.

Frequency of anomalies and hospital outcomes in infants with gastroschisis and omphalocele

BACKGROUND

Gastroschisis and omphalocele are the most common anterior abdominal wall defects affecting infants. There are few large cohort studies describing the frequency of associated anomalies in infants with these 2 conditions. We describe associated anomalies and outcomes in infants with these defects using a large, multi-center clinical database.

METHODS

We identified all infants with gastroschisis or omphalocele from a prospectively collected database of infants discharged from 348 neonatal intensive care units in North America from 1997 to 2012. Maternal and patient demographic data, associated anomalies, and outcome data were compared between infants with gastroschisis and omphalocele.

RESULTS

A total of 4687 infants with gastroschisis and 1448 infants with omphalocele were identified. Infants with omphalocele were more likely to be diagnosed with at least 1 other anomaly compared with infants with gastroschisis (35% vs. 8%, p<0.001). Infants with omphalocele were more likely to develop pulmonary hypertension compared with those with gastroschisis (odds ratio [OR] 7.78; 95% confidence interval 5.81, 10.41) and had higher overall mortality (OR 6.81 [5.33, 8.71]).

CONCLUSION

Infants with omphalocele were more likely to have other anomalies, be diagnosed with pulmonary hypertension, and have higher mortality than infants with gastroschisis.

Umbilical endometriosis associated with large umbilical hernia. Case report

Umbilical endometriosis is a rare condition, usually following laparoscopic and surgical procedures involving the umbilicus.Spontaneous umbilical endometriosis occurring without any previous abdominal or uterine surgery is extremely rare. The maximal depth of penetration of the umbilical endometriosis described is up to fascial level. There have been only two cases of endometriosis reported arising within umbilical hernia. The authors report a case of a patient with spontaneous umbilical endometriosis associated with a large umbilical hernia, treated by surgical excision and mesh repair of the abdominal wall. To the best of our knowledge, this is the first described case of the association of umbilical endometriosis with a large umbilical hernia that requires prosthetic mesh repair of the abdominal wall defect.

Plurimalformative syndrome associating trisomy 18 and omphalocele. Case report and review of the literature

Trisomy 18 or Edwards syndrome is a rare chromosomal anomaly, associated with mild to severe intellectual disabilities and multiple congenital anomalies. Trisomies 18 and 13 are lethal, only 5-10% of patients surviving the first year of life. Although prenatal biological and ultrasound investigations are mandatory and free and the detection rate of chromosomal abnormalities is high, the birth of children with no real chance at a normal life being thus avoided by therapeutic abortion, the parents of the here presented child did not benefit from medical examination or prenatal tests, unfortunately the case of many families in Romania. The policy of limiting medical intervention in newborns with Edwards syndrome due to the broad spectrum of severe congenital malformations, severe mental retard and reduced life expectancy is unanimously accepted, but yet difficult to apply from an ethical point of view. That is why very important for both healthcare providers and families to have accurate and detailed knowledge of survival, disease course, and quality of life so that they can make fully informed decisions regarding care of these babies. The particularity of this case is the association of multiple congenital anomalies in a male newborn with trisomy 18, almost all apparata and systems being affected, with the presence of an omphalocele and complete right labiopalatine cleft, which are less frequent at children with trisomy 18.

[Ileus caused by trocar sites after laparoscopic hysterectomy]

Trocar site herniation (TSH) is a rare condition after laparoscopy and may cause obstruction of the bowel. TSH may be present despite attempted fascial closure. This case report includes two simultaneous TSH in a patient who had laparoscopic hysterectomy performed. She presented with symptoms with severe abdominal pain, excessive vomiting and bloating of the abdomen. A computed tomography showed herniation of the small bowel at two previous trocar sites. The case resulted in emergency laparoscopy with decompression of the herniated bowel.

Ileal atresia secondary to antenatal strangulation of Littre's hernia in an exomphalos minor

We describe an unusual case of ileal atresia, resulting from antenatal strangulation of a Meckel's diverticulum in an exomphalos minor. This is a rare antenatal complication of Littre's hernia, which has not been previously described. A small exomphalos minor at the base of umbilical cord and late onset vascular accident at the narrow defect leading to ileal atresia may be missed in the prenatal diagnosis. The triad of exomphalos minor, Meckel's diverticulum and terminal ileal atresia secondary to antenatal strangulation of Littre's hernia is very rare to find in the same patient. A small exomphalos minor at the base of the umbilical cord can be missed even in the postnatal period. Our case lends direct evidence of vascular accident as a cause of ileal atresia and supports vascular theory. Whenever possible umbilicus should be preserved naturally and exomphalos sac should be opened higher up for excellent cosmetic results.

Major omphalocele with liver protrusion. Liver dysmorphism. A case study

In the Renaissance (1634), Ambroise Paré described for the first time the omphalocele, highlighting the serious prognosis of this malformation. The incidence of omphalocele varies between 1/2000-1/6000 births, both sexes being equally affected. We present the case of a male infant, born at term after a pregnancy that was not followed by the family doctor or by the specialist obstetrician and who died after five days. On the anterior abdominal wall in the umbilical region, there was a formation of about 10 cm in diameter, covered by a membrane apparently avascular through whose transparency there could be observed a blue-reddish tumor, of discreet firm consistency that while breathing compressed the apparently avascular membrane that covers it. Intraoperative there was noticed liver herniation by parietal defect, operating the liver reintegration in umbilical cavity, subsequently the child dying from a cardio-respiratory arrest. The particularity of this case is on one hand the liver herniation without intestinal loops, the most common liver hernia being with intestinal loops and, on the other hand the presence of hepatic dysmorphism. We also mention the trilaminar structure of omphalocele membrane sac, which makes us think that the herniation was secondary, after the tenth week, through a defect of the anterior abdominal wall closure in the umbilicus region. The combination of these elements creates the uniqueness of this case.

Profile of paediatric umbilical hernias managed at Federal Medical Centre Umuahia

BACKGROUND

Umbilical hernias are common in children but many resolve spontaneously within the first five years of life. Most umbilical herniorrhaphies in our environment are due to symptomatic hernias which constitute a small percentage of all umbilical hernias.

PATIENTS AND METHODS

A retrospective review of all pediatric patients with UH treated at Federal Medical Centre Umuahia, Abia State from February 2001 to February 2011.

RESULTS

There were 22 patients but only 20 of the folders were found and analyzed. They were made up of 11 males and 9 females with a mean age of 6.19 +/- 0.83 years and median age of 6 years. Nine(7 males and 2 females) had acute incarcerations, nine (3 males and 6 females) had recurrent umbilical pains without incarceration and two (1 male and 1 female) had recurrent incarcerations. Age range for acute incarceration was 2-8 years (mean: 4.69 years, median: 4 years); recurrent umbilical pains was 4 months -15 years (mean: 7.7 years, median: 8 years) and for recurrent incarceration 2-10 years (mean: 6 years). All had standard umbilical hernia repairs except one whose parents declined surgery after reduction of acute incarceration. One patient with acute incarceration had gangrenous bowel with hernia sac abscess and was offered bowel resection with end-to-end anastomosis. On short-term follow-up, the symptoms resolved in all the patients following surgery. Five patients had six complications: 1 exuberant granulation tissue, 2 stitch reactions, 2 superficial wound dehiscence and one superficial wound infection. There were no mortalities and no recurrence on short-term follow-up. Only one patient (5%) registered under the National Health Insurance Scheme (NHIS).

CONCLUSIONS

Active observation of all umbilical hernias at all ages will ensure early detection of complications and prompt treatment. Elective repair of umbilical hernias in patientsabove five years with fascia defect greater than 1.5cm is encouraged. Comprehensive NHIS will ensure early presentation and reduced complications.

[Giant omphalocele correction in a patient with pentalogy of Cantrell]

Pentalogy of Cantrell is a rare congenital malformation characterised by a large defect in the lower region of the sternum, diaphragm, and lower abdominal region. It is also characterised by the migration of organs, and its prognosis depends on the presence of cardiac malformations. We present the case of an 18 year-old male subjected to a scheduled giant omphalocele correction. Invasive monitoring, including cardiac output, was used to avoid episodes of instability due to the increase in abdominal pressure and the increase in venous return (as had happened on two previous operations). The prognosis depends on multiple factors, with good haemodynamic and respiratory control being the most important. Mortality is high despite the advances in monitoring.

Adherent umbilical hernia containing Meckel's diverticulum resected due to intraoperative injury

PURPOSE

The aim of this report was to describe a rare case of a male patient with dry umbilical hernia with Meckel's diverticulum adherent to the neck of hernia sac. The patient's history, results of physical examination, laboratory testing, intraoperative findings, treatment method and postoperative course are summarized in details in this report. Follow-up visits were performed 14 days, one month and one year after the operation.

CASE REPORT

A 35-year-old overweight Caucasian male patient (initials: D-B, body weight 90 kg, height 172 cm) was admitted to the hospital on 2nd April 2009 with reducible umbilical hernia for elective surgical treatment. The patient was operated on in the Specialist Diagnostic and Therapeutic Centre Medicina in Cracow and discharged from the hospital on fourth postoperative day. This case is compared with a few similar cases which have been described in the literature till now--all of these reports dealt with strangulated umbilical hernias but not reducible one. The patient underwent elective operation performed on the day of admission. Antibiotic prophylaxis included single dose of pefloxacine (400 mg intravenously) administered just before start of the operation. Subarachnoid anaesthesia was applied 15 minutes before start of the operation. The procedure lasted 75 minutes. Hernia sac was dissected and opened. In the hernia neck adherent Meckel's diverticulum was found. It was localised 80 cm from ileocecal valve and its length was 45 millimetres. During dissection process the diverticulum was injured in the apical region so cuneiform resection of the ileum with Meckel's diverticulum was performed. Ileum was sutured with two layers of absorbable sutures. The tissue defect in umbilical region was repaired primarily with onlay synthetic mesh prosthesis (polypropylene mesh, size 7 x 12 cm).

CONCLUSIONS

1) Adherent incidental Meckel's diverticulum in a sac of reducible umbilical hernia is a very rare finding. 2) During umbilical herniorrhaphy (elective or urgent) the presence of Meckel diverticulum in hernia sac should be taken into consideration. 3) If Meckel diverticulum is adherent to the hernia sac it requires careful dissection and resection of the diverticulum in selected patients. 4) When there is a tumour palpable in the wall or basis of Meckel diverticulum segmental resection of the small intestine with appropriate margins should be performed.

Incarcerated umbilical hernia as the debut of abdominal actinomycosis

BACKGROUND

Abdominal actinomycosis is a rare infection with a difficult diagnosis that can simulate multiple surgical scenarios such as neoplasms or complications of inflammatory bowel disease.

CLINICAL CASE

We present the case of a 69-year-old female who underwent emergency surgery due to a difficult and painful tumor, suggesting an incarcerated umbilical hernia. Whitish lesions were discovered in the abdominal wall and a stenotic colonic mass was managed similar to a neoplasm. Anatomopathological study showed abdominal actinomycosis, requiring a lengthy course with penicillin.

CONCLUSION

Actinomycosis infection is a chronic disease with granulomatous lesions and areas of fibrosis. Its incidence is increasing and the location usually is cervicofacial. The great challenge of this pathology lies in the diagnosis because it simulates different diseases of diverse natures. This type of infection can be treated successfully with drugs if the etiology is identified in a timely manner. However, in the case of our patient, the manner of presentation made diagnosis more difficult prior to surgical trauma.