External hernia of the supravesical fossa: Rare or simply misidentified?

BACKGROUND: External hernias of the supravesical fossa are considered rare, perhaps wrongly. Highlighting clinical and anatomical features could be useful for correct, preoperative diagnosis, thus avoiding the risk of complications such as incarceration. The study aims to demonstrate that the incidence of external protrusions of the supravesical fossa is higher that supposed. Probably, being mistaken for direct hernias, these hernia types are misidentified and not included in current classifications. This issue deserves attention due to the elevated risk of incarceration related to its distinctive structure. MATERIAL AND METHODS: 249 consecutive open anterior inguinal hernia procedures were analyzed. Hernias were categorized according to the Nyhus classification. A subgroup of direct hernias involved true hernias of the supravesical fossa. Multiple ipsilateral, as well as combined hernias having a multi-component structure, were also considered. RESULTS: 13 true hernias of the supravesical fossa and 19 multiple ipsilateral or combined hernias composed of direct and/or indirect hernia, together with one hernia of the supravesical fossa were identified. 4 true hernias of the supravesical fossa presented signs of incarceration. In three other combined protrusions, the herniated component of the supravesical fossa also showed incarceration of the visceral content. CONCLUSIONS: Hernias of the supravesical fossa would appear to be more frequent than imagined. These protrusions show a diverticular shape and the base is often tightened by the stiffer medial umbilical fold. This explains the apparently higher tendency to incarceration that distinguishes this hernia type. Preoperative signs of inguinal pain and irreducibility are pathognomonic for correct diagnosis. In these cases, surgical treatment in the short term is recommended.

Novel exomphalos genetic mouse model: the importance of accurate phenotypic classification.

BACKGROUND: Rodent models of abdominal wall defects (AWD) may provide insight into the pathophysiology of these conditions including gut dysfunction in gastroschisis, or pulmonary hypoplasia in exomphalos. Previously, a Scribble mutant mouse model (circletail) was reported to exhibit gastroschisis. We further characterise this AWD in Scribble knockout mice. METHOD: Homozygous Scrib knockout mice were obtained from heterozygote matings. Fetuses were collected at E17.5-18.5 with intact amniotic membranes. Three mutants and two control fetuses were imaged by in amnio micro-MRI. Remaining fetuses were dissected, photographed and gut length/weight measured. Ileal specimens were stained for interstitial cells of Cajal (ICC), imaged using confocal microscopy and ICC quantified. RESULTS: 127 fetuses were collected, 15 (12%) exhibited AWD. Microdissection revealed 3 mutants had characteristic exomphalos phenotype with membrane-covered gut/liver herniation into the umbilical cord. A further 12 exhibited extensive AWD, with eviscerated abdominal organs and thin covering membrane (intact or ruptured). Micro-MRI confirmed these phenotypes. Gut was shorter and heavier in AWD group compared to controls but morphology/number of ICC was not different. DISCUSSION: The Scribble knockout fetus exhibits exomphalos (intact and ruptured), in contrast to the original published phenotype of gastroschisis. Detailed dissection of fetuses is essential ensuring accurate phenotyping and result reporting.

Omphalocele management using goal-oriented classification in African centre with limited resources.

In 2000-09, 96 children comprising 57 males and 39 females who were presented between 2 h and 1 week of birth with omphalocele were prospectively managed using goal-oriented classification at the University of Benin Teaching Hospital, Nigeria. All were born through spontaneous vaginal delivery, out of which 9 (9.4%) were preterm. Eighty-two (85.4%) mothers in villages with no supervised antenatal care/delivery and/or prenatal diagnosis presented their babies late. Thirty-three (34.4%) babies in group A, with defect size ≤ 4.5 cm and intact sac, were managed conservatively and had fascial closure after neonatal period, resulting in 32 (97%) survivors. Forty-two (43.8%) babies in group B, with defect size > 4.5 cm and intact sac, were managed conservatively and had fascial closures for 9 months to 5 years, resulting in 40 (95.2%) survivors. Group C comprised of 21 (21.9%) babies with defect of any size/ruptured sac and who had immediate repair, resulting in two (9.5%) survivors owing to lack of facilities (p < 0.0001). Hospital delivery and provision of facilities are advocated.

Classification of primary and incisional abdominal wall hernias.

PURPOSE: A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. METHODS: Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. RESULTS: To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. CONCLUSIONS: A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial.

BACKGROUND: Omphalitis contributes to neonatal morbidity and mortality in developing countries. Umbilical cord cleansing with antiseptics might reduce infection and mortality risk, but has not been rigorously investigated. METHODS: In our community-based, cluster-randomised trial, 413 communities in Sarlahi, Nepal, were randomly assigned to one of three cord-care regimens. 4934 infants were assigned to 4.0% chlorhexidine, 5107 to cleansing with soap and water, and 5082 to dry cord care. In intervention clusters, the newborn cord was cleansed in the home on days 1-4, 6, 8, and 10. In all clusters, the cord was examined for signs of infection (pus, redness, or swelling) on these visits and in follow-up visits on days 12, 14, 21, and 28. Incidence of omphalitis was defined under three sign-based algorithms, with increasing severity. Infant vital status was recorded for 28 completed days. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. Analysis was by intention-to-treat. This trial is registered with , number NCT00109616. FINDINGS: Frequency of omphalitis by all three definitions was reduced significantly in the chlorhexidine group. Severe omphalitis in chlorhexidine clusters was reduced by 75% (incidence rate ratio 0.25, 95% CI 0.12-0.53; 13 infections/4839 neonatal periods) compared with dry cord-care clusters (52/4930). Neonatal mortality was 24% lower in the chlorhexidine group (relative risk 0.76 [95% CI 0.55-1.04]) than in the dry cord care group. In infants enrolled within the first 24 h, mortality was significantly reduced by 34% in the chlorhexidine group (0.66 [0.46-0.95]). Soap and water did not reduce infection or mortality risk. INTERPRETATION: Recommendations for dry cord care should be reconsidered on the basis of these findings that early antisepsis with chlorhexidine of the umbilical cord reduces local cord infections and overall neonatal mortality.

Abdominal wall defects in Denmark, 1970-89.

In the last two to three decades, increasing rates of gastroschisis but not of omphalocele have been reported from different parts of the world. The present study represents a register containing 469 children born with abdominal wall defects based on data retrieved from 20 birth cohorts (1970-89) in three nationwide registries. A tentative estimate of the completeness as regards identification of liveborn and stillborn infants is a minimum of 95% and 90% respectively. All cases were reclassified to 166 cases of gastroschisis, 258 of omphalocele and 16 of gross abdominal wall defect. The average point prevalence at birth of gastroschisis was 1.33 per 10 000 live and stillbirths. During the first decade, an increase in prevalence occurred culminating in 1976, followed by a decrease reaching its initial value in 1983 and then a new increase. Overall, no significant linear trend could be demonstrated for the entire period. The average point prevalence at birth for omphalocele was 2.07 and for gross abdominal wall defect 0.12 per 10 000 live and stillbirths with no significant change in the period. The geographical distribution of gastroschisis and omphalocele showed no difference per county.

[Diagnostic prenatal ultrasonography of malformations of the fetal anterior abdominal wall]. / Diagnostic échographique anténatal des malformations de la paroi anterieure du foetus.

Abdominal wall defects include a broad spectrum of structural malformations with variable severity and prognosis. The purpose of prenatal ultrasound examination is to correctly diagnose and classify these malformations according to their localization (particularly their relation to the umbilical cord insertion), their contents, their size and associated malformations or karyotypic abnormalities. Based on this examination, two groups can be distinguished: gastroschisis or omphalocele (when the latter is isolated, in particular without karyotypic abnormalities) which can be surgically corrected at birth, and for which predictive criteria of outcome must be evaluated (vitality of herniated bowel, size and contents of omphalocele); severe malformations (ectopia cordis, cloacal exstrophy, Beckwith-Wiedemann syndrome, short umbilical cord, amniotic band syndrome) for which pregnancy termination could be proposed.

[A new case report of omphalocele in a newborn (Kamenge University Hospital Center at Bujumbura, Burundi)]. / Une nouvelle observation d'omphalocèle du nouveau-né (Centre Hospitalier Universitaire Kamengé Bujumbura-Burundi).

A new case report of new born baby's omphalocele allows us to precise the embryological data indispensable to understand the genesis of this pathology. The future of the primitive intestinal loop and the explanation of the temporary physiological hernia, are the basis of such phenomenons rarely reported and they complete the three cases' report recently published.

Gastroschisis: no myth.

The question has been raised whether omphalocele and gastroschisis are fundamentally different pathologic entities, or whether they are only different manifestations of the same underlying cause. After studying the family history of 37 patients with omphalocele and 14 patients with gastroschisis, it seems probable that hereditary factors contribute to the origin of omphaloceles. Such factors were not shown in patients with gastroschisis. Therefore genetic evaluation and counseling is advocated for the parents of a child with omphalocele.