Improving Shared Decision-making and Treatment Planning Through Predictive Modeling: Clinical Insights on Ventral Hernia Repair.

Abdominal wall hernia repair, including ventral hernia repair, is one of the most common general surgical procedures. Nationally, at least 350 000 ventral hernia repairs are performed annually, and of those, 150 000 cases were identified as incisional hernias. Outcomes are reported to be poor, resulting in additional surgical repair rates of 12.3% at 5 years and as high as 23% at 10 years. Healthcare costs associated with ventral hernia repair are estimated to exceed $3 billion each year. Additionally, ventral hernia repair is often complex and unpredictable when there is a current infection or a history of infection and significant comorbidities. Accordingly, a predictive model was developed using a retrospectively collected dataset to associate the pre- and intra-operative characteristics of patients to their outcomes, with the primary goal of identifying patients at risk of developing complications a priori in the future. The benefits and implications of such a predictive model, however, extend beyond this primary goal. This predictive model can serve as an important tool for clinicians who may use it to support their clinical intuition and clarify patient need for lifestyle modification prior to abdominal wall reconstruction. This predictive model can also support shared decision-making so that a personalized plan of care may be developed. The outcomes associated with use of the predictive model may include surgical repair but may suggest lifestyle modification coupled with less invasive interventions.

Using Crowdsourcing as a Platform to Evaluate Lay Perception of Prophylactic Mesh Placement.

BACKGROUND: Prophylactic mesh placement (PMP) at the time of open abdominal surgery has gained momentum over the last decade. However, there remains an identifiable gap in the literature regarding patient-reported outcomes and qualitative metrics. In effort to gauge the population's understanding or familiarity with PMP, this study provides an educational framework and uses crowdsourcing as a novel means to assess perception among the general population. METHODS: A cross-sectional survey study was conducted among the general public to elicit perspectives on PMP. An online crowdsourcing platform was used to capture responses to a questionnaire. Pearson's correlation coefficients, paired t-test, chi-square test, and Fisher's exact tests were performed. RESULTS: Of 433 respondents, 338 (78.1%) were included. Individuals who had previously undergone surgery and those who had prior hernia repair were more likely to choose PMP than surgically naïve patients (P = 0.06). CONCLUSIONS: The majority of respondents support the use of PMP. This study contributes to the existing body of literature on PMP and serves as the first qualitative description to gauge the population's perception and understanding of this surgical technique. Within the evolving health care landscape, understanding quality-of-life measures have become increasingly important in defining successful surgical outcomes. Although the data-driven level-I evidence supports the clinical use of PMP, this study intends to establish a framework for future patient-reported outcome studies.

Impact of Abdominal Wall Hernias and Repair on Patient Quality of Life.

BACKGROUND: The modified Activities Assessment Scale (AAS) is a 13-question abdominal wall quality of life (AW-QOL) survey validated in patients undergoing ventral hernia repair (VHR). No studies have assessed AW-QOL among individuals without abdominal wall pathology. The minimal clinically important difference (MCID) of the modified AAS and its implications for the threshold at which VHR should be offered also remain unknown. Our objectives were to (1) establish the AW-QOL of patients with a clinical abdominal wall hernia versus those with no hernia, (2) determine the MCID of the modified AAS, and (3) identify the baseline quality of life (QOL) score at which patients derive little clinical benefit from VHR. METHODS: Patient-centered outcomes data for all patients presenting to General Surgery and Hernia Clinics October-December 2016 at a single safety-net institution were collected via a prospective, cross-sectional observational study design. Primary outcome was QOL measured using the modified AAS. Secondary outcome was the MCID. RESULTS: Patients with no hernia had modified AAS scores of 81.6 (50.4-94.4), while patients with a clinically apparent hernia had lower modified AAS scores of 31.4 (12.6-58.7) (p < 0.001). The MCID threshold was 7.6 for a "slight" change and 14.9 for "definite" change. Above a modified AAS score of 81, the risk of worsening a patient's QOL by surgery is higher than the chances of improvement. CONCLUSIONS: VHR can improve 1-year postsurgical AW-QOL to levels similar to that of the general population. The MCID of the modified AAS is 7.6 points. Patients with high baseline scores should be counseled about the lack of potential benefit in QOL from elective VHR.

Long-term quality of life and functionality after ventral hernia mesh repair.

BACKGROUND: The absence of recurrence and pain are important for good quality of life (QoL) after ventral hernia mesh repair. We wanted to study long-term outcome after laparoscopic (LVHR) and open ventral hernia mesh repair (OVHR) using validated scales to measure QoL and functional outcome. METHODS: We conducted a single-center follow-up study of 194 consecutive patients after LVHR and OVHR between March 2000 and June 2010. Of these, 27 patients (13.9 %) died and 14 (7.2 %) failed to attend their follow-up appointment. Of 153 (78.9 %) patients who attended, 81 (52.9 %) patients had LVHR and 72 (47.1 %) patients had OVHR, including 11 conversions (surgery group). One hundred and twelve patients with non-recurrent ventral hernia were also enrolled consecutively as controls (non-surgery group). Quality of life was measured by the SF-36 short form questionnaire and functional outcome by the Activities Assessment Scale (AAS) with the revised Life Orientation Test to measure the influence of dispositional optimism on pain and functionality. Assessment of pain was done using a 100-mm visual analogue scale ruler anchored by word descriptors. RESULTS: Median time from hernia mesh repair to follow-up was 48 and 52 months after LVHR and OVHR, respectively. There were no long-term differences between LVHR and OVHR measured by SF-36 and AAS. Physical dimensions in SF-36: physical function, restrictions in physical function and bodily pain, were significantly better in the surgery group compared to the non-surgery group, but only for incisional hernia. Recurrence was associated with a significant reduction in QoL in all dimensions of SF-36 in both hernia repair cohorts. Chronic pain and impairment were closely related. Optimistic patients had less impairment than pessimistic patients. CONCLUSION: LVHR and OVHR reduce chronic pain and physical impairment and improve long-term QoL. Hernia recurrence and persistent pain reduce the beneficial effect of hernia surgery. Dispositional optimism can modulate QoL reporting and improve functionality.

[Treatment of paracolostomic hernias using polypropylene mesh].

It was analyzed the results of treatment of 23 patients with large paracolostomic hernias. Twenty patients underwent colostomy suturing and hernial ring Onlay-plasty with polypropylene mesh without tension. Onlay-plasty of hernial ring with own tissues and polypropylene mesh and colostomy reconstruction outside of implant were performed in 3 patients. Onlay-alloplasty with polypropylene mesh "PROLENE" is effective method of treatment of postoperative paracolostomic ventral hernias with colostomy closing as well as with its reconstruction outside of implant.

[The remote results of treatment of patients with postoperative abdominal hernias depending on surgical access].

The modern concept of life quality research in herniology is applied in the work. 202 patients with postoperative abdominal hernias who underwent making a prosthetic appliance hernioplasties for the period from 2000 to 2010 were included in the study. 105 patients (studied group) and 97 patients were operated by using of laparoscopic and conventional techniques, respectively. Quality of life was evaluated by using of standardized russified questionnaire SF-36 which allowed to make idea about two main components of health - physical and mental. Laparoscopic plasty has certain advantages in comparison with conventional techniques. Also it increases quality of life of patients in terms more than 1 year after surgery.

[Influence of lifting of muscular aponeurotic tissues of the hypogastrium area on quality of life in abdominoplasty patients].

An analysis of complex clinical and ultrasonic investigations of the abdominal wall and the following surgery in 42 women with ventral hernia of big size accompanied by the ptosis of the abdomen was made. The patients were divided into two groups, each consisting of 21 patients.The endoprosthesis replacement of defect of the abdominal wall was made with standard polypropylene implant in the first group. The endoprosthesis replacement was complemented by lifting of muscular aponeurotic tissues of the hypogastrium using the implant of the original construction in the second group. The polypropylene endoprosthesis includes the main flap (15 x 15 cm) with rounded corners and the additional flap (5 x 40 cm) as a broad band situated at the lower edge of main flap in across-track direction. The increase of physical component of health was noted in 1.8 times in the second group patients and psychological component raised in 2.5 times.

Long term outcome and quality of life after open incisional hernia repair--light versus heavy weight meshes.

BACKGROUND: Mesh repair of incisional hernia is superior to the conventional technique. From all available materials for open surgery polypropylene (PP) is the most widely used. Development resulted in meshes with larger pore size, decreased mesh surface and lower weight. The aim of this retrospective non randomized study was to compare the quality of life in the long term follow up (> 72 month) after incisional hernia repair with "light weight"(LW) and "heavy weight"(HW) PP meshes. METHODS: 12 patients who underwent midline open incisional hernia repair with a HW-PP mesh (Prolene® 109 g/m2 pore size 1.6 mm) between January 1996 and December 1997 were compared with 12 consecutive patients who underwent the same procedure with a LW-PP mesh (Vypro® 54 g/m2, pore size 4-5 mm) from January 1998. The standard technique was the sublay mesh-plasty with the retromuscular positioning of the mesh. The two groups were equal in BMI, age, gender and hernia size. Patients were routinely seen back in the clinic. RESULTS: In the long term run (mean follow up 112 ± 22 months) patients of the HW mesh group revealed no significant difference in the SF-36 Health Survey domains compared to the LW group (mean follow up 75 ± 16 months). CONCLUSIONS: In this study the health related quality of life based on the SF 36 survey after open incisional hernia repair with light or heavy weight meshes is not related to the mesh type in the long term follow up.

[Postoperative ventral hernia in cancer patients].

Surgical patients with cancer of the stomach, colon and genitals (316) were followed up. Frequencies of postoperative ventral hernia and certain factors of their development were evaluated. It was found that surgical complication occurred in 29.4%, aged 4-192 months. Hernia was mostly registered in gynecological and colorectal cancer patients who had had laparotomy and radiotherapy in their case history. Considering its frequency, postoperative ventral hernia is a serious health problem.

Patient quality of life before and after ventral hernia repair.

BACKGROUND: Recurrence is often reported as the primary outcome among studies of patients with hernias; however, there is growing interest in patient quality of life. The relationship between quality of life and recurrence is poorly understood. This study evaluates this relationship. METHODS: A secondary analysis of 3 prospective clinical trials was performed. The modified Activities Assessment Scale, a validated, abdominal wall-specific quality of life tool was used (1 = poor quality of life and 100 = perfect quality of life). Patients with and without a hernia recurrence were compared. Baseline quality of life, follow-up quality of life, and change in quality of life were measured. The relationship between quality of life and clinical outcomes was examined. RESULTS: A total of 238 patients were followed for median (range) 30 (14-44) months, of whom 31 (13.0%) had a clinical recurrence, whereas 207 (87.0%) had no clinical recurrence. Patients with recurrence were more likely to have a lower mean baseline quality of life (14 vs 26; P = .035), follow-up quality of life (42 vs 82; P < .001), and change in quality of life (19 vs 33; P < .018). The majority of patients with or without recurrence still experienced an improvement in quality of life (68% vs 79%; P = .142). CONCLUSION: Patients with lower baseline quality of life are likely to experience a recurrence following repair; however, most still report substantial improvements in quality of life. Assessing follow-up quality of life without accounting for baseline quality of life is incomplete; follow-up quality of life should be assessed with appropriate adjustment for baseline quality of life.

Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score.

BACKGROUND: The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. METHODS: Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). RESULTS: A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). CONCLUSIONS: In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques.

SUMMARY: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Mesh-fixation method and pain and quality of life after laparoscopic ventral or incisional hernia repair: a randomized trial of three fixation techniques.

BACKGROUND: Persistent, activity-limiting pain after laparoscopic ventral or incisional hernia repair (LVIHR) appears to be related to fixation of the implanted mesh. A randomized study comparing commonly used fixation techniques with respect to postoperative pain and quality of life has not previously been reported. METHODS: A total of 199 patients undergoing non-urgent LVIHR in our unit between August 2005 and July 2008 were randomly assigned to one of three mesh-fixation groups: absorbable sutures (AS) with tacks; double crown (DC), which involved two circles of tacks and no sutures; and nonabsorbable sutures (NS) with tacks. All operations were performed by one of two experienced surgeons, who used a standardized technique and the same type of mesh and mesh-fixation materials. The severity of the patients' pain was assessed preoperatively and at 2 weeks, 6 weeks and 3 months postoperatively by using a visual analogue scale (VAS). Quality of life (QoL) was evaluated by administering a standard health survey before and 3 months after surgery. Results in the three groups were compared. RESULTS: The AS, DC, and NS mesh-fixation groups had similar patient demographic, hernia and operative characteristics. There were no significant differences among the groups in VAS scores at any assessment time or in the change in VAS score from preoperative to postoperative evaluations. The QoL survey data showed a significant difference among groups for only two of the eight health areas analyzed. CONCLUSION: In this trial, the three mesh-fixation methods were associated with similar postoperative pain and QoL findings. These results suggest that none of the techniques can be considered to have a pain-reduction advantage over the others. Development of new methods for securing the mesh may be required to decrease the rate or severity of pain after LVIHR.

[Long-term quality of life of patients with postoperative ventral hernia].

125 patients with postoperative ventral hernia were included in the study. First group included patients who were operated on with the use of polypropylene mesh, second group of patients were operated on, using non-mesh techniques. Quality of life was assessed with the use of standard SF-36 questionnarie. The obtained data demonstrated inexpediency of mesh implantation in small hernias, so far the quality of life tended to be the same in both groups, but complication rate was higher in patients of the first group. Mesh implantation was reasonable in treatment of medium and large ventral hernias.

Long-term impact of incisional hernia on quality of life after colonic cancer resection.

PURPOSE: The objective of the current study was to examine the long-term quality of life (QOL) after colonic cancer resection according to whether or not the patients developed incisional hernia. Furthermore, the impact of incisional hernia repair on QOL was examined in the patient group diagnosed with an incisional hernia. METHODS: This was a nationwide register-based study including patients undergoing colonic cancer resection identified in the Danish Colorectal Cancer Group database. Surviving patients were contacted and answered the EORTC QLQ-C30 questionnaire and grouped according to subsequent incisional hernia diagnosis, and in a subgroup analysis of patients with subsequent incisional hernia according to incisional hernia repair or not. RESULTS: A total of 2466 patients were included. The median time from colonic cancer resection to QOL assessment was 9.9 years, during which a total of 215 (8.7%) patients were diagnosed with incisional hernia, and 156 (72.6%) of these underwent incisional hernia repair. After adjustment for confounders, incisional hernia subsequent to colonic cancer resection was significantly associated with reduced QOL in the domains Global health, Physical functioning, Role functioning, Emotional functioning and Social functioning, as well as significantly associated with increased symptoms in the scales of pain, dyspnoea and insomnia. Of patients with incisional hernia, surgical repair was associated with increased QOL in the domains Physical functioning and Role functioning. CONCLUSIONS: Incisional hernia subsequent to colonic cancer resection was associated with reduced QOL several years after surgery and should be considered taken into account when evaluating the long-term outcome of colonic cancer resection.

Laparoscopic parastomal hernia repair using a keyhole technique results in a high recurrence rate.

INTRODUCTION: Parastomal herniation is a common complication of stoma formation, and its operative treatment is notoriously difficult. Recently we have reported the promising short-term results of a keyhole technique in which a Gore-Tex Dual Mesh with a central keyhole is laparoscopically fashioned around the bowel to close the hernia. In the long-term, recurrence is one of the major issues in hernia repair, therefore, this aspect was prospectively investigated. METHODS: Since 2002, a total of 55 consecutive patients (27 men; median age, 63 years) with a symptomatic primary (n = 45) or recurrent parastomal hernia (n = 10) were electively operated using this technique. Patients were invited to the outpatient clinic on a regular basis and were examined for the occurrence of a recurrent hernia. At the last visit, all patients were asked to complete a short questionnaire. RESULTS: Median follow-up (98%) was 36 (range, 12-72) months. During follow-up a recurrent parastomal hernia was diagnosed in 20 patients (37%). Three recurrences were asymptomatic and were treated conservatively. The other 17 patients (85%) developed mild-to-severe symptoms necessitating redo-surgery in 9 (45%) patients. Surprisingly, satisfaction with the procedure was high among patients (89%), even in the presence of a recurrence. Patients who reported unsatisfactory results belonged mainly to the group in whom the initial laparoscopic approach had to be converted to an open procedure. CONCLUSIONS: Based on the results from the present study, which represents one of the largest patient series with the longest follow up available to date, it is concluded that laparoscopic parastomal hernia repair using a keyhole technique has an intolerably high recurrence rate with the currently available meshes. A new mesh with a less pliable central part and without the tendency to shrink is awaited.

Early repair of ventral incisional hernia may improve quality of life after surgery for abdominal malignancy: a prospective observational cohort study.

PURPOSE: Recent work has shown that over 40% of patients undergoing surgery for abdominal malignancy develop ventral incisional hernias (VIH) within 2 years. We hypothesized that early repair of VIH for cancer survivors could improve long-term quality of life (QoL). METHODS: All patients presenting with a history of surgery for abdominal malignancy and a VIH were prospectively enrolled. QoL was assessed at baseline and 3-, 6-, 12-, 18-, and 24-month follow-up using abdominal wall-specific (HerQLes) and cancer-specific (FACT-G) instruments. At the study's conclusion, patients were divided into 2 groups-those that underwent VIH repair during the study's course (Repair Group) and those that did not (Control Group). Categorical variables were analyzed using Pearson's Chi-square and continuous variables with Wilcoxon rank sum test. RESULTS: Eighty-four patients were enrolled. Overall, 46 patients (55%) underwent VIH repair, with 36 repairs (78%) occurring within 3 months of initial evaluation. Sixty-six (79%) had complete 1-year follow-up data, and 30 (36%) had 2-year data, with a median follow-up duration of 15.6 months. At baseline, both groups were similar with respect to demographics, cancer stage, and HerQLes/FACT-G scores. Compared to the Controls, the Repair Group showed greater improvements over baseline HerQLes Summary Scores at the 3-, 6-, 12-, and 18-month time points (median increase, 37 vs. 26 points), and in FACT-G total scores at the 3-, 6-, and 12-month time points (median increase, 6 vs. 4 points). CONCLUSIONS: Repair of VIH after surgery for abdominal malignancy may improve abdominal wall-specific and cancer-specific QoL, making post-resection abdominal wall reconstruction an important aspect of cancer survivorship.

The impact of preoperative anxiety, depression, and chronic pain on outcomes in abdominal wall reconstruction.

PURPOSE: An association of anxiety with surgical outcomes has been suggested, including with open ventral hernia repair (OVHR). This study examines the interaction of multiple comorbidities, including anxiety, depression, chronic pain, and hernia characteristics with outcomes after OVHR. METHODS: Patients with anxiety were identified in an existing, prospectively collected, data set of OVHR with preoperative work-up including CT scans (2007-2018). A patient with a diagnosis or prescription for anxiolytics, anti-depressants, or narcotics was considered to have anxiety, depression, or chronic pain, respectively. Hernia characteristics were analyzed using 3D volumetric software. Univariate and multivariate analyses were performed to assess for the impact of anxiety on surgical outcomes. RESULTS: A total of 1178 OVHRs were identified. The diagnosis of anxiety (23.9%) was associated with female gender (29.1% females vs. 16.9% males, p = 0.002), depression (56.7 vs. 18.8%, p < 0.0001), preoperative chronic pain (43.6 vs. 26.9%, p < 0.0001), COPD, arrhythmia, history of MRSA, and sleep apnea (p ≤ 0.05 all values). Patients with anxiety had larger hernia volume and defect size, and were more likely to undergo component separation, with higher rates of wound complication and intervention for pain (p ≤ 0.05 all values). After multivariate analysis controlling for multiple potentially confounding factors, the comorbidities of anxiety, depression, and preoperative chronic pain were not found to be significantly associated with adverse outcomes. CONCLUSIONS: The diagnosis of anxiety is associated with preoperative comorbidity, surgical complexity, and adverse outcomes after OVHR. However, when comorbidities are controlled for, the diagnosis of anxiety, depression or preoperative pain does not independently predict adverse outcomes. In this context, anxiety may be considered a marker of patient comorbidity in a complex patient population.

Underserved Patients Seeking Care for Ventral Hernias at a Safety Net Hospital: Impact on Quality of Life and Expectations of Treatment.

BACKGROUND: The purpose of this study was to identify issues important to patients in their decision-making, expectations, and satisfaction when seeking treatment for a ventral hernia. STUDY DESIGN: An exploratory qualitative study was conducted of adult patients with ventral hernias seeking care at a safety-net hospital. Two semi-structured interviews were conducted with each patient: before and 6 months after surgical consultation. Interviews were audiotaped, transcribed, and coded using latent content analysis until data saturation was achieved. RESULTS: Of patients completing an initial interview (n = 30), 27 (90%) completed follow-up interviews. Half of the patients were Spanish-speaking, one-third had a previous ventral hernia repair, and two-thirds underwent initial nonoperative management after surgical consultation. Patient-described factors guiding management decisions included impact on quality of life, primarily pain and limited function; overwhelming challenges to meeting surgical criteria, primarily obesity; and assuming responsibility to avoid recurrence. Patients were uninformed regarding potential poor outcomes and contributing factors, even among patients with a previous ventral hernia repair, with most attributing recurrence to inadequate self-management. CONCLUSIONS: Understanding patients' perspective is crucial to engaging them as stakeholders in their care, addressing their concerns, and improving clinical and patient-centered outcomes. Patient reports suggest how care can be improved through developing more effective strategies for addressing patients' concerns during nonoperative management, preoperative risk reduction strategies that are sensitive to their sociodemographic characteristics, treatment plans that harness patients' willingness for self-management, and patient education and decision-making tools.

Preservation of the umbilical cord at the primary fascial closure in infants with gastroschisis.

Recently, the survival of patients with gastroschisis has been dramatically improved and it has reached more than 90%. Over the last 10 years, 20 of 21 cases (95%) survived in our hospital. We have been using the primary fascial closure of the abdominal wall as a standard operative procedure. The umbilical cord was usually excised at the operation in order to secure the suture line and prevent wound infection. The survivors sometimes complained of the absence of the umbilicus. However, it was somewhat difficult to create a new umbilicus later by use of the surrounding skin. In the last five cases, we tried to carry out the primary fascial closure with preservation of the umbilical cord. All patients could obtain good cosmetic results with near-normal appearance. Omphalitis or cellulitis was never observed, but a small umbilical hernia occurred in one case.