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.

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.

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.

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.

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.

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.

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.

Prevalence of rectus diastasis is higher in patients with inguinal hernia.

PURPOSE: To determine the prevalence of rectus diastasis (RD) in patients with inguinal hernia. MATERIAL AND METHODS: Multicenter, cross-sectional study. Patients with inguinal hernia were included in the study group (IH) and those with benign proctologic complaints created the control group (CG). Age, gender, BMI, family history for inguinal hernias, comorbid diseases, alcohol use, smoking, constipation, malignancy, chemotherapy, number of births, multiple pregnancies and prostate hypertrophy history of all patients in both groups were recorded. All patients were evaluated for RD and umbilical hernias by physical examination. RESULTS: A total of 528 consecutive patients were included in the study (292 IH / 236 CG). Overall prevalence of RD was 35.6% and it was significantly higher in IH than in CG (46.9% vs 21.6%, p < 0.001). Also, umbilical hernia was more frequently detected in the patients with inguinal hernia. Other risk factors for RD were age, BMI, DM, BPH and smoking. The mean inter-rectus distance for 528 patients was 18.1 mm; it was 20.71 ± 10.68 mm in IH and 14.88 ± 8.82 in CG (p < 0.001). It was determined that the increase in age and BMI caused an increase in the inter-rectus distance, and that the presence of DM, inguinal hernia and umbilical hernia increased the inter-rectus distance quantitatively. CONCLUSIONS: The prevalence of RD seems to be higher in patients with inguinal hernia comparing to that in general population. Increased age, high BMI and DM were found to be independent risk factors for RD development.

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.

Mesothelial Inclusion Cyst in an Infant with Beckwith-Weidemann Syndrome.

Mesothelial inclusion cysts are rare benign tumors not frequently reported in the literature. When reported, they are primarily found in adults. One report from 2006 reports an association with Beckwith-Weideman syndrome, but no other reported cases discuss this correlation. We describe a case of an infant with Beckwith-Weideman syndrome who, in the setting of omphalocele repair, was found to have hepatic cysts with pathology revealing mesothelial inclusion cysts.

A woman with recurrent umbilical bleeding: a case report.

BACKGROUND: Umbilical discharge in an adult is rare and generates broad diagnostic considerations. Umbilical anatomy is variable owing to congenital abnormalities and acquired pathology such as umbilical hernias. The umbilicus can be a site of primary or metastatic malignancy or endometriosis. CASE PRESENTATION: A 40-year-old white American woman came to the clinic with a 2-day history of spontaneous umbilical bleeding. She reported periumbilical pain associated with nausea and emesis. There were no visible skin abnormalities, but deep palpation of the abdomen produced a thin, watery, serosanguineous fluid from the umbilicus. She experienced a similar episode of umbilical bleeding 5 years prior without clear cause. Laboratory workup was notable for mildly elevated C-reactive protein . Computed tomography imaging revealed a fat-containing umbilical hernia with fat necrosis, necessitating complete surgical resection of the umbilicus. CONCLUSIONS: Umbilical hernia with fat necrosis is a rare condition that should be considered in adults with umbilical discharge. Additional diagnostic considerations in adults with spontaneous umbilical bleeding/discharge include embryonal remnants, omphalitis, and metastasis. If the cause is not readily apparent on physical exam, imaging with computed tomography should be considered to assess for hernia and embryonal anomalies.

A unique case of a newborn with a hemangioma on the omphalocele sac.

BACKGROUND: Mass lesions of the umbilical cord are rare anomalies. There have been rare reports of hemangiomas of the umbilical cord, but the co-occurrence of omphalocele and hemangioma of the umbilical cord has not been previously reported. Nonetheless, the condition is clinically significant as it may cause the disturbance of intrauterine fetal circulation, retardation of fetal growth and development, non-immune hydrops fetalis, morbidity and mortality. CASE: Here we aim to report a case that was prenatally diagnosed with an omphalocele and that presented after birth with a hemangioma on the omphalocele sac. CONCLUSIONS: When dealing with umbilical mass lesions in the prenatal and postnatal periods, a hemangioma on the omphalocele sac should be considered in the differential diagnosis of patients when an omphalocele is suspected.

Percutaneous surgical repair for a patient with adult pararectal hernia caused by intractable ascites associated with liver cirrhosis.

Patients with liver cirrhosis are at increased risk of various visceral hernia because of persistent ascites and tissue fragility. Here we report successful treatment in a patient with pararectal hernia due to liver cirrhosis by a less invasive approach via para-anal region. The patient was a 73-year-old woman with a history of chronic hepatitis B that had been untreated for at least 20 years. At the age of 68 years, she was referred to our hospital for treatment of persistent ascites and thrombocytopenia due to advanced liver cirrhosis. Neither diuretics nor cell-free and concentrated ascites reinfusion therapy could decrease the ascites. She needed repeated paracentesis. She was referred to the surgical department due to the painful swelling of the left buttock which was diagnosed as the pararectal hernia. The welling was huge enough with the erosion of the covering skin. Surgery was planned in view of concern about the possible rupture of the hernia. Due to the massive ascites with the advanced liver cirrhosis, we were reluctant to do the laparotomic approach, and simple closure of the hernial orifice via direct approach from the cutaneous side was planned and performed. The patient was fortunately discharged seven days after the operation without any complications. One year later, there has been no recurrence of the hernia. Even in cases with massive ascites, direct simple closure of the hernia by percutaneous approach may be one of the options for the treatment of the pararectal hernia in case of urgent situation.

Omphalocele and biliary atresia: chance or causality. A case report.

To relate omphalocele and biliary atresia and investigate possible embryological correlations that justify the simultaneous occurrence. A female preterm newborn diagnosed as omphalocele; cesarean delivery, weight 2,500g, 46 XX karyotype. Initially, the newborn remained fasting and on parenteral nutrition, and enteral diet was introduced later, with good acceptance. On the 12th day of life, the newborn presented direct hyperbilirubinemia, increased levels of liver enzymes and fecal acholia, with a presumptive diagnosis of biliary atresia. However, the ultrasound was inconclusive, due to anatomical changes resulting from omphalocele. A surgical approach was chosen on the 37th day of life aiming to confirm diagnosis of biliary atresia and to repair omphalocele. During the surgical procedure, structural alterations compatible with biliary atresia were observed, later confirmed by pathological examination; a hepatoportoenterostomy was performed and the omphalocele was corrected. She evolved well in the postoperative period, with a decrease in direct bilirubin and liver enzymes, as well as resolution of fecal acholia, and was discharged in good clinical condition. This is a bizarre and extremely rare association, but the prognosis may be good when an early diagnosis is made and surgery performed, besides support and clinical management to prevent complications in the perioperative period. Although the pathogenesis of the diseases has not been fully defined yet, there is, to date, no direct relation between them. The association between omphalocele and biliary atresia is extremely uncommon, with only two published cases.

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.

A novel approach to managing ruptured umbilical hernias in cirrhosis.

BACKGROUND: Ruptured umbilical hernias in patients with ascites (Flood Syndrome) is an uncommon problem with high morbidity and mortality. The treatment of patients experiencing Flood Syndrome is controversial, with a multitude of different treatments being proposed. METHOD: This paper presents our experience in treating Flood syndrome, and presents a standardized way of treating these patients. RESULTS: Six consecutive patients with Flood syndrome were treated with the same standardized management and surgical technique. All patients had Cirrhosis (Child B and C). All were treated as open emergency operations, with no recurrence or post-operative complications. CONCLUSION: Though there is a lack of level I or II evidence, the data suggests that ruptured umbilical hernias in cirrhotic patients are a surgical emergency that can be optimally managed with operative management. We present a standardized technique for the repair of these hernias which is simple, reliable and appears to have reproducible results. The technique aims to provide a hermetic seal immediately peri-operatively and is supported by medical optimization of the post-operative period. Our small case series represents effective and safe management in appropriately selected patients.

Umbilical hernia repair in patients with cirrhosis: who, when and how to treat.

PURPOSE: Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. METHODS: The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. RESULTS: Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. CONCLUSION: Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and 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.