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.

Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital

Background Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population. Methods From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance. Results The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m2) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair. Conclusion Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.

Is the frequency of simultaneous umbilical hernia repairs in laparoscopic and open cholecystectomy similar?

The aim of this study was to compare the frequency of umbilical hernia repair during open and laparoscopic cholecystectomies. Consecutive patients who underwent laparoscopic and open cholecystectomy between January 1993 and June 2005 were retrospectively reviewed. Among those, cases of patients who underwent simultaneous cholecystectomy and umbilical hernia repair were included in the study, and the distribution of hernia repairs via laparoscopic and open cholecystectomy were investigated. In addition, patients who underwent umbilical hernia repair only during the study period were also screened and the type of repair was noted in order to be compared to the types of hernia repair in the patients who underwent cholecystectomy. In total, there were 3,028 patients who underwent cholecystectomy, out of which 2,281 were performed via laparoscopy. In total, 46 patients underwent cholecystectomy and simultaneous umbilical hernia repair; 44 underwent laparoscopic cholecystectomy and umbilical hernia repair at the same time (P < 0.001), out of which only 2 were repaired through the use of a mesh. In contrast, 284 patients underwent only umbilical hernia repair, out of which 156 underwent primary repair. Simultaneous umbilical hernia repair during laparoscopic cholecystectomy was more common than hernia repair during open cholecystectomy.

O47 MESH-RELATED COMPLICATIONS, CHRONIC PAIN, AND ECONOMIC CLAIM COMPENSATION AFTER UMBILICAL HERNIA REPAIR

Aim The risk of mesh-related surgical complications after umbilical hernia repair is not known and chronic pain has only sparsely been analysed. Economic claims may represent a surrogate for poor postoperative surgical outcomes. Thus, the present study used mesh-related complications and chronic pain as primary and secondary outcomes, respectively. Material and Methods Blinded assessment of Swedish and Danish nationwide consecutive economic claim data from 2007 –2019. The study variables and outcomes were pre-study defined. Major complications were defined as acutely life-threatening complications requiring emergency surgery, clinically important complications were defined as all complications requiring surgical intervention but not emergency surgery. Results During the 13-years study period 181 patients were eligible for analysis. There were 96 patients with a surgical complication. In 52 (54%) and 44 (46%) patients the complication was mesh- or non-mesh-related, respectively. In the group of mesh- and non-mesh-related complications, major complications were found in 14 (14,6%) vs 21 (21,9%) patients and clinically important complications were found in 38 (39,5%) vs 23 (23,9%) patients respectively (P &lt; 0.05). Chronic pain was reported in 18%, followed by wound complications (14%) and cosmetic claim reasons (11%). After open repair, claim because of chronic pain was significantly more common after mesh repair (48%) compared with non-mesh repairs (32%), P = 0.05. The economic compensation after a mesh- and non-mesh complication was 3,488€ (291 – 188,186€) and 2,342€ (507€ - 58,437€) (P = 0.55), respectively. Conclusions Mesh-repair was related to postoperative complications and chronic pain after umbilical hernia repair

P003 SUMMER TRIAL: MESH VERSUS SUTURE REPAIR IN SMALL UMBILICAL HERNIAS IN ADULTS: A STUDY PROTOCOL FOR A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, MULTICENTER CLINICAL TRIAL

Aim A gold standard procedure for small umbilical hernia repairs is still lacking today. There is an increasing evidence that mesh could be advantageous in lowering recurrence rates. A question remains with regard to optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay-mesh can reduce recurrence rates without increasing complications compared to a simple-suture repair. Material and Methods A prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4x4 cm onlay mesh to a conventional suture repair will be conducted. 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place. Trial participants and follow-up clinical surgeons will be blinded to the assigned allocation. The primary outcome assessed will be postoperative recurrence at 1 and 3 years. Secondary outcomes assessed will be postoperative complications at 30 days and pain 1 year after surgery. Results 140 participants are included since February 2020 and 95 participants are randomized. Conclusions How to best repair a small umbilical hernia continues to be debated. A small onlay-mesh may become an easy and a safe method of choice to reduce recurrence rates in small umbilical hernia defects. This trial design should allow for a good assessment of differences in recurrence rate with due to the large sample size and the adequate follow-up. Guidelines for small umbilical hernia repairs have stressed the need for reliable data to improve treatment recommendations. We can expect that this trial will have a direct implication on small umbilical hernia repair standards.

Laparoscopic Treatment of Early Postoperative Ileus After Laparotomy.

Aim. The case report demonstrates a successful laparoscopic treatment of early postoperative small bowel obstruction after open strangulated umbilical hernia repair with mesh.Case report. An 86-year-old female was admitted to the hospital due to abdominal pain for 2 days localised in the umbilical region. A diagnosis of strangulated umbilical hernia was set, and emergency operative therapy was performed. On the third postoperative day the patient showed symptoms of bowel obstruction, confirmed on CT. An emergency laparoscopy proceeded. It revealed small intestine loop fixation to the mesh through the peritoneal defect. While separating the intestine a defect in bowel wall was found and sutured laparoscopically. Patient was discharged from the hospital on the 8th postoperative day.Conclusion. Laparoscopic treatment after open hernia surgery is an alternative access for redo surgery in early postoperative period. It provides acceptable results even in contaminated area without needs to reopen surgical wound.

Umbilical hernia causing ventriculoperitoneal shunt dysfunction: illustrative cases

BACKGROUND When ventriculoperitoneal (VP) shunts and umbilical hernias coexist in the same patient, unique complications can occur. Typically, these are readily identified problems such as cerebrospinal fluid (CSF) fistulas or entrapment of the peritoneal catheter in the hernia. The authors present cases of two children whose VP shunt dysfunction resolved after repair of their umbilical hernias. OBSERVATIONS The authors present two cases of infant patients with shunted hydrocephalus and umbilical hernias. In both cases, the patients presented with distal shunt malfunctions not due to infection. Their shunt function improved once the umbilical hernia was repaired by pediatric surgery. Neither has required shunt revision since umbilical hernia repair. LESSONS Although there are case reports of VP shunts eroding through the umbilicus, developing CSF fistulas, or becoming trapped inside umbilical hernias, there is no case of VP shunt dysfunction caused by just the presence of an umbilical hernia. The authors suspect that the catheter may intermittently enter and exit the hernia. This may cause intermittent obstruction of the distal catheter, or inflammation in the hernia may occur that limits CSF absorption.

Umbilical hernia repair and recurrence: need for a clinical trial?

Introduction Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons. Aims This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors. Methods A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms ‘Umbilical hernia’ AND ‘repair’ AND ‘recurrence’ were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement. Results Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers. Conclusion This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence.

Enterocutaneous Fistula and Abscess Diagnosed with Point-of-care Ultrasound

Case Presentation: A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain. The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension. The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control. Discussion: A rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.