Elective Umbilical Hernia Repair Research Articles

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

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

Evaluation of Treatment Differences Between Men and Women Undergoing Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative

INTRODUCTION: Sex is emerging as an important clinical variable associated with surgical outcomes and decision-making. Its impact on baseline and treatment differences in primary and incisional ventral hernia repair remains unclear. METHODS: This retrospective cohort study uses the Abdominal Core Health Quality Collaborative (ACHQC) database to identify elective umbilical, epigastric, or incisional hernia repair. Propensity matching was performed to investigate confounder-adjusted treatment differences between men and women. Treatments of interest included surgical approach, mesh use, mesh type, mesh position, anesthesia type, myofascial release, fascial closure, and fixation use. RESULTS: A total of 8,489 umbilical, 1,801 epigastric, and 16,626 incisional hernia repairs were identified. Women undergoing primary ventral hernia repair were younger (umbilical 46.4 vs 54 years, epigastric 48.7 vs 52.7 years), with lower BMI (umbilical 30.4 vs 31.5, epigastric 29.2 vs 31.1), and less likely diabetic (umbilical 9.9% vs 11.4%, epigastric 6.8% vs 8.8%). Women undergoing incisional hernia repair were also younger (mean 57.5 vs 59.1 years), but with higher BMI (33.1 vs 31.5), and more likely diabetic (21.4% vs 19.1%). Propensity analysis included 3,644 umbilical, 1,232 epigastric, and 12,480 incisional hernias. Women with incisional hernia were less likely to undergo an open repair (60.2% vs 63.4%, p < 0.001) and have mesh used (93.8% vs 94.8%, p = 0.02). Women had a higher rate of intraperitoneal mesh placement, and men had a higher rate of preperitoneal and retromuscular mesh placement. CONCLUSION: Small but statistically significant treatment differences regarding operative approach, mesh use, and mesh position exist between men and women undergoing ventral hernia repair.

Risk factors for adverse outcomes in emergency versus nonemergency open umbilical hernia repair and opportunities for elective repair in a national cohort of patients with cirrhosis

BackgroundWhether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair. MethodsVeterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair. ResultsAmong 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years. ConclusionsNonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.

AB183. SOH21AS215. A 2019 nationwide review of emergency vs. elective umbilical hernia repair Ireland: is there a role for non-operative management?

Background: Asymptomatic umbilical hernias are often repaired electively, however there are no high-quality studies defining benefits of elective repair compared to watchful waiting. Low evidence studies suggest that elective repairs are safer than emergencies, with 30-day readmission rates of 5.9% compared to 18.8% in emergency surgery. 16% of those managed conservatively require surgery within 5 years, 3.9% as emergencies.

Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial)

PurposeTo establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites.MethodsPatients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate.ResultsThirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI − 0.87 to 24.77; MCS 10.04, 95% CI − 2.78 to 22.86).ConclusionThis trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints.Trial registrationClinicaltrials.gov, NCT01421550, on 23 August 2011.

Treatment of small (

Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3cm. Suture repair should only be considered for small hernia defects of less than 1cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2cm) umbilical hernias over the past 10years. Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented. A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013. A suture technique is still used to treat 75% of patients with small (< 2cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

Assessment of potential influencing factors on the outcome in small (

How best to treat a small (< 2cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors. The data of patients with primary elective umbilical hernia repair and defect size < 2cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up. 31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates. Suture repair continues to be used for 78% of umbilical hernias with a defect < 2cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

Is there an advantage to laparoscopy over open repair of primary umbilical hernias in obese patients? An analysis of the Americas Hernia Society Quality Collaborative (AHSQC).

The most common techniques used to repair umbilical hernias are open and laparoscopic. As the obesity epidemic in the United States is growing, it is essential to understand how this morbidity affects umbilical hernia repairs. This study compares laparoscopic versus open umbilical hernia repairs in obese patients. All patients with body mass index (BMI) ≥ 30kg/m2 who underwent elective, open or laparoscopic repair of a primary umbilical hernia with mesh were identified from the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review of the prospectively collected data was conducted. Outcomes of interest included surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), hernia-related quality-of-life survey (HerQles), and long-term recurrence. A logistic regression model was used to generate propensity scores. Of 1507 patients who met the inclusion criteria, 322 were laparoscopic, and 1185 were open cases. The laparoscopic group had higher mean BMI (37 ± 6 vs. 35 ± 5kg/m2 , P < 0.001 ) and mean hernia width (3cm ± 1 vs. 2cm ± 2, P < 0.001). Using a propensity score model, we controlled for several clinically relevant covariates. Propensity score adjustment showed no differences in the 30-day HerQles score (OR 0.93, 95% CI 0.58-1.49), SSI (OR 1.57, 95% CI 0.52-4.77), SSOPI (OR 2.85, 95% CI 0.84-9.62) or hernia recurrence (hazard ratio 0.86, 95% CI 0.50-1.49). In obese patients with primary umbilical hernias, there is likely no benefit to laparoscopy over open umbilical hernia repair with mesh with regard to wound morbidity. Although, the long-term recurrence also showed no difference between these two approaches, overall follow up was lacking.

Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis.

BackgroundMesh repair of umbilical hernia has been associated with a reduced recurrence rate compared with suture closure, but potentially at the expense of increased postoperative complications and chronic pain. The objective of this systematic review and meta‐analysis was to examine the outcomes after elective open mesh and suture repair for umbilical hernia in adults.MethodsA literature search was conducted to identify studies presenting original data on elective open mesh and suture repair of umbilical hernia. The primary outcome was hernia recurrence. Secondary outcomes included surgical‐site infection (SSI), seroma, haematoma and chronic pain. Meta‐analyses were undertaken.ResultsThe search resulted in 5353 hits and led to 14 studies being included (6 RCTs and 8 observational studies) describing a total of 2361 patients. Compared with suture, mesh repair was associated with a lower risk of recurrence (risk ratio (RR) 0·48, 95 per cent c.i. 0·30 to 0·77), with number needed to treat 19 (95 per cent c.i. 14 to 31). Mesh repair was associated with a higher risk of seroma (RR 2·37, 1·45 to 3·87), with number needed to harm 30 (17 to 86). There was no significant difference in the risk of SSI, haematoma or chronic pain.ConclusionThe use of mesh in elective repair of umbilical hernia reduced the risk of recurrence compared with suture closure without altering the risk of chronic pain.

Combined factor V and factor VIII deficiency: A rare case report and literature review

Background: Combined factor V and factor VIII deficiency (F5F8D) is a rare autosomal recessive inherited coagulopathy. It has a higher prevalence in the Mediterranean region (1:100,000) compare to its prevalence in the general population which is estimated to be (1:1000,000). Case report: We report a 59 years old Lebanese lady who was referred from the general surgery clinic with an asymptomatic prolongation of prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (aPTT) detected during preoperative work up for an elective umbilical hernia repair. The patient had history of bleeding following dental procedures since childhood as well as easy bruising with minimal trauma. Physical examination was unremarkable. haematological investigations were normal apart from the prolonged PT, INR and aPTT which were corrected following mixing studies. Factor assay revealed factor V level of 5.5% and factor VIII level of 11.9% with other factors within normal ranges confirming the diagnosis of combined F5F8D. Conclusion: Combined factor V and factor VIII deficiency should be suspected in patients with prolonged PT, INR and aPTT especially if they are of Mediterranean, Middle east or Arabic origin with a history of consanguineous marriages. Treatment is generally not indicated unless the patient has recurrent serious bleeding manifestations.

Efficacy of caudal block versus rectus sheath block forpostoperative analgesia in children undergoing umblical hernia repair: Randomized controlled study

Background Umbilical hernia repair, a common day-case surgery in children, is associated with postoperative discomfort. Different modes of postoperative analgesia for umbilical hernia repair had been used, such as rectus sheath block (RSB) and caudal block (CB). Aim The aim of this study is to improve the quality of postoperative analgesia and decrease pain score and analgesia requirement for pediatric patients undergoing umbilical hernia repair using ultrasound (US)-guided RSB. Patients and methods A total of 60 patients undergoing elective umbilical hernia repair were allocated randomly into two groups: US-guided RSB (group A) and CB (group B). All patients received the same general anesthetic technique. In group A, bilateral US-guided RSB was performed using 0.25% bupivacaine at 0.25 ml/kg. In group B, CB was performed using 0.25% bupivacaine at 1 ml/kg. Postoperative analgesia using a modified Children’s Hospital of Eastern Ontario Pain Scale and total amount of postoperative paracetamol requirement as rescue analgesia were recorded. Results There were significant decrease in pain score in group A than group B at 2, 4, 6, and 8 h postoperatively, with P=0.0001, 0.0357, 0.0095, and 0.0249, respectively. The mean value of paracetamol consumption is significantly reduced in group A, with mean value of 444 mg, in comparison with group B at 718.83 mg. Conclusion US-guided RSB can be considered a good alternative to CB in analgesia of postoperative pain after umbilical hernia repair in pediatrics.

Conservative Treatment versus Elective Repair of Umbilical Hernia in Patients with Liver Cirrhosis and Ascites

Background: management of umbilical hernia in patients with liver cirrhosis remains controversial. The general surgical opinion is that umbilical hernia in patients with liver cirrhosis and ascites has high operative risks and high recurrence rates after elective repair. Conservative treatment, however, can also have severe complications resulting in emergency repair. In these patients such operations carry an even greater risk of complications than compared to elective operations. Objective: Aiming at comparing between conservative treatment and elective repair of umbilical hernia in patients with liver cirrhosis and ascites. Patients and Methods: a randomized prospective interventional study Our series was carried out on 40 consecutive patients at General Surgery department, Al-Azhar University hospital; Bab Elshaeria, Cairo, Egypt in the period from June 2017 till September 2018. The patients were divided into 20 patients (group A) undergo surgical repair and 20 patients (group B) undergo conservative treatment. Mean follow up was 6 months. Results: elective repair of umbilical hernia in patients with liver cirrhosis and ascites had fewer complications than conservative treatment. Conclusion: Our study showed that elective repair of umbilical hernia in cirrhotic and ascetic patients had less complication than conservative treatment.

Conservative Treatment versus Elective Repair of Umbilical Hernia in Patients with Liver Cirrhosis and Ascites

Background: management of umbilical hernia in patients with liver cirrhosis remains controversial. The general surgical opinion is that umbilical hernia in patients with liver cirrhosis and ascites has high operative risks and high recurrence rates after elective repair. Conservative treatment, however, can also have severe complications resulting in emergency repair. In these patients such operations carry an even greater risk of complications than compared to elective operations. Objective: Aiming at comparing between conservative treatment and elective repair of umbilical hernia in patients with liver cirrhosis and ascites. Patients and Methods: a randomized prospective interventional study Our series was carried out on 40 consecutive patients at General Surgery department, Al-Azhar University hospital; Bab Elshaeria, Cairo, Egypt in the period from June 2017 till September 2018. The patients were divided into 20 patients (group A) undergo surgical repair and 20 patients (group B) undergo conservative treatment. Mean follow up was 6 months. Results: elective repair of umbilical hernia in patients with liver cirrhosis and ascites had fewer complications than conservative treatment. Conclusion: Our study showed that elective repair of umbilical hernia in cirrhotic and ascetic patients had less complication than conservative treatment.

Surgical repair of umbilical hernia in cirrhotic patients with ascites: is it safe?

Background Umbilical herniorrhaphy in cirrhotic patients with ascites is not usually done due to high postoperative morbidity and mortality rates. However, recent reports recommending elective surgery in these patients with perioperative preparation will result in good and safe outcome to avoid emergent repair later on. The aim of this study was to evaluate the outcome of umbilical herniorrhaphy in patients with liver cirrhosis and ascites regarding postoperative morbidity and mortality. Patients and methods A retrospective study was done on 102 patients with umbilical hernia and ascites in the period between March 2014 and April 2017 who had undergone surgical repair either electively or emergently at Tanta University Hospital. Patient characteristics, morbidity, and mortality are recorded. Results Seventy-two men and 30 women with a mean age of 51.3 years were analyzed. Eighteen (17.6%) patients were of Child–Pugh–Turcotte (CPT) class A, 54 (53%) patients were of class B, and 30 (29.4%) patients were of class C. The patients had a model for end-stage liver disease score of 16.23. Fifty-seven patients underwent elective operations while 45 patients underwent emergency surgery of whom 24 patients had incarceration, 12 cases had rupture of the hernia sac, and nine cases had skin ulceration or necrosis. Primary repair was done in 60 (58.8%) patients and meshes were used in 42 (41.2%) patients. The morbidity and mortality rates were 37.2% (n=38) and 3.9% (n=4), respectively. Conclusion Elective repair of umbilical hernia can be performed easily and safely in cirrhotic patients with ascites with good perioperative preparation with better results than emergent repair.

Elective and emergency repair of umbilical hernia in cirrhotic patients with ascites

Background Umbilical hernia is a common finding in cirrhotic patients with ascites. The incidence of umbilical hernia is 20–40% in cirrhotic patients, and emergency repair is indicated in critical cases if there is ascites leakage, irreducibility, and infection, with high rate of morbidity and mortality than elective cases. Aim To evaluate the effectiveness of elective hernioplasty rather than emergent one. Patients and methods A total of 50 patients were included in this study between December 2017 and December 2018 at Al Zahraa University Hospital. They were divided into two groups: (a) elective group included 25 patients with moderate to severe ascites, and (b) emergent group included 25 patients with moderate to severe ascites, of them 10 (40%) cases presented with spontaneous eruption of umbilical hernia, whereas 15 (60%) patients presented with irreducible umbilical hernia. There were 30 (60%) males and 20 (40%) females. Their age ranged between 40 and 65 years, with an average age of 45 years. Umbilical hernioplasty was done for all patients in both groups by using polypropylene mesh after preparation. Results In this study, one operative procedure was done for all patients. Using polypropylene mesh with peritoneal dialysis, a catheter was placed in all cases of both groups. There is difference between elective and emergency groups in operative time, postoperative hospital stay, and also early postoperative complication. Long-term follow-up was done in both groups and revealed death owing to liver failure as a complication of cirrhosis in three (12%) patients in the emergent group and in only one (4%) patient in the elective group. Conclusion Higher morbidity and mortality are associated with the emergency surgery in advanced cirrhotic patients. The prognosis is favorable for patients with good hepatic reserve.

The Effect of Rectus Sheath Block as a Supplement of General Anesthesia on Postoperative Analgesia in Adult Patient Undergoing Umbilical Hernia Repair.

Ultrasound guided rectus sheath block can block the ventral rami of the 7th to 12th thoracolumbar nerves by injection of local anesthetic into the space between the rectus muscle and posterior rectus sheath. The aim of this randomized double-blind study was to evaluate the analgesic effect of the bilateral ultrasound guided rectus sheath block as supplement of general anesthesia on patents undergoing elective umbilical hernia repair. After the hospital ethics committee approval, 60 (ASA I-II) adult patients scheduled for umbilical hernia repair were included in this study. The group I (n=30) patents received only general anesthesia. In the group II (n = 30) patents after induction of general anesthesia received a bilateral ultrasound guided rectus sheath block with 40 ml of 0.25% bupivacaine. In this study we assessed demographic and clinical characteristics, pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after operation and total analgesic consumption of morphine dose over 24-hours. There were statistically significant differences in VAS scores between the groups I and II at all postoperative time points - 2hr, 4 hr, 6 hr, 12 hr and 24 hr. (P < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in the group II (mean = 3.73 ± 1. 41) than the group I (mean = 8.76 ± 2.41). This difference was statistically significant (p = 0.00076). The ultrasound guided rectus sheath block used for umbilical hernia repair could reduce postoperative pain scores and the amount of morphine consumption in 24 hours postoperative period.

Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis

IntroductionDespite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge. MethodsWe retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge. ResultsTotal narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047). ConclusionPreincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery. Retrospective comparative studyLEVEL III EVIDENCE.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial

BackgroundRegional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair. MethodsA single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong–Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay. ResultsFifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar. ConclusionFollowing umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted. Type of studyRandomized controlled trial. Level of evidenceLevel I.

Factors Associated With Long-term Outcomes of Umbilical Hernia Repair

Umbilical hernia repair is one of the most commonly performed general surgical procedures. However, there is little consensus about the factors that lead to umbilical hernia recurrence. To better understand the factors associated with long-term umbilical hernia recurrence. A retrospective cohort of 332 military veteran patients who underwent umbilical hernia repair was studied between January 1, 1998, and December 31, 2008, at the VA Boston Healthcare System. Recurrence and mortality outcomes were tracked from that period until June 1, 2014. Data were collected on patient characteristics, operative, and postoperative factors and univariate and multivariable analyses were used to assess which factors were significantly associated with umbilical hernia recurrence and mortality. All patients with primary umbilical hernia repair, with or without a concurrent unrelated procedure, were included in the study. Patients excluded were those who underwent umbilical hernia repair as a part of another major planned procedure with abdominal incisions. Data were collected from June 1, 2014, to November 1, 2015. Statistical analysis was performed from November 2, 2015, to April 1, 2016. The primary study outcomes were umbilical hernia recurrence and death. Of the 332 patients in this study, 321 (96.7%) were male, mean age was 58.4 years, and mean (SD) time of follow-up was 8.5 (4.1) years. The hernia recurrence rate was 6.0% (n = 20) at a mean 3.1 years after index repair (median, 1.0-year; range, 0.33-13 years). The primary suture repair recurrence rate was 9.8% (16 of 163 patients), and the mesh repair recurrence rate was 2.4% (4 of 169 patients). On univariate analysis, ascites (P = .02), liver disease (P = .02), diabetes (P = .04), and primary suture (nonmesh) repairs (P = .04) were significantly associated with increased recurrence rates. Patients who had a history of hernias (125 [39%]) were less likely to have umbilical hernia recurrences (χ21 = 4.65, P = .03). On multivariable regression analysis, obesity and ascites were associated with significantly increased odds ratios of recurrence of 3.3 (95% CI, 1.0-10.1) and 8.0 (95% CI, 1.8-34.4), respectively. Mesh repair was seen to decrease recurrence with odds of 0.28 (95% CI, 0.08-0.95). There was no significant difference in complication rates between mesh repair and primary suture repair. The survival rate was 73% (n = 242) at the end of the study. Factors associated with mortality were older age, smoking, liver disease, ascites, emergency or semiurgent repair, and need for intraoperative bowel resection. Ascites, liver disease, diabetes, obesity, and primary suture repair without mesh are associated with increased umbilical hernia recurrence rates. Elective umbilical hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.

Efficacy of combined ultrasound guided anterior and posterior rectus sheath block for postoperative analgesia following umbilical hernia repair: Randomized, controlled trial

BackgroundAnatomical variations in the thoracic nerves T7 to T11was found in up to 30% of the population as the anterior cutaneous branch of the nerves are formed before the rectus sheath and so do not penetrate the posterior wall of the rectus sheath. Posterior rectus sheath block was found to be effective for perioperative analgesia. We tested the efficacy of addition of anterior rectus sheath block to capture the anterior cutaneous branch of intercostal nerves as they emerge from the rectus muscle in anterior rectus sheath.MethodSixty-three ASA I/II adult patients listed for elective umbilical hernia repair were randomly allocated in one of three groups: Bupivacaine hydrochloride 0.25% was injected by ultrasound guided bilateral posterior rectus sheath in Group I (PRSB) and bilateral anterior and posterior rectus sheath in Group II (APRSB). Group III received bilateral anterior and posterior rectus sheath block using isotonic saline. Twenty-four hours postopetrative morphine consumption, Intraoperative rescue fentanyl dose, equivalent morphine dose in the recovery unit and first morphine dose were recorded. The quality of analgesia is assessed by Visual Analogue Scale for 24 h.ResultsMean intraoperative rescue fentanyl dose was 19.23 ± 4.96 μg, 15.28 ± 2.75 μg and 12.85 ± 3.65 μg in control, PRSB and APRSB groups respectively (P < 0.001). The mean opioid consumptions in PACU was PRSB 3.47 ± 0.13 mg, APRSB 2.91 ± 0.15 mg and control 4.04 ± 0.56 mg respectively (P < 0.001). Significant difference in intraoperative rescue fentanyl was found between PRSB and APRSB group (P = 0.020). Also statistically significant difference was found between PRSB and APRSB groups in 24 h morphine consumption (P = 0.034).ConclusionAddition of ultrasound anterior rectus sheath block together with posterior rectus sheath block added more significant analgesia than if we perform posterior rectus sheath alone. This was evidenced by decrease in Intraoperative rescue fentanyl, PACU morphine analgesia, 24 h morphine and pain assessment score.