Small Umbilical Hernia Research Articles

Abdominoplasty With Umbilical Hernia Repair: A Long-term Comparative Analysis of Clinical Outcomes.

The risks and benefits of performing small fat-containing ventral or umbilical hernia repair (HR) during cosmetic abdominoplasty remains a reconstructive and aesthetic challenge for plastic surgeons. This study aimed to compare clinical outcomes in patients undergoing abdominoplasty with concurrent HR and abdominoplasty alone. Retrospective review of patients undergoing abdominoplasty with and without a concurrent HR from January 2015- June 2022 was performed. Patients were stratified by concurrent HR. All hernia patients underwent primary fascial repair, without the use of mesh. Demographics, surgical site occurrences (SSO) and cosmetic complications, including delayed healing and necrosis were assessed. Multivariate analysis was used to compare association of umbilical hernia repair with clinical outcomes. One hundred and six patients underwent abdominoplasty, 68 (64%) had concurrent HR. No significant difference in demographics was identified between groups including mean BMI (HR=27.2 kg/m2 and No HR= 26.3 kg/m2, P=0.73), and number of previous open hernia repairs (P=0.09). After a mean follow-up of 1.5 years, hernia recurrence rate was 1.4% (n=1), with a time to hernia recurrence of 12.2 months. After controlling for confounders, there was no difference in risk of SSO (OR 1.02 [0.31-3.36] P=0.978), cosmetic complications (OR 0.80 [0.14-4.57] P=0.805), procedure length (-21.5 minutes [-46.92-22.93] P=0.501), readmissions (2.8% vs. 0%, P=0.336), or reoperations (8.8% vs. 10%, P=0.766), compared to patients who underwent abdominoplasty alone. Abdominoplasty with concurrent HR can be performed safely and effectively, with no increase in adverse outcomes or cosmetic complications. The benefit of performing mesh-free HR with abdominoplasty can achieve an enhanced aesthetic outcome and reduce long-term abdominal wall morbidity.

72145 - Mesh versus Suture repair for Small umbilical hernias in adults: Early results from a Randomized Controlled multicenter Trial; The SUMMER Trial

72145 - Mesh versus Suture repair for Small umbilical hernias in adults: Early results from a Randomized Controlled multicenter Trial; The SUMMER Trial

194 An uncommon cause of small bowel obstruction with perforation after a caesarean section

Abstract The incidence of small bowel obstruction after any abdominal surgery is 9%, whereas it is only 0.1% after a C-Section. Small bowel obstruction secondary to herniation of a segment of the small bowel beneath the intact rectus sheath and between the rectus muscle is extremely rare. Reviewing the literature revealed that less than five cases were reported. Here we present a 39-year-old female six days post caesarean section presented with abdomen pain, distension, and not opening bowels. The blood investigations showed White blood cells 15.42x109/L and C-reactive protein 286mg/L. She was hypotensive and tachycardic. On clinical examination, the abdomen was distended and peritonitic. The Computed tomography of the abdomen and pelvis with contrast showed there is small bowel obstruction with multiple loops of proximal dilated bowel with a transition point within the pelvis and in midline a small inferior umbilical or incisional hernia containing a knuckle of small bowel with a moderate amount of pneumoperitoneum and free fluid. She underwent an emergency laparotomy and was found to have four quadrants of purulent peritonitis. In addition, a 3cm defect in the midline peritoneum allowed herniation of approximately 30cm of small bowel into preperitoneal space between the recti with ischaemia and perforation at the neck of the hernia. She had small bowel resection anastomosis, and the peritoneal defect was formally closed to prevent re-herniation of bowel loops. The NICE guidelines recommend not closing the peritoneum during the c-section. However, this case is an example of severe postoperative morbidity, which could be avoided by peritoneal closure.

Suture versus open mesh repair for small umbilical hernia: Results of a propensity-matched cohort study

BackgroundThe objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes. MethodsThis propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11. ResultsMesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients. ConclusionBoth techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias.

Ventralex™ ST Hernia Patch Repair for Small Umbilical Hernia is Safe and Effective: A Retrospective Cohort Study.

Background: Hernia patches for umbilical hernia repair have gained popularity due to their short operation time and ease of use. However, up to 10% re-operation and 8% recurrence rates at 2-year follow-up have been published. This retrospective cohort study presents the long-term results of the hernia patch technique for umbilical hernia repair. Methods: All adult patients who underwent a primary umbilical hernia repair at Oulu University Hospital hernia surgery units during 2014-2018 were included in the study. The primary outcome measure was recurrence rate. Secondary outcomes were complications and re-operation rate. Results: A total of 619 elective primary umbilical hernia repairs were performed during 2014-2018. The major technique used was Ventralex™ ST hernia patch repair (79.0%, 488/619) for small hernias with a mean width of 1.8 (SD 0.79) cm. Most of the patches (84.7%, 414/488) were placed in the preperitoneal space. Hernia recurrence rate of patient operated on using Ventralex™ ST hernia patch was 2.5% (12/488) during a mean follow-up time of 68 (SD 16, 43-98) months. Re-operation rate for another reason than recurrence was 1.6% (8/488). Clavien-Dindo complications ≥3 occurred in 4.1% (20/488) of cases and surgical site infection rate was 3.3% (16/488). Conclusion: Umbilical hernia repair using a Ventralex™ ST hernia patch placed in preperitoneal space have acceptable results in terms of recurrence and re-operations in this cohort study.

V-028 HYBRID (LAPAROSCOPIC AND OPEN) REPAIR WITH REVERSE TAR TO TREAT A LATERAL INCISIONAL HERNIA WITH DENERVATION OF THE RIGHT ABDOMINAL MUSCLES

Abstract Aim Lateral incisional hernias with denervation of the muscles of the abdominal wall are a problem difficult to solve. The repair of the defect does not guarantee a functionality of the abdominal muscles if the lack of force of the abdominal wall is not solved. With the technique we present there is a minimally invasive reinforcement of the mid lateral wall affected. Material and Method 54 yo female. Previous surgeries: biliary cystadenoma 2014 by Makuuchi laparotomy (2 surgeries), Ooforectomy 2011, Hysterectomy 2013, Mamoplasty 2001, 3 vertebral surgeries. Six months after the surgery she felt a growing lump in the right side of the incision. Physical exam: right lateral incisional hernia and small umbilical hernia. Asymmetry of the abdominal wall because of flaccidity of the right abdominal muscles. Ultrasound Voluminous incisional hernia in the right flank dependent of the right transverse sub-costal incision with a hernia ring of 20mm and hernia sac 60mm of diameter increasing with Vasalva maneuvers. Surgical technique Hybrid approach laparoscopic and lateral by e-TEP to dissect the retrorectal bilateral space and lateral preperitoneal approach with reverse TAR. A macroporous polipropilene preperitoneal mesh is placed from the right psoas to left semilunar line and from top to bottom of the abdominal wall. Result Discharged 2nd po. day without complications. 5 months after surgery she has a symmetric abdominal wall without recurrence. Conclusion Hybrid technique to repair lateral hernias with denervation allows a wide repair with low morbidity and good tolerance with excellent result in abdominal functionality.

15. Comparative Analysis of Abdominoplasty with and without Concurrent Hernia Repair: An Assessment of a Reconstructive Problem in a Cosmetic Patient Population

PURPOSE: The risks and benefits of performing small fat-containing ventral or umbilical hernia repair (HR) during cosmetic abdominoplasty remains a reconstructive and aesthetic challenge for plastic surgeons. This study aimed to compare clinical outcomes in patients undergoing abdominoplasty with concurrent HR and abdominoplasty alone. METHODS: Patients (2015-2021) who underwent abdominoplasty with and without a concurrent HR by a single surgeon were identified. Patients were stratified by concurrent HR. All hernia patients underwent primary fascial repair, without the use of mesh reinforcement. Demographics, surgical site occurrences (SSO) and cosmetic complications, including delayed healing and necrosis, were assessed. Risk adjusted modeling was utilized to compare HR with clinical outcomes. RESULTS: One-hundred and eleven patients underwent abdominoplasty, 67 (60.4%) had concurrent HR. No significant difference in demographics was identified between groups including mean BMI (HR=27.5 kg/m2 and No HR= 26.7 kg/m2, P=0.79), and number of previous repairs (P=0.31). After a mean follow-up of 1.4 years, hernia recurrence rate was 3% (n=2), which was exclusive to umbilical defects. After controlling for demographics, there was no difference in risk of SSO (OR 1.02 [0.31-3.36] P=0.978), cosmetic complications (OR 0.80 [0.14-4.57] P=0.805), readmissions (6.06% vs. 0%, P=0.336), reoperations (18.18% vs. 3.03%, P=0.299), or procedure length (-7.23 minutes [-29.40-14.93] P=0.522), compared to patients who underwent abdominoplasty alone. CONCLUSION: Abdominoplasty with concurrent HR can be performed safely and effectively, with no increase in adverse outcomes or cosmetic complications. The value of mesh-free HR with abdominoplasty is the ability to achieve an enhanced aesthetic and mitigate long-term abdominal morbidity.

Comparison of Suture Repair and Mesh Repair in Repair of Small Umbilical Hernias: Retrospective Cohort Study

Comparison of Suture Repair and Mesh Repair in Repair of Small Umbilical Hernias: Retrospective Cohort Study

Umbilical Laparoscopic Transabdominal Preperitoneal Repair for Medium-Sized Umbilical Hernia in Overweight and Obese Patients

INTRODUCTION: Despite high prevalence of umbilical hernia, an open anterior approach is still frequently performed. Moreover, suture repair is still routinely applied in cases of small umbilical hernia. However, mesh use may lead to more frequent surgical site infection, especially in obese patients. Some of these limitations may be reconciled by transabdominal-preperitoneal repair (TAPP). The aim of this study was to analyze feasibility, safety and efficacy of umbilical TAPP (u-TAPP). METHODS: A prospective study of early and mid-term outcomes was conducted for all umbilical hernia repair performed in overweight and obese patients. An analysis included 36 patients undergoing elective surgery for primary umbilical hernia between March 2019 and November 2021. The intra- and postoperative data were recorded. All patients reported the outcomes 1 and 3 months after the procedure. RESULTS: The mean width of defect was 26 mm. The operation time was 93.2 ± 22.3 minutes. An area of synthetic mesh in u-TAPP was 164.2 cm2. Median mesh size was 10×15 cm. After 30-day and 3-month follow-up, there was no recurrence or significant postoperative pain. The patients declared their overall satisfaction and quality of life as good or excellent. CONCLUSION: TAPP technique in umbilical hernia repair allows for placement of a large mesh and fulfills current recommendations, especially for patients with additional risk factors, such as obesity or coexistence of diastasis recti. TAPP allows a mesh to be introduced into the preperitoneal space, allowing to avoid direct contact between mesh and intestines. Laparoscopic umbilical TAPP is feasible and safe, but the operation time is longer than with open methods.

S3292 A Rare Complication of End-Stage Liver Disease: Flood Syndrome

Introduction: Flood syndrome describes a condition seen in the setting of end-stage liver disease in which an umbilical hernia ruptures leading to a rush of fluid through the defect. It is a rare complication of cirrhosis and has a high mortality rate. Herein, we present two cases of flood syndrome in patients with advanced liver disease. Case Description/Methods: Case 1: A 37-year-old female with a history of factor Leiden deficiency, MTHFR deficiency, and decompensates alcoholic cirrhosis presented with 1 day of continued fluid leakage from an umbilical wound. She was afebrile, normotensive yet tachycardic to 114 bpm. Abdominal exam showed a positive fluid wave shift and small umbilical hernia with ascitic fluid in the stoma bag. Labs showed a total bilirubin of 11.6 mg/dl, AST of 61 U/L, ALT of 36 U/L, and ALP of 79 U/L. She was treated with antibiotics and underwent hernia repair. She later required large volume paracentesis before the fluid leakage stopped and she was discharged home. Case 2: A 48-year-old female with alcoholic cirrhosis and a history of incisional abdominal hernia secondary to laparotomy presented with abdominal distension, pain and leakage of fluid through the hernia site. Exam showed a midline abdominal protuberance with an ulcerated hernia. CT confirmed the abdominal wall hernia with sigmoid colon in the hernia sac and ascitic fluid and air (Figure 1). She was treated with antibiotics and the defect was closed by general surgery prior to discharge. Discussion: Flood syndrome is a rare complication seen in cirrhotic patients with ascites defined as a rush of fluid through rupture of an umbilical hernia. It is associated with serious complications and a high mortality rate of up to 30%. As such, the most important step in management of ascites is prevention. Sodium and fluid restrictions and diuretics may be used to reduce hypervolemia in these patients. Paracentesis is often necessary to aid in fluid removal in those with recurrent ascites; however, the procedure can also increase the risk of developing flood syndrome. Ultimately, patients may require surgery to repair the defect.Figure 1.: CT demonstrating an abdominal wall hernia with sigmoid colon in the hernia sac and ascitic fluid and air.

Hernia recurrence after primary repair of small umbilical hernia defects

BackgroundAn evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined. MethodsA prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications. ResultsOf 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant. ConclusionsWith long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

EP-29 The prevalence of a small occult umbilical hernia during the trans-umbilical approach in general laparoscopic surgery

Abstract Aims The aim of this study was to firstly determine the prevalence of a small occult umbilical hernia during the trans-umbilical incision technique in general laparoscopic surgery. Secondly, to determine patient satisfaction with post-operative pain and cosmesis. Methods This was a prospective study of 128 patients who underwent a trans-umbilical incision during general laparoscopic surgery by a single surgeon between January 2020 and July 2021. Demographic data, type of surgery, presence of small occult umbilical hernia, time to gain access and time of incision closure were obtained from the operation note. Following the procedure each patient was contacted via telephone and asked questions regarding, post-operative pain, surgical site infection, post-operative complications and cosmetic satisfaction. Results Of the 128 patients within the study, 57.8% were female with a mean age of 44.4 years and a BMI of 26.6 kg/m2. The most common operation performed was laparoscopic cholecystectomy in 51.6% of patients. 62.5% of patients were found to have the presence of a small occult umbilical hernia with a mean of 1.1 minutes to gain access and 6 minutes to close incision. Approximately, 80% of patients stated that post-operative pain experienced was as or less than expected. All patients were satisfied with scar cosmesis. Conclusion Well over half of patients were found to have a naturally occurring small umbilical hernia that could make gaining access to the abdominal cavity via a trans-umbilical incision easier, quicker and safer. As well as excellent patient satisfaction with regards to scar cosmesis and lower than expected post-operative pain scores.

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

Abstract 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.

P121 ONLAY MESH FOR TREATMENT OF SMALL UMBILICAL HERNIAS IN ADULTS - A SINGE CENTER INVESTIGATION

Abstract Aim Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. A remaining important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4x4 cm onlay-mesh for umbilical hernias ≤2cm. Material and Methods A retrospective study was conducted at a single institution in Sweden on all umbilical hernia repairs during 2015-2019. The follow up time was at least four months. Patients were identified using the hospital medical record database. Repairs performed with suture, sublay, ventral patch or laparoscopic mesh positioning were excluded. Patient’s demographics, comorbidities, intra – and postoperative details were considered. Primary outcome was surgical site complications within 30 days. Secondary outcome was recurrence. Results 80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm and were included for statistical analysis. Median (range) follow-up time was 29.0 (4.3-50.1) months. Median age was 46 (26-76) years old. Median body mass index was 28 (19-38) kg/m2. Men to female ratio was 2.1. 4 patients were identified with a surgical site postoperative complication; 3 with seroma and 1 with superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound opening bedside. There were no registered cases of a recurrence. Conclusions Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess weather mesh reduce recurrences in umbilical hernia repairs ≤2cm.

S3059 Clear Cell Sarcoma of the Jejunum: Dissecting an Obscure Malignancy

Introduction: Clear Cell Sarcoma (CCS) of the jejunum is an extremely rare and mortiferous presentation of a poorly understood malignancy. CCS is a cancer of the soft tissue and aponeuroses of tendons, affecting young individuals with predilection towards the ankle. It is often confused for malignant melanoma, as it is also derived from neural crest origin and shares a similar histological appearance. Currently, the only definitive treatment is surgical resection. Even so, CCS is known to recur. Due to the sheer modicum of cases, our medical knowledge is limited. Case Description/Methods: We present a case of a 49-year-old gentleman from Cameroon with a past medical history of hypertension and diabetes mellitus type II, who presented to the emergency department with complaints of abdominal pain, nausea, and vomiting for a one-month duration. CT scan of the abdomen and pelvis revealed left-sided small bowel obstruction. The patient underwent diagnostic laparoscopy, which converted to open surgery, with small bowel resection and umbilical hernia repair. A 2.6 cm circumferential obstructing jejunal mass was identified and resected. The margins of resection were negative for malignancy. There was no lymph vascular invasion, and 12 lymph nodes were negative for malignancy as well. Immunohistochemistry stains resulted positive for S100, SOX 10, and EMA. FISH was positive for EWSR1. Recent studies have revealed a chromosomal translocation, t(12;22) (q13;q12), also known as the EWSR1 and ATF1 gene, respectively, which has been widely accepted as pathognomonic for CCS. At 2 years of follow-up, our patient had a drastic improvement in his symptoms, with active surveillance and close follow-up, as CCS has a high recurrence rate. Discussion: This case report aims to describe the clinical presentation and evolution of this unique soft-tissue malignancy, which can be found in the GI tract in extraordinary cases. We hope this rare case of Clear Cell Sarcoma can enhance our knowledge about this obscure cancer that we still have so much to learn.Figure 1.: This 2.6 cm tumor is present in the submucosa, muscularis propria and subserosa and shows nests and cords of patterns by network of delicate vascular septa. Neoplastic cells are plump with epithelioid, clear cell and focal spindle cell appearance. Mitotic figures are about 5/10HPF. Immunostains show that tumor cells are positive for S100, SOX-10, and EMA but negative for HMB-45, Melan A, carcinoma markers (AE1/AE3, CAM5.2, CK7 and CK20), gastrointestinal stromal tumor markers (CKIT, CD34, and DOG1), lymphoid markers (CD3 and CD20), and desmin and ASMA. EWSR1 is positive by FISH studies. A) (Magnification x40, lower power, hematoxylin-eosin) and B) (Magnification x400, high power, hematoxylin-eosin) show epithelioid and clear cell appearance. C) (Magnification x400, antibody for S100) and D) (Magnification x400, antibody for SOX-10) reveal positivity.

Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation

PurposePrevious studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm.MethodsA retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015–2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient’s demographics, comorbidities, intra—and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence.Results80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3–50.1) months. The median age was 46 (26–76) years old. The median body mass index was 28 (19–38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence.ConclusionsRepairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.

SUMMER Trial: mesh versus suture repair in small umbilical hernias in adults\u2014a study protocol for a prospective randomized double-blind multicenter clinical trial

BackgroundSmall umbilical hernia repair is one of the most common surgical performances in general surgery. Yet, a gold standard procedure for the repair is still lacking today. There is an increasing evidence that mesh could be advantageous compared to suture repair in lowering recurrence rates. An additional important question remains with regard to the optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay mesh in small umbilical hernia defects can reduce recurrence rates without increasing the complications compared to a simple suture repair.MethodsA prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4 × 4 cm onlay mesh to a conventional suture repair will be conducted. A total of 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place using a centralized web-based system resulting in total allocation concealment. Stratification will be done by surgical site and by defect size. 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.DiscussionCurrently, there has been no randomized clinical trial comparing the recurrence rates between an onlay mesh repair and a simple suture repair for small umbilical hernia defects. How to best repair a small umbilical hernia continues to be debated. This trial design should allow for a good assessment of the differences in recurrence rate due to the large sample size and the adequate follow-up. Surgeons’ concerns surrounding optimal anatomical positioning and fear for larger required dissections are understandable. A small onlay mesh may become an easy and safe method of choice to reduce recurrence rates. 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.Trial registrationClinicalTrials.gov NCT04231071. Registered on 31 January 2020. SUMMER Trial underwent external peer review as part of the funding process.

Single Center Observational Study to Evaluate the Safety and Efficacy of Self-expanding Composite Mesh for Repair of Small Umbilical Hernias

Background: There is evidence that mesh repair for umbilical hernias results in fewer recurrences. Early and late complication rates of mesh repair are variable with different techniques of mesh repair. In recent years, several mesh device for the repair of small ventral hernias have been developed, but some reports have been published reporting some adverse outcomes like high recurrences or wound related complications encountered with those mesh devices. The purpose of this study was to evaluate the safety and efficacy of small umbilical hernia(&lt;3cm) repair using self expanding dual mesh.&#x0D; Methods: In this study we used a composite self-expanding mesh with Polypropylene(PP) on one side and expanded polytetrafleuroethylene(ePTFE) on the other side. We introduced this technique in our department at BIRDEM General Hospital and IMC in March 2017 and collected patients data and outcome in an observational study of 25 consecutive patients matching our inclusion criteria until February 2019. In addition to the routine 1st week postoperative follow-up, We did a prospective follow-up at 1 month,6 month and 1 year which included a questionnaire, clinical examination and ultra sonogram after 12 months.&#x0D; Results: The study included 15 female and 10 male patients with age ranging from 25-62 years(Mean- 47) having 16 primary umbilical hernia and 9 umbilical port hernias. The size of gap was &lt;3cm and all except 2 hernias were reducible. In all patients a self expanding dual mesh was used with a diameter of 8cm(18 patients) or 6.4(7 patients) cm. Early complications included superficial wound infection-1(4%), seroma-1(4%), serosanguinous discharge-1(4%) and ecchymosis-1(4%). No major wound problems were noted in 1 month or 6 month follow-up except 1 patient reporting hypertrophied scar. At 1st month follow up 21 patientswere pain free, after 6 month only 1 patient reported mild pain, after 1 year 100% patients were pain free. 24 out of 25 patients ie 96% were very satisfied with the result of their repair. There was no recurrence after one year.&#x0D; Conclusion: Umbilical and umbilical port hernia repair with Self expanding dual mesh is effective and is cosmetically very appreciated by patients as good as laparoscopic repair. Therefore, we recommend using these meshes only for umbilical and umbilical port hernias smaller than 3 cm. For larger or incisional hernias other techniques allowing the use of larger meshes is advocated.&#x0D; Journal of Surgical Sciences (2020) Vol. 24 (2) : 43-50

Sutureless Abdominal Closure in twin gastroschisis

Gastroschisis is the most common congenital abdominal wall defect and the incidence of gastroschisis is increasing globally. Twin gastroschisis remains an extremely rare phenomenon. We present a case of premature dizygotic twins with simple gastroschisis born at 33 weeks and 3 days gestation. Both twins underwent primary reduction and sutureless closure using the umbilical cord remnant. We describe our technique for sutureless closure and subsequent wound care management. Neither twin required general anesthesia, intubation, mechanical ventilation, or antibiotics as a direct result of their gastroschisis management, and both twins had swift progression to full oral feeds by day of life 25 and 29. They have both had good cosmetic results with small umbilical hernias. This case report highlights a rare twin pairing of a common congenital anomaly and underlines the benefits of the sutureless closure technique.

Treatment of small (< 2cm) umbilical hernias: guidelines and current trends from the Herniamed Registry.

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.