Umbilical Defects Research Articles

Morphological and clinical findings in placentas and newborns with a history of tobacco, alcohol, and other substance abuse during pregnancy.

Exposure to toxins during pregnancy is the main modifiable behavior that affects the placenta and, consequently, the fetus. In particular, smoking is a recognized risk factor for negative outcomes. Our study pretended to examine gross and microscopic placental features in women who reported exposure to tobacco, alcohol, or other psychoactive substances. In this observational case-control study, we collected 706 placentas to assess precise substance exposure histological-interaction features of in the placenta. We examined gross and microscopic placental features, and then recorded maternal and newborn clinical conditions. We found that 4.8% of mothers admitted to consumption of some type of (harmful) substance. The most common pre-existing maternal condition was obesity (20.3%); predominant complications included amniotic infection (32.3%), urinary tract infection (14.5%) and hypertensive disorders of pregnancy (14.5%). In newborns, we discovered positive associations as respiratory distress syndrome. Macroscopically, exposed mothers had heavier placentas, more true knots, and single umbilical artery; microscopically, they were more likely to exhibit fetal vascular malperfusion (FVM). Until our present study, no research linked umbilical cord defects to toxic substance exposure; our study results do confirm association with adverse outcomes in neonates and alterations in the neuro-cardio-placental circuit through FVM. The results are confirming the importance of this modifiable risk factor and how its presence may potentially affect the course of pregnancy, as well as the health of both mother and child.

Hysteroembryoscopy in repeated early pregnancy loss due to suspected thrombophilia

Introduction: The cause of a 1st trimester repeated pregnancy loss (RPL) under treatment with aspirin and /or heparin due to suspected thrombophilia was investigated. Using hystero-embryoscopy (HEpy) and embryo genetic analysis the embryo development was correlated to its karyotype. Patients and methods: Seventeen first trimester pregnant women recruited in the study. They all had a history of at least 2 consecutive 1st trimester recurrent miscarriages, underwent an investigation for the cause of RPL and diagnosed to suffer from hypercoagulation. Thromboprophylaxis was administrated in all 17 pregnant women during their next pregnancy, postulating that their past cause of miscarriage was due to a hypercoagulability state. Twelve patients had positive Anticardiolipin and /or Antiphospholipid antibodies and 5 patients had MTHFR high titers. Embryo autopsy was performed by hysteroscopy technique using 2.9mm – 5mm hysteroscopes, 5Fr graspers and scissors and normal saline as distending medium. The embryo morphology results were correlated with the genetic results and compared with the patients’ diagnosis and treatment during the last miscarriage. Results: HEpy revealed that in 11 out of 17 cases embryos had chromosomal abnormalities ensuring patients that the problem of their loss was not the followed treatment. In all 4 cases with decidua haematoma and umbilical cord defect patients received aspirin and LWMH, raising the possibility of anticoagulation overtreatment. Conclusion: In-situ autopsy of a miscarriage embryo can provide useful information regarding the morphology of the embryo, ruling out anatomical defects and collecting the embryo under direct vision anticipating an accurate embryo karyotyping. Embryoscopy results may assist to change the management of the next pregnancy in RPL cases and patients with hypercoagulability state.

Formation and annihilation of electrically driven defects in nematic liquid crystals with negative dielectric anisotropy

Orientationally ordered liquid crystals (LCs) exhibit remarkable physical anisotropy and responsiveness to external fields, which give rise to distinguished physical effects and have led to the emergence of a new generation of electric-optical applications. The LCs are also renowned for their abundance of phases and topological defects, which are of significance in studying both fundamental science and practical technology. One simple approach to generating umbilic defects involves applying an electric field to a homeotropically aligned nematic LC with negative dielectric anisotropy <inline-formula><tex-math id="M8">\begin{document}$\Delta \varepsilon $\end{document}</tex-math><alternatives><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="5-20231655_M8.jpg"/><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="5-20231655_M8.png"/></alternatives></inline-formula>. However, the influence of material properties and external conditions on the dynamic process of nematic LC defects remains unclear. Here, we select seven kinds of nematic LCs with negative dielectrically anisotropy, ranging from –1.1 to –11.5, to explore the dynamics of electric-field-induced umbilics. By using a linearly increasing electric field parallel to the molecular orientation of LC, we systematically investigate the effects of material property (dielectric anisotropy) and external conditions (temperature and electric field parameters) on the formation and annihilation of umbilic defects. The experimental results show that the dynamic process of forming the umbilic defects in nematic LCs is independent of dielectric anisotropy, temperature, and electric field frequency, but follows the Kibble-Zurek mechanism, in which the density of generated umbilic defects exhibits a power-law scaling with the change of the electric field ramp rate, with a scaling exponent of approximately <inline-formula><tex-math id="M9">\begin{document}$1/2$\end{document}</tex-math><alternatives><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="5-20231655_M9.jpg"/><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="5-20231655_M9.png"/></alternatives></inline-formula>. Interestingly, a stronger dielectric anisotropy leads to a higher density of umbilic defects. Additionally, a change in temperature has a significant influence on the density of umbilic defects , in which higher temperature leads to greater defect density under the same external electric field conditions. Furthermore, the annihilation rate of umbilic defects is closely related to the material properties and the ramp of the applied electric field. Specifically, the annihilation rate of umbilic defects becomes faster when dielectric anisotropy is stronger or the electric field ramp is larger. This study provides valuable insights into the relationship between the formation and annihilation of defects, material properties, and external conditions in nematic LCs with dielectrically negative anisotropy, contributing to our comprehensive understanding of the dynamic process of topological defects in soft matter.

Laparoscopic IPOMPLUS repair-current outcomes and complications

Purpose: The study aims to assess the current outcomes and complications of laparoscopic ventral hernia repair using intraperitoneal onlay mesh with defect closure (IPOM PLUS) technique by use of dual-sided synthetic mesh. Material and methods: Retrospectively clinical data for 27 patients with umbilical, paraumbilical, incisional, ventral, and primary hernia, operated in the Department of General, Visceral and Emergency Surgery “Pirogov” from 01.06.2022 to 01.06. 2022 was analyzed. The diagnosis was based on history, physical examination(mainly), ultrasound, and CT. Of the hospitalized, women were 16 (59.26%) men 11 (40.74%). Results: Of the selected group, 13 patients had umbilical defects, 3 with an epigastric hernia, 7 with a paraumbilical hernia, and 4 with incisional defects. Adhesiolysis was needed in 18 cases, while others were performed straight with hernia closure. The operating time varied between 49 and 127 minutes (average 57.4 minutes). The hospital stay ranged from 1 day to 4 days (average 1.7 days). We had noticed complications in three of the cases (11.11%). Conclusion: IPOM PLUS repair is safe, practicable, and advantageous over a standard IPOM or open repair as reported in the literature. Accordingly, we prefer this approach with the closure of the fascial defect first while repairing ventral abdominal wall hernias.

Modified circumumbilical approach for duodenal atresia repair : A scarless surgery

Background: Duodenal atresia is a common congenital anomaly causing neonatal intestinal obstruction. The definitive treatment is to restore the intestinal continuity. Laparotomy via upper transverse abdominal incision has been described by many authors as a standard approach for duodenal atresia repair. Here we report a case of newborn underwent duodenal atresia repair via modified circumumbilical approach with satisfactory postoperative outcome. Case presentation: This is a case of premature baby boy, born at 32-week gestation with a birth weight of 1.5kg. Antenatally he was detected to have double bubble sign which was confirmed upon postnatal abdominal radiograph, suggestive of duodenal atresia. He was noted to have a fleshy lump at the umbilicus presumed to be a patent vitello-intestinal duct from the referring hospital. Subsequently he developed umbilical swelling suspicion of umbilical hernia with incarceration and scheduled for emergency umbilical exploration. A circumumbilical incision was made and found to have an umbilical defect with omental herniation, instead of a patent vitello-intestinal duct. A proximal midline incision was made as an extension to the circumumbilical wound enabling a duodenal kocherization and subsequently had duodeno-jejujonostomy anastomosis for the duodenal atresia repair. Postoperative recovery was uneventful with appealing cosmesis. Conclusion: A modified circumumbilical incision is an attractive alternative approach for a duodenal atresia repair. Apart from its cosmetic advantage, the approach provides adequate exposure for similar outcome with transverse abdominal incision.

Laparoscopy-assisted percutaneous correction of abdominal wall defects in the umbilical region in a cadaveric model of bovine fetus.

Abdominal wall defects in calves are commonly diagnosed and treated via laparotomy. This technique has witnessed several advancements in the management of these disorders. This study aimed to create a study model and evaluate the feasibility of video-assisted percutaneous correction of abdominal wall defects in bovine fetuses (corpses) compared with the conventional technique. Sixteen bovine fetuses from pregnant cows slaughtered in slaughterhouses were included in this study. The fetuses were categorized into the control group (CG, n = 8), which was subjected to umbilical abdominorrhaphy via laparotomy, and the video-surgical group (VG, n = 8), which received video-assisted percutaneous sutures with two lateral accesses on the right flank. An abdominal wall defect was created in the VG group to generate a study model, which was corrected using the laparoscopic technique. The procedures were performed in two steps. The first step consisted of creating an abdominal wall defect in the umbilical region by laparoscopic approach in an iatrogenic manner (Step 1: E1). The second stage consisted of conventional abdominorrhaphy of the umbilical region wall defect in the CG group and video-assisted percutaneous suturing of the edges of the iatrogenic abdominal wall defect in the VG group, until reversal of the laparoscopic accesses (Step 2: E2). Step 1 showed no statistically significant difference between the two groups. However, a significant statistical difference (p < 0.0001) was observed between the two groups in step 2. The surgical time of step 2 was longer in the CG group (33.10 ± 0.43 minutes) than that in the VG group (10.13 ± 0.68 minutes, p < 0.0001), and the total surgical time was also longer in the CG group (38.48 ± 0.35 minutes) than that in the VG group (15.86 ± 0.67 minutes). The proposed laparoscopic technique allowed the creation of a study model for video-assisted percutaneous suturing with two portals and reduced the surgical time compared with the conventional technique. However, this method needs to be studied further in live animals.

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.

Two separate subcutaneous pedicled flaps for repair of total umbilical defects: a simple reconstruction technique

Two separate subcutaneous pedicled flaps for repair of total umbilical defects: a simple reconstruction technique

V-056 LAPAROSCOPIC VENTRAL HERNIA REPAIR WITH GORE SINECOR INTRAPERITONEAL BIOMATERIAL: OUR CENTER EXPERIENCE

Abstract Aim Ventral hernias including incisional ones are very common in our population. Mesh reinforcement options for ventral/incisional hernia repair continue to evolve with advances in polymer science and better understanding of the extracellular matrix. Consensus on the safety and efficacy of these various types of synthetic and biologic mesh has yet to be reached. Intraperitoneal onlay mesh (IPOM) is the laparoscopic technique most frequently used in our center to treat umbilical and abdominal ventral defects sized 3 cm to 8 cm. Our equipe built an expertise with Gore DualMesh prosthesis (2% recurrence ratio in our center); we used the Gore Sinecor Intraperitoneal Biomaterial for the first time here. Methods Symptomatic supraumbilical incisional hernia in a 74 years old man; parietal defect sized 7×8 cm. We performed an Ipom repair procedure using a 20×25 cm Gore Sinecor Intraperitoneal Biomaterial, trimmed to 18×20 cm. Follow-up at one and six months from surgery. Results The patient was discharged the day after surgery. He did not complain severe pain in the first week after surgery and he only use Paracetamolo 1g die as antalgic therapy. After seven days he resumed his daily activities. He did not experience any short-term sieroma nor long-term complication at follow up. Conclusions The Gore Sinecor Intraperitoneal Biomaterial, while maintaining a firm peritoneal adhesivity, has a better handling and feels lighter than the Gore DualMesh we routinely use. The transparency makes it possible to visualize the overlying abdominal wall, allowing a safer tacs positioning.

V-020 LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY: FIRST EXPERIENCE AT HOSPITAL UNIVERSITARIO DE CANARIAS

Abstract We present the case of a 46-year-old-male patient, personal history: Chronic smoking; no previous abdominal surgeries. Height: 1,88 m. Weight: 100 Kg. BMI: 28. Clinical and ultrasound diagnosis of a painful and reducible ventral hernia M3 W1 (EHS Classification) associated with supraumbilical rectal diastasis (RD) of 4 cm transverse diameter T2 D2 H1 (EHS Classification). It is programmed for hernia and RD correction using de Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) technique. Access is laparoscopic at the left anterior axillary line level. Reduced umbilical hernia is identified and sickle cell ligament dissection is performed to identify and treat RD. The size of the umbilical defect and that of the supraumbilical RD are measured and, by means of a mathematical formula, the posterior aponeurosis of both rectal muscle is opened longitudinally parallel to both margins of the defect and the diastasis in order to suture the two flaps in the midline, allowing a tensión-free closure and also avoinding seroma formation and post-op bulging effect. We ended the procedure by placing an intraperitoneal mesh that we fixed covering the defect generated in the posterior aponeurosis. The LIRA technique could be considered an alternative to conventional defect closure (CD) or endoscopic component separation for midline defects smaller than 10 cm in transverse diameter. This is the first case of LIRA published in our latitude. It is a safe, effective and reproducible technique.

V-015 ROBOTIC TARUP: TECHNICAL DETAILS AND INNOVATIVE METHOD OF FIXATION

Abstract Aim With the recent evolution of minimally invasive hernia repairing techniques, robotic platform has exponentially gained consensus in the field of abdominal wall surgery, leading to the placement of retromuscolar synthetic meshes avoiding the need of extensive tissue dissection as the open approach. Our aim was to describe the introduction of Robotic Transabdominal Retromuscular Umbilical Prosthetic Hernia Repair (TARUP) at a referral centre for advanced mini-invasive surgery, by reporting the preliminary experience and the technical aspects of the procedure. Material &amp; Methods We present a case of a 3 cm umbilical defect associated to supraumbilical diastasis in a young man undergoing TARUP with the Da Vinci Xi system. The robotic boom was placed on the patient's right side, with three trocars on the anterior axillary line. The outline for the mesh was marked by centering the hernia defect with transcutaneous needles to delineate the extent of dissection corresponding to mesh area. Intra-abdominal pressure was of 8–12 mmHg. A retromuscolar plane was created starting from the incision of the ipsilateral posterior rectus sheat. The hernia content was reduced. The junction between the anterior and posterior rectus fascia was incised to cross-over the linea alba and continue the dissection controlaterally. A 15×15 cm polypropylene mesh was positioned in the retrorectus space and fixed with cyanoacrylic glue tack. Results Intervention lenght was of 100 minutes. No intra- or post-operative complications occurred. At present, no early recurrences were observed. Conclusions Robotic TARUP represents a safe and reproducible alternative in selected cases where retromuscolar mesh is preferred.

What is the ideal repair technique for triple hernia accompanied by umbilical and bilateral inguinal hernias?

Background: For patients with bilateral inguinal hernia (BIH) accompanied by an umbilical hernia (UH), there may be hesitations regarding the repair of all three hernias in the same session in terms of pain and possible problems in the healing process. Studies on these patients are rather rare in the literature. In the present study, the results of laparoscopic and open surgical treatment in patients with triple hernia accompanied by BIH and UH were compared.Methods: The data of patients were analyzed retrospectively. Patients whose hernias were fully repaired with open surgery made up group 1, and patients who underwent laparoscopic transabdominal preperitoneal (TAPP) repair together with open UH repair made up group 2. There were 10 patients in group 1 and 11 patients in group 2. The patients’ umbilical defect diameter, whether inguinal hernia (IH) was scrotal or not, applied surgical technique, length of hospital stay, duration of the operation, postoperative complications, and recurrence status were evaluated. Results: While 19 (90.5%) of the patients were male, 2 (9.5%) were female. In group 2, recurrence of unilateral IH was seen in 1 (4.5%) patient. Complications developed in 3 (14.3%) patients: seroma in 1 patient in group 1; and seroma in 1 patient; and wound infection in another patient in group 2. There was no significant difference between the groups in terms of duration of the operation, length of hospital stay, or postoperative complications (p value, p=0.251, p=0.756, p=0.538, respectively)Conclusion: In patients with triple hernia where umbilical and BIH occur together, open UH repair and IH repair can be performed safely by TAPP repair.

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.

Giant omphalocele treated with simple daily dressing changes

Omphalocele, also called exomphalos, is an anterior abdominal wall midline defect of variable size involving the umbilical ring containing the herniated viscera into a sac made up of peritoneum, amnion and Wharton's jelly. Giant omphalocele is an extreme version of this defect management of which is challenging. Author is reporting here a case of giant omphalocele managed initially by a simple yet novel conservative technique yielding subsequently good result. • Although no standard definition of GO exists, some authors consider the malformation to be a giant omphalocele (GO) when the abdominal wall defect exceeds 5–6 cm in diameter and the sac contains the whole or most of the liver. • Numerous methods for managing giant omphaloceles have been described since ages, but however, still there is no standard definition as well as its universal way of is management. • Since many GOs cannot be closed at birth due to various reasons, better to manage initially with non operatively with topical agents to facilitate epithelialization of the sac by dry eschar formation promoting subsequent scar tissue leaving behind small umbilical defect as the baby grows. • A technique of dry desiccated antiseptic and antibiotic dressings with graduated compression pressure applied daily is a simple yet innovative method of dealing with morbid congenital anomaly called giant omphalocele, yielding subsequently good results with perseverance from the involved medical team without any morbidity or mortality.

Pentalogy of cantrell, type 2- A rare entity

Pentalogy of Cantrell is rare congenital disorder which present with ectopic cordis, diaphragmatic defect, pericardial defect, supra umbilical abdominal wall defects and congenital heart defect.: We are reporting here a case of Pentalogy of Cantrell, Type 2 in a female child. Pentalogy of Cantrell, its rarity and unknown etiology is the reason of reporting.

Electrically Powered Locomotion of Dual-Nature Colloid-Hedgehog and Colloid-Umbilic Topological and Elastic Dipoles in Liquid Crystals.

Colloidal particles in liquid crystals tend to induce topological defects and distortions of the molecular alignment within the surrounding anisotropic host medium, which results in elasticity-mediated interactions not accessible to their counterparts within isotropic fluid hosts. Such particle-induced coronae of perturbed nematic order are highly responsive to external electric fields, even when the uniformly aligned host medium away from particles exhibits no response to fields below the realignment threshold. Here we harness the nonreciprocal nature of these facile electric responses to demonstrate colloidal locomotion. Oscillations of the electric field prompt repetitive deformations of the corona of dipolar elastic distortions around the colloidal inclusions, which upon appropriately designed electric driving synchronize the displacement directions. We observe the colloid-hedgehog dipole accompanied by an umbilical defect in the tilt directionality field (c-field), along with the texture of elastic distortions that evolves with a change in the applied voltage. The temporal out-of-equilibrium evolution of the director and c-field distortions around particles when the voltage is turned on and off is not invariant upon reversal of time, prompting lateral translations and interactions that markedly differ from those accessible to these colloids under equilibrium conditions. Our findings may lead to both technological and fundamental science applications of nematic colloids as both model reconfigurable colloidal systems and as mesostructured materials with predesigned temporal evolution of structure and composition.

Enhancing safety in ventral patch repair for umbilical hernia by utilizing a hybrid technique

BACKGROUND: Both suture and mesh repairs are used for smaller (1-3 cm) umbilical hernias. But primary repair has a higher recurrence rate in literature. The use of mesh repairs has become the way to go for small and medium sized ventral hernias. Ventral patch placement is a simple and effective procedure for the repair of umbilical hernias of 1–3 cm size. We demonstrate the safety and efficacy of the ventral patch for the same with our modification of the technique in 100 consecutive patients. We would initially insert the patch as described by the company, but had one patient presenting with intestinal obstruction, who on diagnostic laparoscopy had a small bowel loop entrapped between the patch and the anterior abdominal wall. This brought about a change in the original technique at our institute, which we adopted for all patients thereafter. MATERIALS AND METHODS: A single centre retrospective analysis of prospectively collected data was done. Our modified technique was done in 100 consecutive patients with umbilical hernia defect size ranging from 1 cm to 2.5 cm, from January 2017 to January 2021. Demographics, post-operative pain, duration of hospital stay, surgical site occurrences (early and late), post-operative complications and recurrences were noted. RESULTS: A total of 100 patients were included in the study. Two patients had superficial surgical site infection which was managed conservatively. We did not record any other major complications or recurrence. Visual analogue scale for pain was recorded at 24 hours. Majority (95%) of the patients had none to mild pain and were discharged at 24 hours. Five patients experienced moderate pain and were discharged at 36–48 hours. No patient experienced chronic pain at follow up. CONCLUSION: The hybrid technique of the ventral patch placement is a safe way for optimum visualization for the correct mesh placement and may improve results, decrease complications and recurrences.

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.

Ruptured Meckel's diverticulum coexisting with a duplex appendix

Duplicate appendix is a rare anatomic variation of the vermiform appendix with an incidence rate of 0.004–0.009 %. A Meckel's diverticulum (MD) is a common congenital anomaly resulting from the persistence of the omphalomesenteric duct. It may present as lower gastrointestinal hemorrhage, intestinal obstruction, or inflammation. The co-existence of a MD and duplex appendix is rare and our literture search revealed only 2 previous reports. The objective of this article is to report a co-existing duplex appendix and symptomatic MD in a child, review the literature, and illustrate the challenges with the diagnostic process in a resource-limited setting. We present a 3-year-old male who was referred to our facility following a successful reduction of an incarcerated umbilical hernia at a peripheral facility. He presented 5 days later with signs of peritonitis and was optimized for surgery. Laparotomy was performed which revealed perforated MD with minimal peritoneal soiling. He also had an incidental duplex appendix consistent with Cave-Wallbridge type B1 and a 2 × 2cm umbilical defect. Segmental resection of the MD, double appendectomies, and peritoneal lavage was performed. A co-existing duplex appendix with MD is extremely rare. Complications of MD are challenging to diagnose. A duplex appendix has clinical and medicolegal implications. Surgeons should explore the cecum during appendectomy to avoid missed diagnosis.

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.