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RESUMEN Antecedentes: Las hernias de línea media asociadas a diástasis de los músculos rectos anteriores (DRA) son frecuentes y se ha propuesto el tratamiento de ambas patologías simultáneamente para reducir la recurrencia. Las técnicas mínimamente invasivas permiten el tratamiento adecuado con reducción de complicaciones asociadas a la herida quirúrgica; sin embargo, aún no hay consenso acerca de cuál es la mejor técnica. Objetivo: Evaluar los resultados posoperatorios a corto y mediano plazo de una serie de pacientes con defectos de línea media y DRA tratados con la técnica Trans-umbilical Endoscopic Sublay Repair (TESuR). Material y método: Se realizó un estudio observacional descriptivo retrospectivo de pacientes a quienes se les aplicó técnica TESuR entre diciembre de 2020 y marzo de 2023, con un seguimiento posoperatorio mínimo de 6 meses. Se analizaron variables demográficas y perioperatorias. Resultados: En el período de estudio se realizaron 24 reparaciones. Todos los pacientes fueron varones. La edad promedio fue de 57 años (rango 41-81) y el índice de masa corporal (IMC) de 28,9 (21,7- 36,1) kg/m². El área del defecto fue de 8,8 (4-25) cm2, con una DRA de 5,1 (3-9) cm. La tasa de complicaciones a 30 días posoperatorios alcanzó el 17% (4/24); todas fueron Clavien-Dindo I. Con un promedio de seguimiento de 18,6 meses (rango 6-25) no se detectaron recidivas herniarias, aunque dos pacientes (8%) presentaron recidiva de la DRA. Conclusiones: La técnica TESuR presentó una baja morbilidad sin recidivas, por lo que la consideramos una alternativa segura y eficaz para el tratamiento de la DRA asociada a defectos de la línea media.

ABSTRACT Background: Midline hernias associated with diastasis recti abdominis (DRA) are common. Simultaneous treatment of both conditions has been recommended to reduce recurrence. Minimally invasive techniques allow adequate treatment while reducing surgical site complications. However, there is still no consensus regarding the optimal technique. Objective: The aim of this study was to evaluate the short and mid-term outcomes of Trans-umbilical Endoscopic Sublay Repair (TESuR) in patients with midline defects and DRA. Material and methods: We conducted a retrospective descriptive observational study of patients undergoing TESuR between December 2020 and May 2023, with a minimum postoperative follow-up of 6 months. The demographic and perioperative variables were analyzed. Results: A total of 24 procedures were performed during the study period. All the patients were men. Mean age was 57 years (range 41-81) and body mass index (BMI) was 28.9 (21.7- 36.1) kg/m². Mean size of the defect was 8.8 cm2 (4-25) with a mean diastasis width of 5 cm (3-9). The rate of complications at 30 days was 17% (4/24) and were all are grade 1 of the Clavien-Dindo classification. After a mean follow-up of 18.6 months (range 6-25), there were no hernia recurrences, although 2 patients (8%) had a recurrence of DRA. Conclusions: TESuR showed low morbidity rate and absence of recurrences, constituting a safe and effective option for the management of DRA associated with midline defects.

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PURPOSE: Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS: We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS: 2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION: The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION: A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

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INTRODUCTION: Umbilical hernias (UHs) are commonly underdiagnosed due to their asymptomatic presentation. The aim was to determine the prevalence of UHs by computed tomography (CT) in a trauma center, to assess the magnitude of their underdiagnosis. METHODS: A cross-sectional study was designed, using CT studies to evaluate the integrity of the abdominal wall. The images were obtained from consecutive cases of adult patients (≥18 y) from the database of the radiology and imaging service during a 4-mo period. The sociodemographic features, type of CT scan, and description of the abdominal wall were obtained and compared with the radiology report. In the case of UH presence, the transversal, cephalocaudal, and anteroposterior lengths, as well as its content, were registered. RESULTS: A total of 472 CT scans were included with a 67.6% (n = 319) prevalence of UH. These were most common in men (58.9%, n = 188/319), but women were more likely to have UH ≥ 10 mm (55%, n = 72/131). Of those with UH, 63.6% were unreported by radiology. The most common content was peritoneal fat (87.5%). UH had medians (interquartile range) of 9.1 mm (6.8, 12.5), 8.3 mm (6, 11.5), and 12.8 mm (8.6, 18.2) in its transversal, cephalocaudal, and anteroposterior lengths, respectively. Transversal length had a high positive correlation with cephalocaudal length (r = 0.877). This datum relationship can be explained by at least 76% due to this factor. Interobserver reliability analyses resulted in substantial reliability (ICC>0.85 and k > 0.85). CONCLUSIONS: CT is an effective imaging tool for diagnosing UH. There is a high prevalence among the general adult population, with a high radiologic underreporting.

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ABSTRACT BACKGROUND: Umbilical and epigastric hernias are among the most common hernias of the abdominal wall; however, there is a lack of standardization for their treatment. AIMS: To clarify the controversies regarding therapeutic possibilities, indications, and surgical techniques for umbilical and epigastric hernia repair. METHODS: A systematic review and qualitative analysis of randomized clinical trials published in the last 20 years, involving adults (aged 18 years and over) with umbilical and/or epigastric hernias, was performed by systematically searching the PubMed/Medline, Cochrane, SciELO, and LILACS databases. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias Tool. RESULTS: Initially, 492 studies were selected and, subsequently, 15 randomized controlled clinical trials were chosen that met the inclusion criteria and underwent full reading and qualitative analysis, considering possible bias. CONCLUSIONS: This review concluded that it is evident the superiority of the use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm, even in certain emergency situations. However, suture repair is a good option for patients with a defect smaller than 1 cm. In the laparoscopic approach, recent evidence points towards possible superiority in fixation with fibrin sealant, and fascial defect closure is recommended. In addition, due to a scarcity of randomized controlled trials with low risk of bias, further studies are needed on types, positioning and fixation techniques, as well as the real role of video-assisted laparoscopic surgery in the correction of hernias, especially umbilical.

RESUMO RACIONAL: As hérnias umbilicais e epigástricas estão entre as hérnias mais comuns da parede abdominal, porém falta padronização em relação ao seu tratamento. OBJETIVOS: Esclarecer as controvérsias acerca das possibilidades terapêuticas, indicações e técnicas cirúrgicas relacionadas ao tratamento das hérnias umbilicais e epigástricas. MÉTODOS: Foi realizada revisão sistemática e análise qualitativa dos estudos publicados nos últimos 20 anos, envolvendo indivíduos maiores de 18 anos com hérnias umbilicais e/ou epigástricas, por meio de busca nas bases de dados PubMed/Medline, Cochrane, LILACS e SciELO, sendo selecionados estudos do tipo ensaios clínicos randomizados controlados para análise. Foi determinado o risco de viés de cada estudo individualmente de acordo com a ferramenta Cochrane Risk of Bias Tool. RESULTADOS: Foram inicialmente selecionados 492 estudos e, posteriormente, escolhidos 15 ensaios clínicos randomizados controlados que preencheram os critérios de inclusão e foram submetidos à leitura integral e análise qualitativa, considerando os possíveis viés. CONCLUSÕES: Esta revisão concluiu que é evidente a superioridade do uso de telas no tratamento das hérnias epigástricas/umbilicais primárias com defeito superior a 1 cm, mesmo em certas situações de emergência. No entanto, o reparo com sutura pode ser uma opção em pacientes com defeito menor que 1 cm. Na abordagem laparoscópica, evidências recentes apontam para possível superioridade na fixação com selantes de fibrina e o fechamento do defeito fascial é recomendado. Ademais, devido à escassez de ensaios clínicos randomizados controlados com baixo risco de viés, foi identificada a necessidade de desenvolver mais estudos sobre os tipos, técnicas de posicionamento e fixação das telas, assim como sobre qual o real papel da cirurgia videolaparoscópica na correção das hérnias, especialmente as umbilicais.

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Umbilical disorders, which frequently occur in calves, are among the major causes of economic losses in herds. Antibiotic therapy alone is effective for some infectious cases, but surgical intervention is often indicated. This review aims to provide an overview of the clinical and surgical perspectives of the principal umbilical disorders in calves. The umbilicus may be affected by infectious or non-infectious conditions, including hernia, persistent urachus, omphalitis, urachitis, omphalophlebitis, and omphaloarteritis. Infectious varieties can culminate in sepsis and sometimes even involve other organs. Under these conditions, the chief complaint of calves tends to be apathy and visible swelling in the umbilical region. When surgery is indicated, the veterinary surgeon needs to have a thorough understanding of umbilical disorders, which coupled with careful clinical examination, will enable the formulation of an effective surgical plan. Surgical principles linked to pre-, trans-, and post-operative care must be considered, as recovery depends upon the surgery performed, pathological factors, and the patient's individual response. Some of the most common surgeries performed include herniorrhaphy, urachus, and umbilical vein resection. Several technological resources, such as ultrasonography and laparoscopy, are new tools that can help improve the performance of these procedures.

As afecções umbilicais são frequentes em bezerros e causam prejuízos econômicos e produtivos nos rebanhos. Apesar da antibioticoterapia ser eficaz em muitos casos infecciosos, o tratamento cirúrgico pode ser indicado. Pela incipiência de revisão relacionada a temática, objetivou-se produzir uma revisão sobre a abordagem clínica e cirúrgica das principais afecções umbilicais de bezerros. O umbigo pode apresentar infecções, como onfalite, uraquite, onfaloflebite, onfaloarterite, paratopias cirúrgicas e persistência de úraco. As infecções podem progredir para quadros septicêmicos com acometimentos de outros órgãos. A queixa principal dessas afecções consiste na protrusão da região umbilical e apatia dos bezerros. Quando a indicação terapêutica for cirúrgica, uma adequada compreensão das afecções umbilicais aliada a um bom exame clínico possibilitará ao cirurgião veterinário estabelecer um bom plano cirúrgico. Princípios cirúrgicos relacionados ao pré, trans e pós-operatório devem ser levados em consideração, pois a recuperação do paciente está diretamente relacionada à tratamento cirúrgico executada, fatores patológicos e resposta individual do paciente. Dentre as cirurgias mais comuns realizadas estão as herniorrafias, cirurgias de úraco e de veias umbilicais. Vários recursos tecnológicos trazem novidades nesses procedimentos, como a ultrassonografia, com destaque para videocirurgia.

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Se describe el caso clínico de una grávida de 26 años de edad y tiempo gestacional de 34,4 semanas, quien fue remitida del Hospital General de Rusape al Hospital Central de Harare, ambos en Zimbabwe, por presentar una hernia umbilical, que la aquejaba desde la infancia. La paciente había padecido ese volumen herniario en 3 embarazos anteriores, cuyos partos fueron normales. Luego de efectuar los estudios pertinentes, que demostraron el diagnóstico, y evaluar el caso en equipo multidisciplinario, se decidió practicar cesárea de urgencia. Durante el procedimiento quirúrgico se halló que todo el útero se encontraba dentro del saco herniario cubierto por el epiplón; se extrajo al recién nacido, el cual poseía buena vitalidad, índice de Apgar de 9-10 y peso de 2590 gramos; posteriormente, se resecó el tejido herniario redundante. La paciente evolucionó favorablemente en el período posoperatorio inmediato y recibió el alta hospitalaria a los 5 días.

The case report of a 26 years pregnant woman and gestacional age of 34.4 weeks is described, who was referred from General Hospital of Rusape to Harare Central Hospital, both in Zimbabwe, due to an umbilical hernia that afflicted her since the childhood. The patient had suffered from that hernial volume in 3 previous pregnancies whose childbirths were normal. After the pertinent studies that demonstrated the diagnosis, and evaluate the case in multidisciplinary team, it was decided to practice an emergency Cesarean section. During the surgical procedure it was found that the whole uterus was inside the hernial sack covered by omentum; the new born was extracted, who possessed good vitality, Apgar index 9-10 and 2590 grams weight; later on, the redundant hernial tissue was dried up. The patient had a favorable clinical course in the immediate postoperative period and she was discharged 5 days after.

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Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

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RESUMO: Modelo do estudo: Revisão sistemática. Objetivo: Avaliar se é facultativo ou imprescindível o uso de malha cirúrgica no reparo das pequenas hérnias umbilicais primárias, com orifício menor que 2 cm, a fim de oferecer melhores evidências aos cirurgiões e, assim, aprimorar o método cirúrgico e o seu desfecho. Métodos: Trata-se de uma revisão da literatura, cuja busca foi direcionada aos artigos que abordassem o manejo operatório das hérnias abdominais, sobretudo das hérnias umbilicais de pequeno tamanho. A pesquisa foi realizada nas bases de dados primárias PubMed, LILACS, Cochrane Library e Periódicos CAPES. Resultados: No total, foram incluídos quatro es-tudos. Foram avaliadas as taxas de recorrência, bem como as de complicações pós-operatórias após a correção da hérnia umbilical com e sem o uso de tela, observando-se o tamanho do defeito abdominal. Foi observada diminuição da recorrência das hérnias após o reparo com tela. No entanto, complicações, como infecção da ferida operatória, foram mais comumente observadas com o uso da prótese. Não houve consenso quanto ao uso da tela em hérnias menores que 1 cm. Conclusão: O uso de próteses pode vir a ser o tratamento de escolha no reparo das hérnias umbilicais primárias. Contudo, mais estudos são necessários para avaliar o papel dessa estratégia no manejo das hérnias menores que 1 cm (AU)

ABSTRACT: Study design: Systematic review. Objective: Evaluate whether surgical mesh is optional or essential for the repair small primary umbilical hernias, with an orifice smaller than 2 cm, in order to provide better evidence for surgeons, thus enhancing surgical method and its outcomes. Methods: This is a literature review, whose search was directed towards papers that depicted surgical management of abdominal hernias, especially small umbilical hernias. The research was carried out in the primary the primary databases PubMed, LILACS, Cochrane Library, and Periódicos CAPES. Results: A total of four studies were included. Recurrence rates, as well as postoperative complications, were assessed after an umbilical hernia was corrected with or without the use of a mesh, observing the size of the abdominal defect. A reduction in the re-occurrence of hernias was observed when using a mesh. However, complications, such as surgical site infection, were more commonly noticed with the use of the prosthe-sis. There was no consensus regarding the use of the mesh in hernias smaller than 1 cm. Conclusion: The use of surgical mesh may prove to be the treatment of choice for the repair of primary umbilical hernias. However, more studies are needed to evaluate the role of this strategy in the management of hernias smaller than 1 cm. (AU)

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RESUMEN Antecedentes: la ascitis es una complicación de frecuente aparición en el paciente cirrótico que al producir un aumento de la presión intraabdominal puede originar una hernia de la pared abdominal; el defecto umbilical latente es su localización más habitual. Objetivo: presentar la incidencia y los beneficios que ofrece la resolución electiva de la patología um bilical en estos pacientes. Material y método: se presentan 15 pacientes, todos masculinos, que fueron intervenidos por hernia umbilical sintomática en forma electiva en el medio hospitalario. El período comprende desde enero del año 2015 a enero de 2019. El 100% de los enfermos cursa un cuadro de cirrosis hepática, con antecedentes de etilismo crónico. Se efectuó la reparación de la hernia con cierre del defecto y malla supraaponeurótica de polipropileno en la mayoría de los casos. Resultados: los pacientes fueron evaluados desde el punto de vista clínico con la escala (score) de Child en el preoperatorio. Se procedió a la evacuación de la ascitis en todos los casos y el control posoperatorio se efectuó cada 30 días los primeros 6 meses. Luego dos veces al año. No se evidenció recidiva. Dos pacientes no volvieron al control luego del año de la cirugía y 1 paciente falleció por la enfermedad de base a los 6 meses de la cirugía. Conclusiones: los enfermos con cirrosis hepática y hernia umbilical deben ser intervenidos quirúrgica mente en forma electiva. La observación y abstención quirúrgica conllevan el riesgo de rotura del saco herniario con alta morbimortalidad.

ABSTRACT Background: Background: Ascites is a common complication in patients with cirrhosis, and elevated intraabdominal pressure can lead to the development of abdominal wall hernias, particularly in patients with latent umbilical defects. Objectives: The aim of this study was to report the incidence and benefits of elective surgery for the management of umbilical hernias in cirrhotic patients with ascites. Material and methods: Between January 2015 and January 2019 15 patients with symptomatic umbi lical hernia underwent elective surgery in a public hospital; 100% were men with a history of alcoho lism and were hospitalized due to liver cirrhosis. The defect was closed, and a polypropylene mesh was placed in the supra-aponeurotic plane in most cases. Results: The preoperative risk was estimated using the Child-Pugh score. Ascites was evacuated in all the cases. Patients were followed-up every 30 days during the first 6 months and then twice a year. There were no hernia recurrences. Two patients were lost to follow-up 12 months after surgery and 1 patient died 9 months after the procedure due to progression of cirrhosis. Conclusions: Patients with liver cirrhosis and umbilical hernia should undergo elective surgery. Wat chful waiting is associated with higher risk of hernia rupture and high morbidity and mortality.

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INTRODUCCIÓN: La pentalogía de Cantrell abarca la presencia de cinco defectos congénitos que representan un gran desafío para los cirujanos. Las anomalías del corazón, pericardio, diafragma, esternón y pared abdominal anterior son los hallazgos principales. Su incidencia es baja, sin embargo, es fundamental identificarla oportunamente para adoptar una terapia adecuada para todos los defectos descritos, puesto que se reporta una mortalidad elevada. CASO CLÍNICO: Se trató de un recién nacido a término, de sexo masculino, con antecedentes de defecto de la pared abdominal compatible con onfalocele detectado mediante ecografía prenatal. Tras cesárea programada, se evidenció defecto en la pared abdominal a través del cual emergían el lóbulo hepático izquierdo, intestinos y corazón; el esternón además presentaba una fisura baja. En ecocardiograma se evidenció foramen oval permeable, insuficiencia tricuspídea leve e hipertensión pulmonar severa. EVOLUCIÓN: Se decidió su manejo quirúrgico inmediato. Se colocó silo, con cierre progresivo de la línea media en 7 días. En segundo tiempo quirúrgico, se corrigió el defecto diafragmático y pericárdico con prótesis de pericardio bovino. Pese a la evolución adecuada de la cirugía, a los 28 días, el paciente presentó cianosis súbita, sin responder a maniobras de reanimación y falleció. CONCLUSIÓN: La Pentalogía de Cantrell es una enfermedad rara, con características clínicas, anatómicas y embriológicas peculiares, representa un desafío único para los cirujanos. Su diagnóstico temprano, así como el seguimiento durante el embarazo, la planificación de una cesárea en un centro de alto nivel y la aproximación quirúrgica inmediata con un equipo multidisciplinario, son componentes clave en el manejo integral de pacientes con Pentalogía de Cantrell.

BACKGROUND: Cantrell's pentalogy includes the presence of five birth defects that represent a great challenge for surgeons. Abnormalities of the heart, pericardium, diaphragm, sternumand anterior abdominal wall are the main findings. Its incidence is low, however, it is essential to identify Cantrell´s pentalogy timely to adopt an adequate therapy for all specific defects, since it has high mortality. CASE REPORT: The patient was a full- term male newborn, with a history of abdominal wall defect compatible with an omphalocele detected by prenatal ultrasound. After the caesarean section, the abdominal wall defect was notable, the left liver lobe, intestines and heart emerged through it, the sternum also had a low fissure. The echocardiogram revealed a permeable oval foramen, mild tricuspid regurgitation, and severe pulmonary hypertension. EVOLUTION: Immediate surgical management was decided. Silo was placed, with progressive closure of the midline in 7 days. During the second surgical procedure, the diaphragmatic and pericardial defect was corrected with a bovine pericardial prosthesis. Despite the adequate evolution after surgery, at day 28 he presented with sudden cyanosis and didn't respond to cardiopulmonary resuscitation and died. CONCLUSIONS: Cantrell's Pentalogy is a rare disease, with peculiar clinical, anatomical and embryological characteristics, it represents a unique challenge for surgeons. Early diagnosis, as well as follow-up during pregnancy, planning a cesarean section in a high-level center and immediate surgical approach with a multidisciplinary team, are the key components in the management of patients with Cantrell's Pentalogy.

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OBJECTIVE: To evaluate whether patient age or other sociodemographic and clinical characteristics are associated with recurrence or unplanned related hospital revisits after pediatric umbilical hernia repair. STUDY DESIGN: We performed a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases of 7 states. Pediatric umbilical hernia repairs performed at any hospital or surgery center in 2010-2014 were included. Hernia recurrences and occurrences of unplanned and related hospital revisits within 30 days were evaluated. RESULTS: Of 9809 included patients, 52.0% were female and 50.5% were black. The 3-year hernia recurrence rate was 0.57% (95% CI 0.42, 0.73). In multivariable analysis, the recurrence rate was higher in children <4 years of age than in children 4-10 years of age (hazard ratio [HR] 1.93, 95% CI 1.09, 3.44). Unplanned related hospital revisits within 30 days occurred in 2.5% of patients. Patient characteristics associated with the risk of an unplanned related hospital revisit included age <4 years (HR 2.17, 95% CI 1.70, 2.77) or >10 years (HR 2.11, 95% CI 1.46, 3.05), public insurance (HR 2.10, 95% CI 1.58, 2.79), asthma (HR 1.74, 95% CI 1.32, 2.29), and initial presentation to the emergency department (HR 2.46, 95% CI 1.08, 5.61). CONCLUSIONS: Rates of recurrence and unplanned related hospital revisits following pediatric umbilical hernia repair are higher in children younger than 4 years of age. These findings support delaying the repair of asymptomatic umbilical hernia in children until 4 years of age.

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Abstract Pentalogy of Cantrell (PC) is a rare congenital anomaly characterized by changes in the mesodermal median structures and congenital heart disease, often with a poor prognosis. In 1958, Cantrell et al2 defined the full spectrum of the syndrome with the following anomalies: defects of the anterior diaphragm, of the lower part of the sternum, of the supraumbilical region and the abdominal wall, of the diaphragmatic pericardium, and various intracardiac congenital abnormalities. The present report describes a case of ectopia cordis associated with PC and the importance of the participation of a multidisciplinary team in the treatment of this condition.

Resumo A pentalogia de Cantrell (PC) é uma rara anomalia congênita caracterizada por alterações nas estruturas medianas mesodérmicas e doenças cardíacas congênitas, cursando muitas vezes com um mau prognóstico. Em 1958, Cantrell et al2 definiram o espectro completo da síndrome com as seguintes anomalias: defeitos do diafragma anterior, da parte inferior do esterno, da região supraumbilical e parede abdominal, do pericárdio diafragmático, e várias anormalidades congênitas intracardíacas. O presente relato relaciona-se a um caso de ectopia cordis associado à PC e à importância da participação de uma equipe multidisciplinar no acompanhamento da doença.

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BACKGROUND: Abdominal wall defects (AWDs) include recti diastasis and midline hernias (umbilical, epigastric, and incisional). In the coexistence of such fascia defects, simultaneous repair is recommended. Conventional and hybrid techniques have been reported as an option of approach. This study aims to present the results of a total minimal invasive access to treat AWD with mesh reinforcement (subcutaneous videosurgery for abdominal wall defects [SVAWD] technique). PATIENTS AND METHODS: The prospective observational study included patients with small/medium midline incisional hernia and/or multiple AWDs (symptomatic umbilicus and/or an epigastric hernia and/or abdominal rectus diastasis >2 cm) operated between August 2016 and February 2018. The exclusion criteria were, namely, fascia defects >10 cm, complex hernias, excess of skin and/or subcutaneous abdominal fatty tissue, and body mass index >35 kg/m2. RESULTS: Twenty-one patients were treated by SVAWD technique, with a median follow-up of 14 (range 6-22) months. The mean size of all fascia defects was 7.46 cm (range 4.5-10.5). Surgical site occurrence was identified in three (14.3%) patients and surgical site occurrence requiring procedural intervention in two (9.5%). Diabetes mellitus was the only predictor factor for higher intraoperative bleeding (R2 = 0.63, P = .025). Fibrin sealant (used for mesh fixation) and transverse abdominis plane (TAP) block with ropivacaine 0.2% were associated with less oral analgesics intake (P < .001 and P < .001, respectively) and fewer complications (P = .005 and P = .034, respectively). CONCLUSION: Despite the low number of patients operated, the subcutaneous approach presented has proven to be safe, feasible, and effective, as no major complications and relapse occurred. Still, fibrin sealant and TAP block were associated with fewer complications and less oral analgesics intake.

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OBJECTIVE: To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from 3 demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital, and geographic characteristics. STUDY DESIGN: We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012-2014, using the State Ambulatory Surgery and Services Database for Wisconsin, New York, and Florida. Age and demographic characteristics of umbilical hernia repair patients are described. RESULTS: The State Ambulatory Surgery and Services Database analysis included 6551 patients. Across 3 states, 8.2% of hernia repairs were performed in children <2 years, 18.7% in children age 2-3 years, and 73.0% in children age ≥4 years, but there was significant variability (P < .001) in practice patterns by state. In regression analysis, race, Medicaid insurance and rural residence were predictive of early repair, with African American patients less likely to have a repair before age 2 (OR 0.62, P = .046) and rural children (OR 1.53, P = .009) and Medicaid patients (OR 2.01, P < .001) more likely to do so. State of residence predicted early repair even when holding these variables constant. CONCLUSIONS: The age of pediatric umbilical hernia repair varies widely. As hernias may resolve over time and can be safely monitored with watchful waiting, formal guidelines are needed to support delayed repair and prevent unnecessary operations.

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Resumen ANTECEDENTES: Aunque la hernia umbilical es relativamente frecuente en la población africana, la mayoría de los casos cursan asintomáticos. La situación en la que un útero grávido entra en un saco herniario representa una complicación excepcional de la hernia umbilical. CASO CLÍNICO: Paciente de 30 años, con antecedentes médicos de hernia umbilical y obstétricos de 5 embarazos, 4 partos y 1 aborto espontáneo. Acudió a consulta por dolor en la parte baja del vientre, de tres días de evolución. En el interrogatorio refirió amenorrea de 5 meses; 2 semanas antes percibió movimientos fetales y ausencia de los mismos 3 días previos a la consulta médica. Al examen físico se observó el abdomen con aumento de volumen irreductible, de 30 cm de diámetro, de forma pendular, que se protruía a través de un gran anillo herniario umbilical y llegaba hasta la mitad de los muslos; se palpó el feto, pero no se escucharon latidos cardiacos. Por los antecedentes médicos, hallazgos clínicos y ecográficos se estableció el diagnosticó de muerte fetal intrauterina, como complicación de útero grávido en una hernia umbilical. Se decidió la interrupción del embarazo mediante cesárea de urgencia. La hernia umbilical se reparó con reforzamiento del defecto mediante colgajos fascio-aponeuróticos, según la técnica de Mayo. La evolución de la paciente fue satisfactoria. CONCLUSIONES: El tratamiento de pacientes embarazadas con hernia umbilical incluye una conducta conservadora, control prenatal estricto, colocación de un corsé para rectificar el útero grávido, programación de la cesárea y reparación del defecto herniario.

Abstract BACKGROUND: Although umbilical hernia is relatively common in African patients, the majority of cases are asymptomatic. The situation in which a gravid uterus enters a hernia sac is one of the rarest complications of umbilical hernia. CLINICAL CASE: 30-year-old pregnant woman with a history of umbilical hernia and obstetric of 5 pregnancies, 4 deliveries and 1 spontaneous abortion. She reported pain in the abdomen that appeared 3 days ago, absence of menstruation 5 months ago, with fetal movements referred 2 weeks ago and absence of them 3 days ago. At the physical examination, an irreducible volume increase of approximately 30 cm in diameter with a pendulum shape that protruded through a large umbilical hernia ring and reached the middle of the thighs, fetal parts were palpated and absence of fetal heartbeats. Due to the antecedents, the clinic and the obstetric ultrasound, an intrauterine fetal death was diagnosed as a complication of a gravid uterus in an umbilical hernia. The interruption of pregnancy was performed by emergency caesarean section. The umbilical hernia was repaired with reinforcement of the defect using fascio-aponeurotic flaps, according to the Mayo technique. The evolution was satisfactory until hospital discharge. CONCLUSIONS: The treatment of pregnant patients with umbilical hernia includes a conservative behavior, strict prenatal control, placement of a brace to rectify the pregnant uterus, programming of the cesarean and repair of the hernia defect.

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Resumen La ascitis es la complicación más común en los pacientes con cirrosis hepática. Las hernias umbilicales (HU) ocurren en 20% de estos pacientes y 40% en aquellos con ascitis severa. La HU ocurre debido al aumento de presión intraabdominal, al debilitamiento de la fascia abdominal y la pérdida de masa muscular. Además, tienen tendencia a aumentar rápidamente y presentar alto riesgo de complicaciones que amenazan la vida del paciente. El tratamiento de la HU no complicada es controversial, tanto el manejo quirúrgico (herniorrafia) como el manejo conservador (control de ascitis) presentan alta tasa de complicaciones, en consecuencia incrementa la morbimortalidad. Actualmente, se recomienda herniorrafia umbilical con previo control de la ascitis en el manejo de HU no complicada, reduce el riesgo de infección de herida operatoria, evisceración, drenaje de ascitis, peritonitis y reduce hasta 41% la recidiva de HU. El éxito de este enfoque también depende del grado de disfunción hepática. El tratamiento de la HU complicada es quirúrgico (herniorrafia sin malla), con menor tasa de mortalidad respecto al manejo conservador. Estudios revelan ventajas de la herniorrafia umbilical laparoscópica (mínimamente invasiva y sin tensión) en comparación a la cirugía abierta, sin embargo, aún no hay evidencia al respecto.

Ascites is the most common complication in patients with liver cirrhosis. Umbilical hernias (HU) occur in 20% of these patients and 40% in those with severe ascites. HU occurs due to increased intra-abdominal pressure, weakening of the abdominal fascia and loss of muscle mass. In addition, they have a tendency to enlarge rapidly and present high risk of complications that threaten the patient's life. The treatment of the uncomplicated HU is controversial, both the surgical management (herniorrhaphy) and the conservative management (control of ascites) present high rate of complications, consequently high morbidity and mortality. Currently, umbilical herniorrhaphy is recommended with prior control of ascites in uncomplicated HU management, it reduces the risk of surgical wound infection, evisceration, ascites drainage, peritonitis, and it reduces up to 41% of HU recurrence. The success of this approach also depends on the degree of liver dysfunction. The treatment of complicated HU is surgical (herniorrhaphy without mesh), with lower mortality rate compared to conservative management. Studies reveal advantages of umbilical herniorrhaphy laparoscopy (minimally invasive and stress-free) compared to open surgery; however there is still no evidence about it.

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Se describe el caso clínico de un adulto de 47 años de edad, quien acudió al cuerpo de guardia del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba por presentar, desde hacía 3 días, dolor en epigastrio, de comienzo insidioso, que desapareció en las últimas 24 horas, y apareció nuevamente en la fosa ilíaca derecha y mesogastrio, pero esta vez se trasformó en fijo, punzante, de moderada intensidad, que no se aliviaba con analgésicos, y asociado a náuseas; igualmente, refirió y se corroboró al examen físico la presencia de una hernia umbilical que no lograba reducirse. El paciente fue operado y se encontró una hernia de Littre umbilical estrangulada. Se le realizó resección y anastomosis del íleon a nivel del divertículo de Meckel, así como herniorrafia umbilical. La evolución fue favorable y egresó sin complicaciones

The case report of a 47 years adult is described who went to the emergency room of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba due to epigastric distress of insidious beginning for 3 days that disappeared in the last 24 hours, appearing again in the right iliac cavity and mesogastrium, but this time it was transformed in a fixed, sharp, of moderate intensity pain that was not relieved with analgesics, and associated with nausea; equally, he referred the presence of an umbilical hernia that was not able to decrease and it was corroborated in the physical exam. The patient was operated on and a strangulated umbilical Littre hernia was found. A resection and anastomosis of ilium at the Meckel diverticulum level was carried out, as well as umbilical hernia repair. There was a favorable clinical course and he was discharged without complications

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Introdução: A cicatriz umbilical é decorrente da queda do coto umbilical, que ocorre alguns dias após o nascimento. Sua presença, formato e localização na parede abdominal fornecem ao indivíduo uma conotação estética e sensual. Métodos: Estudo primário, prospectivo, de intervenção. A casuística foi de conveniência, no período de fevereiro de 2006 a junho de 2016, incluindo pacientes de ambos os gêneros, alocados do ambulatório do Hospital das Clínicas da Universidade Federal de Pernambuco (HC-UFPE) e clínica privada. Os critérios de inclusão foram pacientes com indicação de abdominoplastia e que apresentavam um comprometimento da irrigação da pele da região umbilical e periumbilical devido a defeitos herniários da região. O estudo seguiu os critérios de Helsinki e os pacientes assinaram o Termo de Consentimento Livre e Esclarecido. Resultados: Foram operados 28 pacientes, sendo observada uma boa integração da pele enxertada, resultando em uma cicatriz umbilical de aparência natural e sem complicações. Conclusões: A neo-onfaloplastia com enxerto cutâneo é de fácil execução e que, a longo prazo, tem demonstrado um bom resultado estético, principalmente nos retalhos abdominais espessos, demonstrando ser mais uma opção técnica na realização de neo-onfaloplastias.

Introduction: The umbilical scar is due to the fall of the umbilical stump that occurs a few days after birth. Its presence, shape, and location on the abdominal wall provide the individual with an aesthetic and sensual connotation. Methods: A primary prospective interventional study. The sample was of convenience, from February 2006 to June 2016, and included patients of both sexes attending the outpatient clinic of the Hospital das Clínicas of the Federal University of Pernambuco (HC-UFPE), a private clinic . The inclusion criteria were patients with abdominoplasty indications presenting with compromised circulation to the skin of the umbilical and periumbilical region caused by hernia defects in this area. The study followed the criteria of Helsinki and the patients signed an Informed Consent Form. Results: Twenty-eight patients underwent surgery and good integration of the grafted skin was observed. This resulted in an umbilical scar with a natural appearance and without complications. Conclusions: Neoomphaloplasty with a cutaneous graft is easy to perform and, in the long term, has shown to provide good aesthetic results, especially in thick abdominal flaps, thus proving to be an additional technical option for neoomphaloplasty procedures.

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Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.

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Distocia é uma complicação comum em cadelas, sendo que anormalidades fetais podem perturbaro parto normal. Neste trabalho é relatado o caso de uma Buldogue inglês primípara,inseminada artificialmente, a qual estava em trabalho de parto e foi encaminhada para atendimentoveterinário 12 horas após o aparecimento dos primeiros sinais do parto. Por meio depalpação vaginal, verificou-se a presença de um feto de tamanho grande no canal do parto,sendo realizada cesariana. Dos cinco filhotes, três eram natimortos e dois destes apresentavamanormalidades externas visíveis compatíveis com anasarca fetal. Um destes dois apresentavaadicionalmente onfalocele.

Dystocia is one common complication in bitches. Foetal abnormalities can disrupt the normaldelivery. It is related a case of a English bulldog, primiparous female, artificially inseminated,that started parturition 12 hours before requiring veterinary care. Through vaginal palpationwas verified the presence of an oversize fetus in the pelvic canal impeding the normal birth.For that reason cesarean was performed. Three of the five puppies were stillbirths. Two of thesehad visible external abnormalities, compatible with fetal anasarca, and one had an additionallyomphalocele.

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