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A 79-year-old female presented with a 3-week history of dysphagia and vomiting, and an upper abdominal mass which had increased in size over the previous 2 weeks. CT scan showed a partial gastric outlet obstruction secondary to an epigastric hernia. This was assessed further on fluoroscopy, showing the distal stomach in the hernial sac and a delay in gastric emptying. We present the CT and fluoroscopic findings of this rare cause of gastric outlet obstruction.

Purpose: There are many surgical techniques for ventral hernias and diastasis recti, both conventional or video-endoscopic, with or without mesh placement, detailed in the literature. Using some details of the techniques proposed by Wolfgang Reinpold (Mini- or Less Open Sublay Operation, MILOS) and Federico Fiori (Totally Endoscopic Sublay Anterior Repair, TESAR) we found modifications that allowed repairing and reinforcement of the posterior fascia with a retro-muscular mesh and achieve primary fascial closure by minimally umbilical access and searching for the best anatomical, functional, and aesthetic results. Method: Describe the surgical technique step by step and analyze 629 surgical treatments. The cohort comprises the period January 2018 to January 2023. Our Database registered 318 men and 311 women who underwent video endoscopicassisted Rives-Stoppa techniques to treat umbilical and epigastric hernias with diastasis Results: All patients were treated on an outpatient basis and discharged home on the same day. The most frequent complications were seromas with conservative management. Other complications recorded were omphalitis in 6 patients, and three patients presented hematomas, one of whom performed surgical evacuation. There were ten patients with recurrences. Conclusion: These hybrid approaches provide the advantages of mini-invasive techniques with a lower rate of complications and a high standard of quality of life, providing anatomical, functional, and aesthetic benefits. [ABSTRACT FROM AUTHOR]

The epigastric hernia sac usually contains preperitoneal fat tissue, omentum, and intestines, but the presence of liver tissue is extremely rare. Epigastric hernia is a type of hernia in the midline of the abdominal wall between the umbilicus and the xiphoid process. It may be asymptomatic in some patients and cause complaints such as pain and nausea in most patients, but serious complications such as incarceration and strangulation are rare. In the present case, a 74-year-old woman was examined and found to have an irreduced omentum, transverse colon and liver tissue inside the hernia sac. She underwent an open procedure with onlay mesh-assisted hernia repair. Rare but serious complications, such as liver tissue incarceration, should be considered in epigastric hernia patients. [ABSTRACT FROM AUTHOR]

The epigastric hernia sac usually contains preperitoneal fat tissue, omentum, and intestines, but the presence of liver tissue is extremely rare. Epigastric hernia is a type of hernia in the midline of the abdominal wall between the umbilicus and the xiphoid process. It may be asymptomatic in some patients and cause complaints such as pain and nausea in most patients, but serious complications such as incarceration and strangulation are rare. In the present case, a 74-year-old woman was examined and found to have an irreduced omentum, transverse colon and liver tissue inside the hernia sac. She underwent an open procedure with onlay mesh-assisted hernia repair. Rare but serious complications, such as liver tissue incarceration, should be considered in epigastric hernia patients.

Background: Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed. Objectives: The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias. Methods: A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work. Results: Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32–0.74; p < 0.001; I2 = 29%). Local infection (RR = 0.30; 95%CI = 0.19–0.49; p < 0.001; I2 = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02–0.32; p < 0.001; I2 = 0%), and local seroma (RR = 0.34; 95%CI = 0.19–0.59; p < 0.001; I2 = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work. Conclusion: The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma. [ABSTRACT FROM AUTHOR]

Introduction: Epigastric hernia repair is a common procedure performed on pediatric patients. These hernias have been demonstrated to be readily identified by ultrasound. This manuscript describes and assesses a novel technique in which ultrasound is used to identify and repair the hernias in a minimally invasive manner. Methods: A retrospective chart review evaluates all the ultrasound-guided epigastric hernia repairs done with prolene suture at one institution over 20 months. Operative details and postoperative complications were compared to patients who underwent traditional open epigastric hernia repair at the same institution during the same time frame. Results: Thirty-two pediatric patients underwent epigastric hernia repair between May 2021 and December 2022. Thirteen (41%) underwent the ultrasound-guided technique with prolene suture and using only a meniscus needle and no incision. Nineteen (59%) underwent standard open repair. There were no recurrences or postoperative complications in either group. The average operative time for the ultrasound hernia repair was 24.4 minutes, which was shorter than the average operative time of 33.6 minutes for the open repair (P = .08). In 3 ultrasound cases (23%), an additional epigastric hernia that had not been clinically apparent was identified and simultaneously repaired. Conclusions: Ultrasound-guided epigastria hernia repair is a feasible alternative to traditional open repair. It has a comparable safety and efficacy profile, has a short operative time, and has the advantages of being minimally invasive and having the ability to identify and repair concurrent epigastric hernias. [ABSTRACT FROM AUTHOR]

Abstract Background Uterine fibroids incarcerated in abdominal wall hernias during pregnancy are rare, with only six cases reported in umbilical hernias. This case report presents the first reported case of an incarcerated uterine fibroid in an epigastric hernia. Case presentation A 31-year-old primigravid Caucasian woman at 28 weeks gestational age presented with sudden onset abdominal pain and vomiting. Physical examination revealed an incarcerated epigastric hernia containing a non-reducible firm mass. Ultrasound showed a healthy fetus, and during surgery, a subserosal and sessile fibroid originating from the anterior uterine wall was found in the hernia sac. It was easily reduced, and the hernia was repaired with no complications. The patient proceeded to deliver a healthy baby boy by cesarean section at full term. Conclusion Uterine fibroids incarcerated in abdominal wall hernias during pregnancy are rare and affect mostly primigravid women in the third trimester. Abdominal ultrasound may facilitate the diagnosis, and pedunculated fibroids may be resected while sessile fibroids should be simply reduced. Clinicians should consider incarcerated fibroid as a differential diagnosis in pregnant women with irreducible ventral abdominal wall hernias. This case report aims to contribute to the literature and optimize the management of abdominal wall hernias in pregnant women.

Key Clinical Message An epigastric hernia usually contains preperitoneal fat, but rarely may contain colon. This fact needs to be kept in mind by the operating surgeons. Abstract An epigastric hernia usually contains preperitoneal fat, but rarely may contain colon. Experience with such a singular case is presented and discussed. This fact needs to be kept in mind by the operating surgeons.

Background: Epigastric hernias account for 4% of abdominal wall defects in children. They present as a painless or tender mass at the supraumbilical midline. Their coventional treatment in children is open herniorrhaphy without the use of meshes. The management of the infrequent cases of multiple epigastric hernias can be challenging, and requires careful consideration to ensure optimal repair that minimizes tissue tearing. Case presentation: We present a case involving an obese adolescent with Down syndrome who experienced abdominal discomfort associated with a mass in the ventral abdominal wall. Ultrasound examination and laparoscopy revealed a total of six epigastric defects. The decision was made to perform a longitudinal plication of the ends of the linea alba using a laparoscopic technique to avoid the manipulation of each defect separately. In addition, a composite intraperitoneal mesh (IPOM) with a hydrogel layer on its visceral side was placed. To our knowledge, this technique has not been previously applied in this clinical context. The postoperative course was uneventful, with no significant pain, seroma, or wound complications. At the 18-month follow-up, the patient remained asymptomatic, showing no evidence of recurrence, and was able to perform regular physical activity. Conclusion: The use of laparoscopic defect suture closure combined with IPOM repair is a minimally invasive, and cosmetically and functionally acceptable method for the repair of multiple epigastric hernias in carefully selected pediatric patients, with good short- and medium-term results.

Purpose: Outpatient pediatric surgical practice often involves conditions of limited morbidity but significant parental concern. We explore existing evidence-based management recommendations and the mismatch with practice patterns for four common outpatient pediatric surgical conditions. Methods: Using the Cochrane Rapid Review Group recommendations and librarian oversight, we conducted a rapid review of four outpatient surgical conditions: dermoid cysts, epigastric hernias, hydroceles, and umbilical hernias. We extracted patient demographics, intervention details, outcome measures and evaluated justifications presented for chosen management options. A metric of evidence volume (patient/publication ratio) was generated and compared between diagnoses. Results: Out of 831 articles published since 1990, we identified 49 cohort studies (10-dermoid cyst, 6-epigastric hernia, 25-hydrocele, and 8-umbilical hernia). The 49 publications included 34,172 patients treated across 18 countries. The evidence volume for each outpatient condition demonstrates < 1 cohort/condition/year. The evidence mismatch rate varied between 33 and 75%; many existing recommendations are not evidence-based, sometimes conflicting and frequently misrepresentative of clinical practice. Conclusions: Published literature concerning common outpatient pediatric surgical conditions is sparse and demonstrates wide variations in practice. All individual practice choices were justified using either risk of complications or patient preference. Most early intervention practices were based on weak or outdated studies and "common wisdom" rather than genuine evidence. Level of evidence: III. [ABSTRACT FROM AUTHOR]

A 20-year-old man presented to the emergency department with a small painful swelling located in the midline of the epigastric region. His medical history included asthma and extramucosal pyloromyotomy for hypertrophic pyloric stenosis when he was a baby. His vital signs were normal. Abdominal ultrasound (US) showed a small hypoechoic formation located in the subcutaneous adipose tissue that penetrated into the abdominal cavity through an orifice of about 7 mm in the linea alba.

Introduction: In recent surgical literature, gender-specific differences in the outcome of hernia surgery has been analyzed. We already know that female patients are at higher risk to develop chronic postoperative pain after inguinal, incisional, and umbilical hernia surgery. In this study, we evaluated the impact of gender on the outcome after epigastric hernia surgery. Methods: A covariable-adjusted matched-paired analysis with data derived from the Herniamed registry was performed. In total of 15,925 patients with 1-year follow-up data were included in the study. Propensity score matching was performed for the 7786 female (48.9%) and 8139 male (51.1%) patients, creating 6350 pairs (81.6%). Results: Matched-paired analysis revealed a significant disadvantage for female patients for pain on exertion (12.1% vs. 7.6%; p < 0.001) compared to male patients. The same effect was demonstrated for pain at rest (6.2% in female patients vs. 4.1% in male patients; p < 0.001) and pain requiring treatment (4.6% in female patients vs. 3.1% in male patients; p < 0.001). All other outcome parameters showed no significant differences between female and male patients. Conclusions: Female patients are at a higher risk for chronic pain after elective epigastric hernia repairs compared to the male patient population. These results complete findings of previous studies showing the same effect in inguinal, umbilical, and incisional hernia repair. [ABSTRACT FROM AUTHOR]

Background: Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed. Objectives: The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias. Methods: A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work. Results: Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32–0.74; p < 0.001; I2 = 29%). Local infection (RR = 0.30; 95%CI = 0.19–0.49; p < 0.001; I2 = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02–0.32; p < 0.001; I2 = 0%), and local seroma (RR = 0.34; 95%CI = 0.19–0.59; p < 0.001; I2 = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work. Conclusion: The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair.Methods: The study was based on umbilical hernia and epigastric hernia repairs registered in the population-based Swedish National Patient Register (NPR) 2010-2019. Reoperation was defined as repeat repair after primary repair.Results: Altogether 29,360 umbilical hernia repairs and 6514 epigastric hernia repairs were identified. There were 624 reoperations registered following primary umbilical repair and 137 following primary epigastric repairs. In multivariable Cox proportional hazard analysis, the hazard ratio (HR) for reoperation was 0.292 (95% confidence interval (CI) 0.109-0.782) after open onlay mesh repair, 0.484 (CI 0.366-0.641) after open interstitial mesh repair, 0.382 (CI 0.238-0.613) after open sublay mesh repair, 0.453 (CI 0.169-1.212) after open intraperitoneal onlay mesh repair, 1.004 (CI 0.688-1.464) after laparoscopic repair, and 0.940 (CI 0.502-1.759) after other techniques, when compared to open suture repair as reference method. Following umbilical hernia repair, the risk for reoperation was also significantly higher for patients aged < 50 years (HR 1.669, CI 1.389-2.005), for women (HR 1.401, CI 1.186-1.655), and for patients with liver cirrhosis (HR 2.544, CI 1.049-6.170). For patients undergoing epigastric hernia repair, the only significant risk factor for reoperation was age < 50 years (HR 2.046, CI 1.337-3.130).Conclusions: All types of open mesh repair were associated with lower reoperation rates than open suture repair and laparoscopic repair. Female sex, young age and liver cirrhosis were risk factors for reoperation due to hernia recurrence, regardless of method. [ABSTRACT FROM AUTHOR]

Background: Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement.Method: Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance.Results: Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met.Discussion: Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost. [ABSTRACT FROM AUTHOR]

A 79-year-old female presented with a 3-week history of dysphagia and vomiting, and an upper abdominal mass which had increased in size over the previous 2 weeks. CT scan showed a partial gastric outlet obstruction secondary to an epigastric hernia. This was assessed further on fluoroscopy, showing the distal stomach in the hernial sac and a delay in gastric emptying. We present the CT and fluoroscopic findings of this rare cause of gastric outlet obstruction., (© 2024 Published by Elsevier Inc. on behalf of University of Washington.)

simultaneous panniculectomy applications in ventral hernia repair increases postoperative morbidity rates. Materials and Methods: The study was carried out retrospectively between January 2018 and December 2020. The patients were evaluated in terms of sex, age, body mass index, accompanying diseases, hernia type and size, abdominal surgery history, ASA value (American Society of Anesthesiology), postoperative complications, hospitalization, and follow-up durations. Post-operative complications were evaluated according to the Clavien-Dindo classification. Results: It was determined that 14 patients underwent simultaneous panniculectomy and ventral hernia repair (Group 1), while 27 patients underwent sole ventral hernia repair (Group 2). In Group 1, the hernia defect area was approximately 6.25-fold higher. In patients with a panniculectomy, hospitalization time was significantly longer. The median follow-up period was 8.5 months (2-14) in Group 1, and 14 months in Group 2 (3-36). In multiple linear regression analyses, only the effect hernia defect area was significant on the hospitalization time. There were no significant differences between the groups in terms of complications and hernia recurrence. Conclusion: Simultaneous panniculectomy applications in ventral hernia repairs do not increase the rate of complications and hernia recurence. A simultaneous panniculectomy application can be applied safely to patients who want to “eliminate” both of their problems in a single session.

INTRODUCTION: The MILOS concept binds the benefit of the sublay mesh augmentation in the way of functional and morphological reconstruction of the abdominal wall without the need to use penetrating fixation elements and with the benefits of minimal surgical access. The transhernial approach is carried out at low cost with standard laparoscopic instruments. MATERIAL AND METHOD: The authors carried out retrospective analysis of the years 2018-2022. Included are all patients operated by the MILOS concept. The patients have suffered of the midline hernias type M according to European Hernia society, eventually combined with rectus diastasis. Authors present their own experience of this new treatment method. The evaluation of complications was performed. RESULT: In the observed time we have operated 61 patients. In the years 2018 and 2019 together 35 patients were treated, none in the year of 2020. Because of the COVID plaque was the 2020 "Year of restrictions". In the year 2021 and first quarter of 2022 we have already cured 26 patients. In this time 2 major complications and 3 minor complications were observed. Since the 2nd quarter of 2022 we have already upgraded to eMILOS. CONCLUSION: Our experience with this new hernia repair shows that this treatment possibility is feasible for general use also in small district departments without the need to use of robotic technology. This skill will be necessary for future F.E.B.S AWS. [ABSTRACT FROM AUTHOR]

Objective: Clinical case report of an uncommon presentation of acute appendicitis with no report in the current literature. Material and Method: review of the clinical record at Hospital General Regional 196 of the Mexican Social Security Institute. Results: 47 year old male with abdominal pain in epigastrium clinically palpated hernial defect, finding edematous vermiform appendix in hernial sac. Discussion: The presentation of acute appendicitis in epigastric hernial sac is extremely rare finding only one case report in the literature. [ABSTRACT FROM AUTHOR]

Introduction: Abdominal wall hernia contents usually consist of omental or mesenteric fat or loops of small or large bowel. Gastric involvement has been only rarely reported. Case report: We present a case of a 62-year-old woman who was admitted to our hospital due to epigastric pain and vomiting. On physical examination, the only observed abnormality was a soft, painless, epigastric bulge located in the upper midline. Based on the clinical presentation, the patient was diagnosed with a probable epigastric hernia. Dynamic ultrasound evaluation of the palpable bulge confirmed the presence of epigastric hernia demonstrating the movement of abdominal contents through a large wall defect. Surprisingly, the herniated contents were found to contain also the anterior wall of the distal stomach together with omental fat and vessels. The patient opted for surgery, which confirmed the presence of an epigastric hernia containing the distal portion of stomach. Discussion: In this case, dynamic ultrasound provided added value over computed tomography by clearly demonstrating stomach passing from the abdominal cavity to enter into the hernia sac and it is therefore reported for both its rarity and interest. To our knowledge, this is the first such ultrasound-based case report presented in literature and certainly the best sonographically documented. Conclusion: We anticiapte that this case report will promote the use of dynamic ultrasound in current practice as an effective imaging tool to recognise unusual types of hernias. [ABSTRACT FROM AUTHOR]

Key Clinical Message: An epigastric hernia usually contains preperitoneal fat, but rarely may contain colon. This fact needs to be kept in mind by the operating surgeons. An epigastric hernia usually contains preperitoneal fat, but rarely may contain colon. Experience with such a singular case is presented and discussed. This fact needs to be kept in mind by the operating surgeons. [ABSTRACT FROM AUTHOR]

Purpose: Midline abdominal wall hernia repair is among the most common surgical interventions performed worldwide. However, the optimal surgical technique remains controversial. To overcome the disadvantages of both open and transabdominal procedures, we developed a totally endoscopic preperitoneal approach (eTPA) with placement of a large mesh. Methods: From December 2019 to October 2020, 20 consecutive patients with small to medium-sized midline ventral hernias underwent repair using a completely preperitoneal subxiphoid top-down approach. The preperitoneal space was entered directly below the xiphoid, and careful endoscopic development of the plane between the peritoneum and posterior sheath of the rectus fascia was then performed behind the linea alba. The hernia sac and its contents were identified and reduced. The hernia defect was closed with sutures, and a mesh with an adequate high defect: mesh ratio was placed in the newly created preperitoneal space. Results: Twenty patients were enrolled in this study, including 14 with primary umbilical hernias, 4 with primary epigastric hernias, and 2 with recurrent umbilical hernias. 15 patients suffered from a mild concomitant diastasis recti. All operations were successfully completed without conversion to open repair. The mean operative time was 105.3 min (range, 60–220 min). Postoperative pain was mild, and the mean visual analog scale score for pain was 1.8 on the first postoperative day. The average postoperative hospital stay was 1.8 days (range, 1–4 days). One patient developed a minor postoperative seroma, but it had no adverse impact on the final outcome. No patients developed recurrence during the 3- to 10-month follow-up period. Conclusions: The subxiphoid top-down totally endoscopic preperitoneal approach (eTPA) technique is feasible and effective. It may become a valuable alternative for the treatment of primary small- (defect size < 2 cm) and medium-sized (2–4 cm) midline ventral hernias, particularly in presence of a concomitant diastasis recti. [ABSTRACT FROM AUTHOR]

Purpose: To investigate short and long-term outcome after the open preperitoneal flat mesh technique (OPFMT) for umbilical, epigastric, spigelian, small incisional and "port-site" hernia performed as a day case procedure. Methods: We retrospectively analyzed records of patients who underwent OPFMT for umbilical, epigastric, Spigelian, small incisional and "port-site" hernia in ambulatory settings between 2004 and 2020 at Clinical Center of Serbia. Demographic and clinical characteristics, operative data and postoperative complications were compared between the groups. Univariate and multivariate analyses were performed to identify predictive factors for mesh infection and recurrence. Results: Overall, 476 patients were divided according to the type of hernia. Early postoperative complications were similar in all study groups. Mesh infection, chronic pain and recurrence were different between groups (p = 0.013, p = 0.019 and p = 0.011, respectively). Overall recurrence rate after OPFMT was 2.5%. Hernia defect, hematoma and length of postoperative stay at the Day Surgery Unit were identified as potential predictors of mesh infection (Odds ratio 6.449, 22.143 and 1.546, respectively; p = 0.027, p = 0.011 and p = 0.038, respectively) while mesh infection was the only potential predictor of recurrence in univariate analysis. Hematoma was an independent predictor of recurrence (Odds ratio 27.068; 95% Confidence interval 2.355–311.073; p = 0.008). Conclusion: The OPFMT performed under local anesthesia as a day case procedure is a safe technique associated with favorable long-term outcome. Hematoma is an independent predictor of mesh infection occurrence. [ABSTRACT FROM AUTHOR]

Introduction: The proportion of epigastric hernias in the total collective of all operated abdominal wall hernias is 3.6–6.9%. The recently published guidelines for treatment of epigastric hernias of the European Hernia Society and the Americas Hernia Society recommend the use of a mesh for defect size of ≥ 1 cm, i.e., a preperitoneal flat mesh technique for sizes 1–4 cm, and laparoscopic IPOM technique for defects > 4 cm and/or obesity. Against that background, this analysis of data from the Herniamed Registry now aims to explore trends in epigastric hernia repair. Methods: To detect trends, the perioperative outcome was calculated separately for the years 2010 to 2019 and the 1-year follow-up for the years 2010 to 2018 and significant differences were identified. Analysis was based on 25,518 primary elective epigastric hernia repairs. The rates of postoperative surgical complications, pain at rest, pain on exertion, chronic pain requiring treatment and recurrence associated with the various surgical techniques were calculated separately for each year. Fisher's exact test for unadjusted analysis between years was applied with Bonferroni adjustment for multiple testing. Results: The proportion of laparoscopic IPOM repairs declined from 26.0% in 2013 to 18.2% in 2019 (p < 0.001). Instead, the proportion of open sublay repairs rose from 16.5% to 21.8% (p < 0.001). That was also true for innovative techniques such as the EMILOS, MILOS, eTEP and preperitoneal flat mesh technique (8.3% vs 15.3%; p < 0.001). This change in indication for the various surgical techniques led to a significant improvement in the postoperative surgical complication rate (3.8% vs 1.9%; p < 0.001). Conclusion: The trend is for epigastric hernia repair to be performed less often in laparoscopic IPOM technique and instead more often in open sublay technique or the new innovative techniques. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to investigate whether simultaneous panniculectomy applications in ventral hernia repair increases postoperative morbidity rates. Materials and Methods: The study was carried out retrospectively between January 2018 and December 2020. The patients were evaluated in terms of sex, age, body mass index, accompanying diseases, hernia type and size, abdominal surgery history, ASA value (American Society of Anesthesiology), postoperative complications, hospitalization, and follow-up durations. Post-operative complications were evaluated according to the Clavien- Dindo classification. Results: It was determined that 14 patients underwent simultaneous panniculectomy and ventral hernia repair (Group 1), while 27 patients underwent sole ventral hernia repair (Group 2). In Group 1, the hernia defect area was approximately 6.25-fold higher. In patients with a panniculectomy, hospitalization time was significantly longer. The median follow-up period was 8.5 months (2- 14) in Group 1, and 14 months in Group 2 (3-36). In multiple linear regression analyses, only the effect hernia defect area was significant on the hospitalization time. There were no significant differences between the groups in terms of complications and hernia recurrence. Conclusion: Simultaneous panniculectomy applications in ventral hernia repairs do not increase the rate of complications and hernia recurence. A simultaneous panniculectomy application can be applied safely to patients who want to “eliminate” both of their problems in a single session. [ABSTRACT FROM AUTHOR]

Primary (umbilical, epigastric hernias) and secondary (incisional hernias) ventral hernias are among the most common surgical indications in general and visceral surgery. The defect width and defect localization have a considerable impact on treatment decision-making and outcomes. Therefore, preoperative computed tomography (CT) examination is increasingly recommended particularly for larger incisional hernias. Despite the good results reported in meta-analyses and registry analyses, in recent years there has been a marked trend away from the intraperitoneal onlay mesh (IPOM) technique as severe complications have repeatedly been reported. To continue to benefit from the advantages conferred by a minimally invasive access route with fewer wound complications, a myriad of new techniques with small incisions or endoscopic access have been developed. These involve mesh placement in the sublay/retromuscular/preperitoneal position. This provides a relatively differentiated tailored approach. [ABSTRACT FROM AUTHOR]

Purpose: Primary midline hernias arising in the linea alba are common. While mesh repair has been shown to reduce recurrence rates even in small hernias, many surgeons still use a suture repair for defects of less than 2 cm. The recent European and Americas Hernia Societies Guidelines recommended suture repair only for hernias smaller than 1 cm. A suture repair implies edge-to-edge or overlapping fascial margins, which necessarily involves tension on the repair. A darn is a tension-free repair where, in effect, a "mesh" is hand-woven across the defect in situ. Methods: The darn repair is a modification of the darn techniques for inguinal hernia repair. Eligible patients undergoing this repair at the Royal Infirmary of Edinburgh between 1 January 2008 and 31 December 2017 were identified from a prospective computer-based medical record system and their case notes reviewed. Inclusion criteria were adult patients with a primary midline abdominal wall defect smaller than 2 cm in the widest diameter of the hernia defect measured intra-operatively. Patients were followed up by telephone in 2019. Those who reported possible recurrence or other symptoms in the region of their hernia repair were reviewed in the outpatient clinic. Results: 47 suture-darn repairs were undertaken over the 10-year period. Fifteen of the darn repair operations (32%) were performed under local anaesthesia. Forty-one patients were followed up with a mean of 80 ± 35 and median of 87 months after surgery. Six patients (13%) were lost to follow-up. Recurrence was found in two cases (5%) and one patient has since been diagnosed with a new epigastric hernia some 5 cm cranial to the previous repair. Conclusions: The darn repair for small primary midline hernias is quick and inexpensive with promising long-term results. It can be performed under local anaesthesia. It can serve as an alternative to mesh repair for defects less than 2 cm in maximum dimension. [ABSTRACT FROM AUTHOR]

The use of enhanced-view totally extraperitoneal (eTEP) repair for patients with ventral hernias has become more widespread due to its ability to prevent mesh-and-tacker-related complications by placing the mesh in the retrorectus space. However, the efficacy of eTEP repair in obese patients remains unknown. Herein, we report a case of a morbidly obese patient with epigastric and umbilical hernias in combination with a rectus diastasis repaired using the eTEP technique. A 42-year-old man with a history of spontaneously reduced incarcerated epigastric hernia two weeks previously was referred to our hospital. His body mass index (BMI) was 42.9 kg/m2. Abdominal computed tomography revealed a small epigastric hernia, an umbilical hernia, and a rectus diastasis. We performed eTEP repair. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. There has been no evidence of hernia recurrence after a follow-up period of 2 years. We consider that the eTEP technique is rarely affected by intra-abdominal fat because endoscopic manipulation is performed in the bilateral retrorectus and preperitoneal spaces. Moreover, the eTEP allows the epigastric artery perforator to be spared. Therefore, eTEP repair is considered the best surgical option for morbidly obese patients with ventral hernias in combination with rectus diastasis. This case provides support for the efficacy of eTEP repair in morbidly obese patients with epigastric and umbilical hernias in combination with a rectus diastasis. • The efficacy of enhanced-view totally extraperitoneal (eTEP) repair for a morbidly obese patient is unclear. • A case of a morbidly obese patient with epigastric and umbilical hernias and rectus diastasis repaired using eTEP technique. • This case provides support for the efficacy of eTEP repair in morbidly obese patients. [ABSTRACT FROM AUTHOR]

Abstract Background This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP). Methods A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed. Results One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4–4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0–6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0–10] at baseline to 0 [0–3] at 1 month (P

Objective: The aim of this study is to describe the technique and to evaluate the outcome of single-incision laparoscopic (SILC) approach for linea alba hernia in children. Materials and Methods: A 2 cm vertical umbilical incision was made and stretched horizontally. A 5-mm trocar was inserted through middle port for the telescope. Another extra-long 5-mm 30° trocar was inserted through the lateral port, 5 mm beside the middle port. The extraperitoneal fat was removed, and the defect of linea alba was repaired after hernial sac was excised. The peritoneum was reconstructed with interrupted suture. Results: From May 2014 to May 2015, eight children with linea alba hernia underwent SILC. Pre-operative abdominal ultrasound showed the average diameter of hernia ring was 3.2 ± 0.7 cm. Mean operation time was 32.5 min (range = 30–45 min). Oral intake was resumed during anaesthesia recovery period. All could endure pain and discharge on the post-operative 12 h. There was no post-operative wound infection. The follow-up period was 1–12 months, no recurrence and other complications occurred. Conclusions: SILC approach for linea alba hernia is a safe and effective, minimally invasive new technology. The linea alba hernia could be repaired with a cosmetic outcome.

Background: The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results. Methods: The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed. Results: 98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1–50) cm2 and 225 (50–500) cm2, respectively. The mean operation duration was 75 (30–270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0–8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1–15) days and 11.5 (1–30) days, respectively. Conclusion: Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies. [ABSTRACT FROM AUTHOR]

A 20-year-old man presented to the emergency department with a small painful swelling in the midline of the epigastric region. His medical history included asthma and extramucosal pyloromyotomy for hypertrophic pyloric stenosis as a baby. Abdominal ultrasound showed a small hypoechoic formation in the subcutaneous adipose tissue that penetrated into the abdominal cavity through a 7 mm orifice in the linea alba. The correct diagnosis was herniation of the round ligament of the liver through the anterior abdominal wall with hyperemia in the surrounding subcutaneous adipose tissue. The patient was discharged with symptomatic therapy and achieved complete pain relief within a few days. Prompt imaging recognition of this rare epigastric hernia can allow for conservative management and avoid unnecessary surgery. [Extracted from the article]

'Abdominal wall defects' is a collective term used to describe two distinct pathologies: primary ventral hernias and incisional hernias. This article describes the pathogenesis, risk factors and the management of each. [ABSTRACT FROM AUTHOR]

Background: Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space). Methods: Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall. Results: All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85–145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1–3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10–27 months). Conclusion: In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques. [ABSTRACT FROM AUTHOR]

Objective: To determine the optimal timing of elective repair, the primary objective of this study was to assess if parity at the time of repair and subsequent pregnancy were associated with reoperation for recurrence. The secondary objective was to examine if parity was associated with hernia formation requiring surgical repair. Summary background data: Women of childbearing age constitute 18% of patients operated on for a primary ventral hernia, but consensus is lacking on the management in women who might subsequently become pregnant. Methods: In this nationwide retrospective cohort-study, all women born in Denmark from 1962 to 1971 were eligible for inclusion and followed from age 15 to 45 years. The follow-up rate was 100%. Data on pregnancies and surgical procedures were obtained from the Danish Medical Birth Registry and National Patient Registry. Extended Cox regression and Poisson regression were used for statistical analysis. Results: In total, 470,646 women were included, of whom 2113 underwent repair of a primary ventral hernia. The 10-year cumulative incidence of reoperation for recurrence was 14.1% (95% CI 12.3%-16.0%). Parity at the time of repair was not associated with reoperation for recurrence, while a subsequent pregnancy was associated with a 1.6-fold increased risk (hazard ratio 1.58, 95% CI 1.08-2.31). Parous women had a 7-fold increased risk of undergoing hernia repair compared with nulliparous, in an age-adjusted model (incidence rate ratio 7.04, 95% CI 5.87-8.43). Conclusion: To reduce the risk of hernia recurrence, the optimal timing of elective repair is after the last pregnancy. [ABSTRACT FROM AUTHOR]

An incarcerated epigastric hernia (localized in linea alba) is a very rare observation. Here, we present a case of a 66-year-old white male who was admitted to the emergency department due to vomiting and epigastric pain. On physical examination, the only observed abnormality was a painless soft epigastric tumor located in the upper midline, measuring about 12 cm in diameter. The patient claimed that he had the tumor for more than 30 years and it never changed in diameter nor caused him any discomfort. A lipoma was initially suspected. However, an ultrasound of the abdomen revealed an incarcerated stomach, trapped due to the defect in the epigastric abdominal wall. The patient was sent for surgery and the presence of an incarcerated epigastric hernia of the linea alba, which contained the anterior wall of the stomach was confirmed. The presented case confirms that the use of ultrasonography may be an effective method to recognize unusual types of hernias, and that ultrasonography should be routinely used in emergency departments. [ABSTRACT FROM AUTHOR]

Epigastric hernias account for 4% of abdominal wall defects in children. They present as a painless or tender mass at the supraumbilical midline. Their coventional treatment in children is open herniorrhaphy without the use of meshes. The management of the infrequent cases of multiple epigastric hernias can be challenging, and requires careful consideration to ensure optimal repair that minimizes tissue tearing. We present a case involving an obese adolescent with Down syndrome who experienced abdominal discomfort associated with a mass in the ventral abdominal wall. Ultrasound examination and laparoscopy revealed a total of six epigastric defects. The decision was made to perform a longitudinal plication of the ends of the linea alba using a laparoscopic technique to avoid the manipulation of each defect separately. In addition, a composite intraperitoneal mesh (IPOM) with a hydrogel layer on its visceral side was placed. To our knowledge, this technique has not been previously applied in this clinical context. The postoperative course was uneventful, with no significant pain, seroma, or wound complications. At the 18-month follow-up, the patient remained asymptomatic, showing no evidence of recurrence, and was able to perform regular physical activity. The use of laparoscopic defect suture closure combined with IPOM repair is a minimally invasive, and cosmetically and functionally acceptable method for the repair of multiple epigastric hernias in carefully selected pediatric patients, with good short- and medium-term results. [ABSTRACT FROM AUTHOR]

Frederik Berrevoet,1 Carl Doerhoff,2 Filip Muysoms,3 Steven Hopson,4 Marco Gallinella Muzi,5 Simon Nienhuijs,6 Eric Kullman,7 Tim Tollens,8 Mark R Schwartz,9 Karl LeBlanc,10 Vic Velanovich,11 Lars Nannestad Jørgensen12 1Department of General and Hepatopancreaticobiliary Surgery, Ghent University Hospital, Ghent, Belgium; 2General Surgery, Surgicare of Missouri, Jefferson City, MO, USA; 3Department of Surgery, AZ Maria Middelares Ghent, Ghent, Belgium; 4Bon Secours Hernia Center, Mary Immaculate Hospital, Newport News, VA, USA; 5University Hospital Tor Vergata, Rome, Italy; 6Catharina Hospital, Eindhoven, the Netherlands; 7Medicinskt Centrum Linköping, Linköping, Sweden; 8Imelda Hospital-General Surgery Imelda Hospital, Bonheiden, Belgium; 9Monmouth Medical Center, Long Branch, NJ, 10Our Lady of Lakes Regional Medical Center, Baton Rouge, LA, 11Tampa General Hospital, University of South Florida, Tampa, FL, USA; 12Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark Purpose: This study assessed the recurrence rate and other safety and efficacy parameters following ventral hernia repair with a polyester composite prosthesis (Parietex™ Composite Ventral Patch [PCO-VP]).Patients and methods: A single-arm, multicenter prospective study of 126 patients undergoing open ventral hernia repair with the PCO-VP was performed. Patient outcomes were assessed at discharge and at 10 days, 1, 6, 12, and 24 months postoperative.Results: All patients had hernioplasty for umbilical (n = 110, 87.3%) or epigastric hernia (n = 16, 12.7%). Mean hernia diameter was 1.8 ± 0.8 cm. Mean operative time was 36.2 ±15.6 minutes, with a mean mesh positioning time of 8.1 ± 3.4 minutes. Surgeons reported satisfaction with mesh ease of use in 95% of surgeries. The cumulative hernia recurrence rate at 1 year was 2.8% (3/106). Numeric Rating Scale (NRS) pain scores showed improvement from 2.1 ± 2.0 at preoperative baseline to 0.5 ± 0.7 at 1 month postoperative (P < 0.001), and this low pain level was maintained at 12 months postsurgery (P < 0.001). The mean global Carolina’s Comfort Scale® (CCS) score improved postoperatively from 3.8 ± 6.2 at 1 month to 1.6 ± 3.5 at 6 months (P < 0.001). One patient was unsatisfied with the procedure.Conclusion: This 1-year interim analysis using PCO-VP for primary umbilical and epigastric defects shows promising results in terms of mesh ease of use, postoperative pain, and patient satisfaction. Recurrence rate is low, but, as laparoscopic evaluation shows a need for patch repositioning in some cases, an accurate surgical technique remains of utmost importance. Keywords: intraperitoneal mesh, epigastric hernia, umbilical hernia, pain

Background: The currently mainly used techniques of primary ventral hernia repair have specific disadvantages and risks.Methods: To minimize complications of the existing open and laparoscopic techniques of ventral hernia repair, the endoscopic-assisted or endoscopic Mini- or Less-Open Sublay (E/MILOS) concept was developed. This paper reports on our experience with the E/MILOS concept for the management of primary umbilical and epigastric hernias. All E/MILOS operations were prospectively documented in the German hernia registry "Herniamed". For 1 year follow-up, all patients and their general practitioners received a questionnaire.Results: Five hundred and twenty primary umbilical and 554 epigastric E/MILOS operations with complete 1-year follow-up were included. Concomitant RD were treated in 18.3% and 14.1% of the umbilical and epigastric hernia cohort, respectively. Total perioperative complication rates and reoperation rates were 1.2% and 0.9% for both umbilical and epigastric hernias, respectively. Infection rates were 0.0% and 0.2% after umbilical and epigastric hernia operations, respectively. Recurrence rates 1 year after E/MILOS umbilical and epigastric hernia were 0.0% and 0.5%, respectively. One year rates of chronic pain at rest, chronic pain during physical activities, and chronic pain requiring treatment after umbilical and epigastric hernia repair were 1.5% and 2.7%, 2.1% and 4.2%, and 0.6% and 1.8%; respectively.Conclusion: The E/MILOS concept allows the endoscopically assisted (MILOS) or endoscopic (EMILOS) transhernial minimal invasive sublay mesh repair of primary umbilical and epigastric hernias with or without rectus diastasis with low complication, recurrence, and chronic pain rates. [ABSTRACT FROM AUTHOR]