POST-OP CASE

CONFERENCE
Shereen S Lucman, MD
July 28, 2020, 8am
 OBJECTIVES OBJECTIVES

 To present a case of a 19/F with protruding mass on the umbilical area

 To discuss the pathophysiology, types of abdominal wall hernias (non-incisional),

clinical presentation, and management of umbilical hernia

 To discuss the recent review article on umbilical hernia

 IDENTIFYING DATA

 AM  Islam
 19/F  Bangon, Marawi City
 Single  Admitted 9/12/19, 1PM
INFORMANT
Patient
95% reliability

CHIEF COMPLAINT
protruding mass on the umbilical area x 4 months
 HISTORY OF PRESENT ILLNESS

4 months PTA 3 days PTA

(+) protuding mass, umbilical area,
reducible
Amai Pakpak
(-) abdominal pain Medical Center
(-) vomiting (Surgery OPD)
no changes in BM
No meds taken
No consultation done
 PAST MEDICAL HISTORY
No history of recent hospitalization nor surgical operation
No known allergies to food and drinks
(-) HPN
(-) DM
(-) Asthma
 

FAMILY HISTORY
No known heredofamilial diseases
PERSONAL-SOCIAL HISTORY

Occupation: College student

(-) smoking
(-) drinking alcoholic beverages
 REVIEW OF SYSTEMS

(-) nasal discharges and congestion

(-) weight loss (-) sore throat, bleeding gums and difficulty
(-) fatigue and fever swallowing

(-) dyspnea
(-) rashes, lumps and itching (-) cough
(-) hemoptysis
(-) dizziness
(-) lesions (-) chest pain
(-) headache (-) palpitations

(-) blurring of vision (-) abdominal pain

(-) pallor
(-) vomiting
(-) redness
(-) sore eyes (-) changes in bowel movement
EVIEW OF SYSTEMS
REVIEW OF SYSTEMS
(-) bladder distention and urinary retention
(-) dysuria , pain at the start of urination (-) sweating
(-) frequency and urgency (-) polydipsia
(-) hematuria

(-) muscle pain

(-) joint pain

(-) nervousness
(-) depression
(-) anxiety
(-) irritabilty

(-) easy bruising

 PHYSICAL EXAM
GENERAL SURVEY:

- ambulatory, awake, alert, coherent, not in

respiratory distress

VITAL SIGNS

BP: 100/60mmHg Temp: 36.9oC

HR: 89 O2 sat: 96%
RR: 18 Wt: 43.5 kg
 PHYSICAL EXAM

SKIN
No rashes, warm to touch, good skin
turgor
 PHYSICAL EXAM

HEENT
Anicteric sclerae, pinkish palpebral
conjuctivae, moist lips and oral mucosa, no
tonsillopharyngeal congestion
 PHYSICAL EXAM

NECK
Supple, trachea at midline, no jugular
vein distention, no lymphadenopathies
 PHYSICAL EXAM

CHEST AND LUNGS

Equal chest expansion, clear breath sounds,
no retractions
 PHYSICAL EXAM

HEART
Distinct heart sounds, normal rate and
regular rhythm, no murmurs
 Cephalad

PHYSICAL EXAM
ABDOMEN
(+) slightly distended
(+) protruding mass, 4x4cm,
umbilical area, reducible
normoactive bowel sounds
no abnormal areas of dullness nor
tympany
(-) organomegaly
Caudad
 PHYSICAL EXAM

EXTREMITIES
Good and equally palpable peripheral
pulses, no edema, CRT < 2sec
 SALIENT FEATURES

 19/F

 (+) protruding mass, umbilical area, reducible

 No previous surgical operation

 PRIMARY IMPRESSION

UMBILICAL HERNIA,
REDUCIBLE
 HEMATOLOGY
Normal Values
WBC 5.60 5.0-10x109/L
RBC 4.70 4.0-5.5X1012/L
Hematocrit 0.35 0.35-0.45
Hemoglobin 11.90 12-16 gm/L
DIFFERENTIALS
Neutrophils 64 50-70%
Lymphocytes 24 20-40%
Monocytes 8 1-5
Platelet 394 140-340x109/L
Blood Type O+
IMMUNOLOGY-SEROLOGY
HbsAg NON-REACTIVE
 BLOOD CHEMISTRY
Sodium 140.0 135-155 mmol/dL
Potassium 4.0 3.5-5.3 mmol/dL
Creatinine 0.63 0.40-1.40 mg/dL
 URINALYSIS
Normal Values
Color Yellow Yellow
Transparency Clear Clear
Reaction (pH) 6.0 5.5-6.5
Sp. Gravity 1.030 1.010-1.030
Sugar Negative Negative
Protein Negative Negative
RBC 1-3 0-2/hpf
WBC 4-6 0-5/hpf
Bacteria Few few
 PRE-OP PLAN

Repair of umbilical hernia

 INTRA-OP FINDINGS

(+) approx. 1 cm fascial defect

(+) ascites
(-) incarcerated intra-abdominal contents
OPERATION PERFORMED

Repair of umbilical hernia;

Aspiration of ascites
 POST-OP DIAGNOSIS

Umbilical hernia, reducible

 COURSE IN THE WARDS

- Diet was resumed

- Discharged improved on 2nd POD

- Ff-up at OPD once w/ fluid cytology

DISCUSSION
 ABDOMINAL WALL HERNIA
 A protrusion or bulge of abdominal contents through the
abdominal wall muscle/fascia

 Present at birth or acquired from weakening or disruption of

the overlying fascia, or from failed healing of a surgical incision

 May present as asymptomatic bulges that increase with

valsalva maneuvers, or with significant discomfort.
 ABDOMINAL WALL HERNIA
 May reduce spontaneously or with manual pressure

 Incarcerated hernia generally requires surgical correction if

bowel obstruction may ensue.

 Hernia is considered strangulated if blood supply to its

contents is compromised.
 NON-INCISIONAL HERNIA
 Based on their location on the abdominal wall:

1. Epigastric – between umbilicus

and xiphoid process

2. Umbilical – umbilicus

3. Spigelian – along the arcuate line

a
 UMBILICAL HERNIA (PEDIA)
 Congenital or acquired
- common in newborns (premature infants)

 Closure occurs after birth as the muscles of the rectus

abdominis grow toward one another

 Close spontaneously by 5 years of age

 UMBILICAL HERNIA (PEDIA)
 Indications for repair:
- incarceration
- symptomatic hernia
- failure to decrease in size
- if the defect fails to close by the age of 5 years
 UMBILICAL HERNIA (ADULT)
 Increased abdominal pressure due to pregnancy, obesity, or
ascites

 More common in females

 Surgical treatment is offered: hernia enlarges in size

causes symptoms, and incarceration
 UMBILICAL HERNIA (ADULT)
 Hernias can be repaired open or laparoscopically

 Defect < 1cm

- Simple figure-of-eight suture
- Repaired by a darn technique (tensionless tissue repair)

 Defect up to 2cm
- Mayo’s vest over
pants repair
• Defect > 2 cm: Mesh repair
 UMBILICAL HERNIA
(ADULT w/ cirrhosis and ascites)

 Due to high intra-abdominal pressure associated with

uncontrolled ascites

 Aggressive conservative management of ascites prior to repair

FACTORS INFLUENCING RECURRENCE

 Large seroma and SSI

 Obesity and excessive weight gain after repair
 BMI > 30 km/m2 and defect > 2 cm
 Cigarette smoking
 Cirrhosis and with uncontrolled ascites
 JOURNALS
“Suture repair was preferred when the defect was between
2-4cm, open mesh and laparoscopic technique were
used for defects >4cm and for patients with BMI >30kg/m2.
Overall recurrence rate was 3.1%,
higher for open mesh group and BMI >30”

Long-term follow-up results of umbilical hernia repair. Venclauskas L, Jokubauskas M,

Zilinskas J, et al. Videosurgery and Other Mini-invasive Techniques. 2017
 JOURNALS
“Arroyo et al. randomized 200 patients into two groups:
primary interrupted suture repair and polypropylene
mesh repair. Recurrence rate was 11% in the suture
repair group vs. 1% after mesh repair. There were no
differences in complications such as seroma, hematoma
or SSI between the groups”

Randomized clinical trial comparing suture and mesh repair of umbilical hernia in
adults. Arroyo A, Garcia P, Perez F, et al. British Journal of Surgery Society. 2017
 JOURNALS
“Cassie et al., in a retrospective cohort study with 13,109 patients
that underwent open hernia repair and 1,543 patients on a
laparoscopic hernia repair group, concluded that
laparoscopic repair presented a decrease wound infection rate
at the expense of increased operative time, length of stay and
respiratory and cardiac complications”

Laparoscopic versus open elective repair of primary umbilical hernias: short-term outcomes from the
American College of Surgeons National Surgery Quality Improvement Program. Cassie S, Okrainec A,
Saleh F, et al. Surgical Endoscopy. 2014
 REFERENCES
Arroyo A, Garcia P, Perez F, et al. RANDOMIZED CLINICAL TRIAL COMPARING SUTURE
AND MESH REPAIR OF UMBILICAL HERNIA IN ADULTS. British Journal of Surgery Society.
2017

Brunicardi, C., et. al. SCHWARTZ’S PRINCIPLE OF SURGERY. 11th ed. 2019

Cassie S, Okrainec A, Saleh F, et al. LAPAROSCOPIC VERSUS OPEN ELECTIVE REPAIR OF

PRIMARY UMBILICAL HERNIAS: SHORT-TERM OUTCOMES FROM THE AMERICAN
COLLEGE OF SURGEONS NATIONAL SURGERY QUALITY IMPROVEMENT PROGRAM.
Surgical Endoscopy. 2014

Venclauskas L, Jokubauskas M, Zilinskas J, et al. LONG-TERM FOLLOW-UP RESULTS OF

UMBILICAL HERNIA REPAIR. Videosurgery and Other Mini-invasive Techniques. 2017
THANK YOU!