Tratamiento de la diástasis de rectos asociada a hernias de línea media vía TESuR (Trans-umbilical Endoscopic Sublay Repair) / Management of diastasis recti associated with midline hernias using TESuR (Trans-umbilical Endoscopic Sublay Repair)

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.

Umbilical and epigastric hernia repair: a systematic review / Tratamento das hérnias umbilicais e epigástricas: uma revisão sistemática

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.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin / Onfalocele gigante: Uma nova abordagem para reparo primário no período neonatal utilizando toxina botulínica

ABSTRACT Introduction: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. Methods: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. Results: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. Conclusion: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

RESUMO Introdução: onfalocele gigante (OG) é uma condição complexa para a qual muitas alternativas terapêuticas foram desenvolvidas; no entanto, não há consenso sobre qual o melhor tratamento. Os benefícios e eficácia da toxina botulínica A (TBA) no reparo de grandes defeitos da parede abdominal em adultos foram comprovados, e o relato de uso em crianças cresceu recentemente. O objetivo deste estudo é descrever uma nova técnica para reparo primário de OG utilizando TBA durante o período neonatal e relatar nossa experiência inicial. Métodos: os pacientes foram acompanhados de agosto de 2020 a julho de 2022. A TBA foi aplicada na parede abdominal lateral nos primeiros dias de vida, seguida de correção cirúrgica do defeito abdominal. Resultados: enquanto aguardavam a cirurgia, os pacientes tiveram mínima manipulação, sem ser exigida ventilação mecânica, permaneceram em alimentação enteral plena e mantiveram contato com os pais. A linha média foi aproximada sem tensão e sem necessidade de técnicas adicionais ou uso de prótese. Os pacientes receberam alta com o defeito reparado. Conclusão: essa abordagem representa um meio-termo entre o reparo estagiado e o tratamento não-operatório. Não requer intervenções agressivas no início da vida, permitindo a manutenção do vínculo materno-infantil e a alta do paciente com defeito reparado sem a necessidade de uso de técnicas adicionais ou prótese. Acreditamos que esta técnica deva ser considerada como um novo possível recurso no manejo desta complexa condição.

Clinical and surgical approach to umbilical disorders in calves: literature review / Abordagem clínica e cirúrgica das afecções umbilicais em bezerros: revisão de literatura

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.

Hernia umbilical en una gestante / Umbilical hernia in a pregnant woman

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.

Omphalocele and biliary atresia: chance or causality. A case report

ABSTRACT To relate omphalocele and biliary atresia and investigate possible embryological correlations that justify the simultaneous occurrence. A female preterm newborn diagnosed as omphalocele; cesarean delivery, weight 2,500g, 46 XX karyotype. Initially, the newborn remained fasting and on parenteral nutrition, and enteral diet was introduced later, with good acceptance. On the 12th day of life, the newborn presented direct hyperbilirubinemia, increased levels of liver enzymes and fecal acholia, with a presumptive diagnosis of biliary atresia. However, the ultrasound was inconclusive, due to anatomical changes resulting from omphalocele. A surgical approach was chosen on the 37th day of life aiming to confirm diagnosis of biliary atresia and to repair omphalocele. During the surgical procedure, structural alterations compatible with biliary atresia were observed, later confirmed by pathological examination; a hepatoportoenterostomy was performed and the omphalocele was corrected. She evolved well in the postoperative period, with a decrease in direct bilirubin and liver enzymes, as well as resolution of fecal acholia, and was discharged in good clinical condition. This is a bizarre and extremely rare association, but the prognosis may be good when an early diagnosis is made and surgery performed, besides support and clinical management to prevent complications in the perioperative period. Although the pathogenesis of the diseases has not been fully defined yet, there is, to date, no direct relation between them. The association between omphalocele and biliary atresia is extremely uncommon, with only two published cases.

Tumor de ángulo hepático del colon incarcerado en hernia umbilical. Reporte de caso

RESUMEN Los tumores de colon ocupan la tercera causa de muerte por cáncer en Cuba. Los tumores de colon incarcerados en hernias umbilicales son raros. Se distinguen con más frecuencia en las hernias inguinales que en las umbilicales. Los síntomas más significativos son: astenia, pérdida de peso, alteraciones en las heces y dolor abdominal. Suelen presentarse como una masa palpable de difícil reducción. El método diagnóstico por excelencia es el colon por enema y el tratamiento es quirúrgico. La variedad histopatológica más frecuente es el adenocarcinoma. Se presenta el caso de una paciente anciana que acudió a consulta por presentar fatiga, pérdida de peso y deposiciones oscuras. Al examen físico se constató una hernia umbilical. Se le realizaron estudios complementarios y de diagnóstico por imagen. Se determinó una posible tumoración de vías digestivas. Se realizó procedimiento quirúrgico de urgencia. Se presenta este reporte con el objetivo de caracterizar un caso de tumor de ángulo hepático del colon incarcerado en una hernia umbilical debido a lo poco frecuente de su localización.

ABSTRACT Colon tumors are the third leading cause of cancer death in Cuba. Incarcerated colon tumors in umbilical hernias are rare. They are more often distinguished in inguinal hernias than in umbilical ones. The most significant symptoms are: asthenia, weight loss, alterations in the stool and abdominal pain. They usually present as a palpable mass that is difficult to reduce. The diagnostic method par excellence is the colon by enema and surgical treatment. The most common histopathological variety is adenocarcinoma. The case of an elderly patient who came to the clinic due to fatigue, weight loss and dark stools it is presented. The physical examination revealed an umbilical hernia. Complementary and diagnostic imaging studies were performed. A possible digestive tract tumor was determined. An emergency surgical procedure was performed. The aim of this report is to characterize a case of an incarcerated colon hepatic flexure tumor in an umbilical hernia due to its infrequent location.

New clues to understand gastroschisis. Embryology, pathogenesis and epidemiology / Nuevas pistas para comprender la gastrosquisis. Embriología, patogénesis y epidemiología

Abstract gastroschisis is a congenital structural defect of the abdominal wall, most often to the right of the umbilicus, through which the abdominal viscera protrude. Its developmental, etiological and epidemiological aspects have been a hot topic of controversy for a long time. However, recent findings suggest the involving of genetic and chromosomal alterations and the existence of a stress-inducing pathogenetic pathway, in which risk factors such as demographic and environmental ones can converge. . We have conducted a review of the medical literature that gathers information on the embryonic development of the ventral body wall, the primitive intestine, and the ring-umbilical cord complex, as well as on the theories about its origin, pathogenesis and recent epidemiological evidence, for which we consulted bibliographic databases and standard search engines

Resumen La gastrosquisis es un defecto estructural congénito de la pared abdominal, localizado con mayor frecuencia a la derecha del ombligo, a través del cual sobresalen las vísceras abdominales. Durante mucho tiempo, sus aspectos evolutivos, etiológicos y epidemiológicos han sido un tema candente de controversia, aunque hallazgos recientes sugieren la participación de alteraciones genéticas, cromosómicas, y la existencia de una vía patogénica inductora de estrés, en la que factores de riesgo como los demográficos y ambientales pueden converger. Con el objetivo de ampliar la frontera del conocimiento sobre una malformación que ha mostrado una creciente prevalencia global, hemos efectuado una revisión que incluye información, del desarrollo embrionario de la pared corporal ventral, el intestino primitivo, el complejo anillo-cordón umbilical, y de las teorías acerca de su origen, patogénesis e información epidemiológica reciente.

Hérnia umbilical primária: melhor manejo operatório no adulto / Primary umbilical hernia: Best surgical management in adults

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)

La hernia umbilical en el paciente cirrótico: ¿tratamiento conservador o cirugía? / Umbilical hernia in cirrhotic patients: conservative treatment or surgery?

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.

New clues to understand gastroschisis. Embryology, pathogenesis and epidemiology.

gastroschisis is a congenital structural defect of the abdominal wall, most often to the right of the umbilicus, through which the abdominal viscera protrude. Its developmental, etiological and epidemiological aspects have been a hot topic of controversy for a long time. However, recent findings suggest the involving of genetic and chromosomal alterations and the existence of a stress-inducing pathogenetic pathway, in which risk factors such as demographic and environmental ones can converge. To expand the frontier of knowledge about a malformation that has showed a growing global prevalence, we have conducted a review of the medical literature that gathers information on the embryonic development of the ventral body wall, the primitive intestine, and the ring-umbilical cord complex, as well as on the theories about its origin, pathogenesis and recent epidemiological evidence, for which we consulted bibliographic databases and standard search engines.

La gastrosquisis es un defecto estructural congénito de la pared abdominal, localizado con mayor frecuencia a la derecha del ombligo, a través del cual sobresalen las vísceras abdominales. Durante mucho tiempo, sus aspectos evolutivos, etiológicos y epidemiológicos han sido un tema candente de controversia, aunque hallazgos recientes sugieren la participación de alteraciones genéticas, cromosómicas, y la existencia de una vía patogénica inductora de estrés, en la que factores de riesgo como los demográficos y ambientales pueden converger.Con el objetivo de ampliar la frontera del conocimiento sobre una malformación que ha mostrado una creciente prevalencia global, hemos efectuado una revisión que incluye información, del desarrollo embrionario de la pared corporal ventral, el intestino primitivo, el complejo anillo-cordón umbilical, y de las teorías acerca de su origen, patogénesis e información epidemiológica reciente.

A propósito de un caso: Resolución quirúrgica en dos tiempos de Pentalogía de Cantrell / Case Report: Two-stage surgical resolution of Cantrell's Pentalogy

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.

Hernia umbilical: un problema no resuelto / Umbilical hernia: an unsolved problem

RESUMEN La cirugía de la hernia umbilical ha sido considerada tradicionalmente como sencilla y de fácil ejecución. El cambio conceptual de la hernia umbilical y los avances en su tratamiento han modificado su abordaje, estableciéndose escenarios de complejidad variable (obesidad, embarazo, cirróticos, distasis de los rectos, etc.) que demandan un conocimiento más profundo del tema por parte de la comunidad médica. El impacto económico en el sistema de salud, debido a su alta prevalencia como patología quirúrgica, implica un uso racional de recursos, así como la necesidad de una nueva categorización dentro de la cirugía de la pared abdominal. Es necesario establecer modificaciones en los procesos diagnósticos y terapéuticos en una entidad que ha sido relegada a los niveles básicos del ejercicio quirúrgico habitual.

SUMMARY Umbilical hernia surgery has traditionally been considered simple and easy to perform. A conceptual change of the umbilical hernia and the advances in its treatment have modified its approach, establishing scenarios of variable complexity (Obesity, pregnancy, cirrhosis, diastasis of the rectus, etc.), which demand a deeper knowledge of the subject on the medical community. The economic impact on the health system, due to its high prevalence as a surgical pathology, implies a rational use of resources, as well as the need for a new categorization within the abdominal wall surgery. It is necessary to establish modifications in the diagnostic and therapeutic processes in an entity that has been relegated to the basic levels of the usual surgical practice.

Ectopia cordis associated with pentalogy of cantrell-a case report / Ectopia cordis associada à pentalogia de cantrell-relato de caso

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.

Histerocele gravídico umbilical. Reporte de un caso / Umbilical gravid hysterocele. A case report

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.

Características de los neonatos con onfalocele intervenidos quirúrgicamente con anestesia regional y local / Characteristics of neonates with omphalocele operated surgically with regional and local anesthesia

Introducción: el onfalocele es un defecto congénito consistente en una herniación en la pared abdominal. Los intestinos, el hígado u otros órganos sobresalen a través del ombligo y quedan envueltos en un saco delgado y casi transparente.Objetivo: caracterizar desde el punto de vista demográfico, clínico y epidemiológico a los neonatos con onfalocele, intervenidos quirúrgicamente con anestesia regional y local en el Hospital Central de Benguela, República de Angola.Método: se realizó una investigación observacional descriptiva prospectiva en el período comprendido entre septiembre de 2011 y agosto de 2013. La población quedó constituida por la totalidad de neonatos que nacieron con el defecto, y la muestra por los 17 que cumplieron los criterios de inclusión. Se cumplieron los procedimientos de preparación inicial, anestésicos, quirúrgicos y posquirúrgicos.Resultados: predominaron los neonatos masculinos (52,9 por ciento) y los menores de 24 horas de nacidos (41,2 por ciento). En 11 de los operados se identificaron malformaciones asociadas (64,7 por ciento), siendo las cardiovasculares las más frecuentes (35,3 por ciento). Más de la mitad presentó onfaloceles grandes (64,7 por ciento). Sin embargo, se logró realizar el cierre total en más de la mitad del total de operados (58,8 por ciento). La dehiscencia parcial de la herida quirúrgica fue la complicación más frecuente (37,5 por ciento). La mortalidad fue baja (17,65 por ciento).Conclusiones: la anestesia regional y local constituyó una opción terapéutica para el cierre quirúrgico del onfalocele ante la limitación tecnológica de los países en vías de desarrollo para evitar la muerte de los niños que nacen con esta malformación(AU)

Introduction: the omphalocele is a congenital defect consisting of a herniation in the abdominal wall. The intestines, liver or other organs protrude through the navel and are wrapped in a thin, almost transparent sac.Objective: to characterize from the demographic, clinical and epidemiological point of view the neonates with omphalocele, surgically treated with regional and local anesthesia in the Central Hospital of Benguela, Republic of Angola.Method: a prospective descriptive observational research was carried out in the period between September 2011 to August 2013. The population was constituted by the totality of neonates that were born with the defect, and the sample by the 17 that met the inclusion criteria. The initial preparation, anesthetic, surgical and postsurgical procedures were completed.Results: male neonates predominated (52,9 percent) and those under 24 hours of age (41,2 percent). In 11 of the operated patients, associated malformations were identified (64,7 percent), with the cardiovascular ones being the most frequent (35,3 percent). More than half presented large omphaloceles (64,7 percent). However, total closure was achieved in more than half of the total number of operated patients (58,8 percent). Partial dehiscence of the surgical wound was the most frequent complication (37,5 percent). Mortality was low (17,65 percent).Conclusions: regional and local anesthesia was a therapeutic option for the surgical closure of the omphalocele due to the technological limitations of the developing countries to avoid the death of children born with this malformation(AU)

Hernia umbilical en pacientes cirróticos con ascitis: ¿tratamiento conservador o quirúrgico? / Umbilical hernia in liver cirrhosis with ascites: conservative or surgical treatment?

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.

Hernia de Littre estrangulada en un adulto / Littre strangulated hernia in an adult

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(AU)

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(AU)

Hernia de Littre estrangulada en un adulto / Littre strangulated hernia in an adult

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

Neo-onfaloplastia com enxerto cutâneo / Neoomphaloplasty with cutaneous graft

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.