Terminology of endoscope reprocessing.
\r\n\tThe book will present up to date knowledge on mentioned ADHD topics in order to be implemented in every day clinical practice.
",isbn:"978-1-83962-495-7",printIsbn:"978-1-83962-475-9",pdfIsbn:"978-1-83962-496-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"176f5275d9e1e06b24e0ae07b90c424f",bookSignature:"Prof. Hojka Gregoric Kumperscak",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9499.jpg",keywords:"Clinical Picture, Symptomatology, Symptoms, Clinical Presentation, Comorbidity, Pharmacotherapy, Nonpharmacological, Nutrition and Diet, Genetics, Neuroimaging, Neurotransmitters, Hormones",numberOfDownloads:515,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 10th 2020",dateEndSecondStepPublish:"August 6th 2020",dateEndThirdStepPublish:"October 5th 2020",dateEndFourthStepPublish:"December 24th 2020",dateEndFifthStepPublish:"February 22nd 2021",remainingDaysToSecondStep:"7 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Prof. Kumperscak, MD, PhD graduated from the Faculty of Medicine in Ljubljana, Slovenia. She was trained in child and adolescent psychiatry in Slovenia and abroad. She has held the Chair of the Department of Psychiatry in the University of Maribor in Slovenia (2017) and has been Head of the Child and Adolescent Psychiatry Unit, University Clinical Center in Maribor (2008). She is a President of the Slovenian Association for Child and Adolescent Psychiatry and Adolescent Identity Treatment psychotherapist.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"53417",title:"Prof.",name:"Hojka",middleName:null,surname:"Gregoric Kumperscak",slug:"hojka-gregoric-kumperscak",fullName:"Hojka Gregoric Kumperscak",profilePictureURL:"https://mts.intechopen.com/storage/users/53417/images/system/53417.jpg",biography:"Prof. Hojka Gregoric Kumperscak, MD, PhD was born in Maribor, Slovenia in 1970. She finished Faculty of Medicine in Ljubljana, Slovenia in 1996. She was trained in child and adolescent psychiatry in Slovenia and abroad (Italy, UK, Germany and Switzerland). \r\nShe has held the Chair of the Department of Psychiatry in the Faculty of Medicine, University of Maribor in Slovenia, since January 2017, and has been Head of the Child and Adolescent Psychiatry Unit, University Clinical Center in Maribor since 2008. She is a President of Slovenian Association for Child and Adolescent Psychiatry and Adolescent Identity Treatment psychotherapist. 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At the time of admission, the patient had an elevated lipase at 14,528, an abdominal ultrasound demonstrating gallstones with a common bile duct measuring 7 mm without choledocholithiasis. In addition, she was noted to have an elevated total bilirubin, without leukocytosis or fever. Patient was admitted with gastroenterology consultation.
The next hospital day, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and sludge removal. Post procedure her pain was improved and she was tolerating a clear liquid diet. Forty-eight hours after the procedure, the patient was noted to have a temperature of 101.8°F, and a leukocytosis of 15,600 per mcL. Two blood cultures drawn at the time of fever resulted in carbapenem-resistant Enterobacteriaceae (CRE). Infectious disease consultation was obtained and the patient was treated with tigecycline plus gentamicin. Within two weeks another patient at the same facility was diagnosed with CRE bacteremia following ERCP, prompting investigation into the technique involved in endoscopy sterilization.
Although the overall risk of exogenous infection from endoscopy and flexible bronchoscopy remains rare, increased concern and awareness has recently been stimulated by outbreaks reported in the literature and newspapers. In 2015, the United States Food and Drug Administration (FDA) released a safety communication about duodenoscopes, after an outbreak of carbapenem-resistant Enterobacteriaceae (CRE) infections were diagnosed following procedural intervention with duodenoscopes. The communication outlined the close monitoring the association between reprocessed endoscopes and multidrug-resistant bacterial infections caused by CRE, such as Klebsiella species and Escherichia coli [1]. Subsequently, the increased awareness as well as the emergence of “super-bugs” and anti-bacterial resistant strains of bacteria has emphasized the importance of proper sterilization techniques involved in the reprocessing of endoscopes and accessory devices.
Infection following endoscopy can be divided into three broad categories: exogenous infection, endogenous infection, and infection transmitted between patient and endoscopy personnel or vice versa [2]. Exogenous infection involves the spread of bacteria via contaminated equipment between one patient and another. Endogenous infection is not due to contaminated equipment, but rather, the translocation of bacteria from the gastrointestinal tract as a result of the endoscopic procedure. An example of an endogenous infection would be a patient that develops bacteremia secondary to traumatic tissue injury during the endoscopy. Lastly, infection may be transmitted from the patient to the endoscopy personnel and vice versa if proper technique and personal protective equipment are not utilized.
The benefit of endoscopy when compared to the risks has been clearly demonstrated throughout literature [3]. Despite the large number of GI endoscopic procedures performed, estimated at over 24 million procedures in 2004 in the United States alone, instances of infectious complications remain rare [4, 5]. Infectious complications are estimated at frequency of 1 in 1.8 million procedures [6]. The majority of infections following endoscopy are endogenous infections, with exogenous infections occurring even less frequently [7].
Endoscopies are performed in a variety of facilities throughout the United States, including the hospital, ambulatory surgical center as well as physician offices. The term endoscope is a broad term encompassing any instrument used to visualize a hollow viscus. Endoscopes can be used to perform a variety of procedures including bronchoscopy, esophagogastroduodenoscopy, sigmoidoscopy, and colonoscopy as well as a variety of others. The equipment of the endoscope is similar, although slight variations exist to facilitate the performance of one procedure over another.
The majority of modern day endoscopes are video-endoscopes. These, although technically similar to the original fiber-endoscopes, which utilized fiber optical viewing bundles, conversely utilize a charged couple device (CCD) “chip” and electronics at the tip of the scope to generate an image that can be viewed upon a screen [8]. This advancement in technology has allowed for changes in instrument design, and limited the need for the endoscopist to place their eye close to the instrument. This has obvious hygienic advantages and minimizes the risk of infection transmitted between patient and endoscopy personnel.
Endoscopes are divided into several sections. In general, the scope has a light source, a “universal cord” which is plugged into the light source and the video processor, a the head of the instrument which contains a variety of switches and valves that control many scope functions and positions, and the “insertion tube” which includes the objective lens and the light guide lens. It is just behind the objective lens that the charge-coupled device (CCD) is located. An understanding of the basic equipment as well as the portion of the scopes which may be removed is important to ensure the adequate cleaning and reprocessing of the endoscope (Figure 1).
Structure of flexible endoscope.
A variety of terms exist to describe the different processes and levels of sterilization involved in reprocessing endoscopes. An understanding of these terms is imperative. In general, there are three levels of disinfection of medical equipment. These include sterilization, high-level disinfection and low-level disinfection, and are based upon the whether the equipment is labeled as critical, semi-critical, or noncritical [2, 9, 10]. A definition of each team, an example and the associated level of sterilization is displayed in Table 1.
Definition | Example | Associated level of sterilization and disinfection | |
---|---|---|---|
Critical | A device that penetrates mucus membranes, blood vessels or body cavities |
| Sterilization |
Semi-critical | A device that comes in contact, but does not penetrate mucus membranes |
| High-level disinfection |
Noncritical | Objects that do not come into contact with patients |
| Low-level disinfection |
Terminology of endoscope reprocessing.
The classification and terminology involved in the associated level of sterilization and disinfection is based on the ability to eliminate microbial life. Sterilization refers to the process of complete elimination of all microbial life. Conversely, high-level disinfection destroys all vegetative bacteria, mycobacteria, fungi, enveloped and nonenveloped viruses. High-level disinfection, however, does not necessarily eliminate bacterial spores. Low-level disinfection kills most vegetative bacteria, some fungi, and enveloped viruses (e.g., HIV, and hepatitis B, C) but does not kill mycobacteria or bacterial spores [11]. Cleaning is often the first step in removing the microbial burden from a device. It refers to the physical removal of debris.
All endoscopy units and facilities should have strict procedural guidelines that exist to ensure the correct reprocessing of equipment. Unit personnel should be proficient with the guidelines and methods unique to that institution and procedural monitoring should also be in place to ensure the method is being carried out effectively. Adherence to guidelines is a critical component of reducing infection.
Following an endoscopy, biomaterial and microorganisms are present on the endoscope. The first step in endoscope reprocessing is an attempt to eliminate as much of the biomaterial as possible. Begin by wiping the insertion tube from the control section to the distal tube with a moist cloth or sponge. Then, all channels and working sites must be cleaned and flushed with detergent/and or water as recommended by the manufacture. This includes channels that are not used, due to the distal end being exposed to material and fluid. We recommend removing the material immediately after the procedure to minimize the risk of the material becoming dry, adherent and hard on the scope. If a delay of over an hour occurs between the endoscopy and pre-cleaning the scope should be soaked within the manufacture recommended detergent [12].
Prior to immersing an endoscope in any fluid, a leakage test should be completed to ensure that the device is air and fluid tight. This is important in the maintenance of the equipment as well as infection control. Begin by ensuring that the water resistant cap is properly attached then, remove the suction valve, air-water channel, cleaning channel, biopsy valve and auxiliary water tube if present. The scope should then be emerged in clean water, with the leakage test device on. Any evidence of continuous bubbles coming from the scope or while moving the control dials indicates a leak and should not be immersed in detergent and reprocessed. The endoscope should be repaired at this point. If no leaks are observed the scope may be removed the water and reprocessed [13].
Mechanical cleaning is a multistep process that utilizes equipment such as tubes, brushes and additional flushing devices to reduce bioburden and reduce the risk of cross contamination [14]. Effective cleaning will remove more than 99.9% of the bioburden from the endoscope [15]. For specific details regarding endoscope mechanical cleaning protocols please see the manufacturing guidelines for cleaning. In general, a basin of detergent solution should be prepared. It is important to ensure that this detergent is freshly prepared at the specific concentration and temperature recommended. Never re-use a solution. The endoscope should be completely immersed within the solution and using a soft sponge or brush to clean the endoscope all working channels, valves and portions of the endoscope should be cleaned. Ensure that any brush that is utilized to facilitate the cleaning process is not damaged. Replace any damaged brush.
The use of flushing the endoscope channel with alcohol promotes drying and inhibits the growth of water born microorganisms. Utilizing 70% Ethyl or Isopropyl alcohol, immerse the injection tube within the beaker of solution. Then flush the solution through the air/water channel as well as the suction port. Complete this step by flushing copious amounts of air through each port with air from a syringe [13].
Once the endoscope has been reprocessed and it is dry, it should be stored vertically, in a well ventilated cabinet. The scope should be labeled or sealed with a date of when it was reprocessed. Ensure that all valves have been removed prior to storage. Angulation locks should also be placed in the “free” position. The distal tip should hang freely, and as straight as possible avoiding contact with other instruments.
The interval of storage between reprocessing and use has been an area of debate and investigation. According to the “American Society of Gastrointestinal Endoscopy Multi-society guideline for reprocessing flexible gastrointestinal endoscopes” it remains an issue requiring further studies [10]. Data suggests that intervals of 7 to 14 days have negligible contamination and is typically related to skin organisms rather than pathogenic bacterial growth [16–18]. The data for maximal duration of re-use is currently undetermined.
All personnel involved in handling of endoscopy equipment that has been used is in danger of transmission of bacterial infections to themselves. Personal protective equipment should be worn at all times while handling soiled equipment for reprocessing. This includes gowns, gloves and eye protection [10]. Occupational Safety and Health Administration (OSHA), and manufacture guidelines should be observed while handling any specific detergents, with an importance placed on diluting detergents per protocol. The proper disposal of all products that is not reprocessed is also recommended to decrease the risk of infection among personnel.
With more than 19 million gastrointestinal endoscopies and bronchoscopies performed each year within the United States [19], the overall risk of exogenous infections, or infections involving the spread of bacteria from one patient to another, remain relatively low. However, the importance of proper reprocessing remains fundamental in reducing the transmission risk, particularly in the time of bacterial resistance and the emersion of “superbugs.” The variability of endoscopy cleanliness and reprocessing protocols has been shown to be significant. In a study published in 2013 approximately 15% of hospitals within the United States failed to achieve an acceptable level of cleanliness [20]. The specific type or endoscopy impacted the results with a higher level of duodenoscopes being unacceptable than other gastrointestinal endoscopes [20]. The suspected rationale for the inadequate reprocessing of endoscopies has been outlined in a study published in 2003, Figure 2 [21]. A systemic review of published literature between 1966 and 2005 revealed only 70 outbreaks of infection reported within 64 articles [22]. This number may underestimate the amount of infections, due to under-reporting. The recognition of exogenous infection risk and adequate reprocessing techniques is imperative to all personnel and staff involved in endoscopy. Proper reprocessing could reduce the number of infections.
Causes of exogenous infection.
The three main types of infection following endoscopy include exogenous infections, endogenous infections and infection spread between patient and medical personnel.
Sterilization, high-level disinfection and low-level disinfection are distinct terms used to clarify the level of sterilization based on the ability to eliminate microbial life. Sterilization refers to the process of complete elimination of all microbial life for critical pieces of equipment.
All personnel should understand the decontamination and reprocessing protocols within their institution. Protocols should be based off specific equipment protocols by the manufacturer.
The main steps of endoscope reprocessing include; pre-cleaning, performing leak test, mechanical cleaning, alcohol flushing and proper storage.
Exogenous infections, though rare, have increased clinical significance given the rise of antibiotic strains of bacteria. All efforts should be made to prevent the exogenous infections from endoscopes.
Increased concern and awareness of infections after endoscopies has gained much attention in the literature in recent times. The rise of superbugs and transmission of potentially lethal microbes has led to an increased awareness of the necessity for proper reprocessing of all endoscopes. An understanding of the specific equipment, protocols within each institution and each manufacture guidelines is essential. Also as important, is the implementation of system of periodic and random review of policies and methods, to ensure that all protocols are being followed as intended. In the future, automated endoscope reprocessors, AERs, which are beginning to emerge from a variety of manufacturers have been proposed to enhance the efficiency, consistency and reliability of endoscope reprocessing and may reduce the potential human error associated reprocessing [23].
This chapter is meant to provide education in the form of a comprehensive review and act as a guideline all medical professionals that treat patients that would benefit from endoscopy. This guideline should not be mistaken for a legal standard of care. Clinical judgment should be considered in all circumstances, and may vary based on endoscopist and facility.
An umbilical hernia is defined as a midline hernia located at or near the umbilicus [1]. Umbilicus is a frequent site of hernia because it represents a natural weak spot of the abdominal wall, being the attachment site of the umbilical cord during the fetal period.
The literature on umbilical hernias in adults remains less extensive compared to other types of hernias. In fact, in adults, groin hernias are more frequent, since umbilical hernias are more studied in children.
The risk of strangulation is important, estimated at up to 17% in umbilical hernias, up to three times higher than in femoral hernia [2]. To avoid these complications, a surgical treatment is required. Despite the recent advances in terms of mesh varieties and minimally invasive surgery (laparoscopic and robotic surgery), there is still no consensus on the optimal method for repair of umbilical hernia.
It is estimated that every year, 20 million abdominal wall hernias surgeries are performed worldwide [3]. Umbilical hernia is the second most frequent type of hernia and accounts for 6–14% of all abdominal wall hernias in adults, after inguinal hernias [1].
It is a very common condition in children, occurring in one of every six children [4]. It represents an important part in the practice of pediatric surgeons, especially in sub-Saharan Africa [5]. However, in adults, nearly 90% of umbilical hernias are acquired with no indication of hernia in childhood [6]. The risk factors are the same as for other abdominal wall hernias and are caused predominantly by intra-abdominal hyper pressure and/or parietal weakness. The repetitive action on the abdominal wall due to increased intraabdominal pressure favor microscopic tears of tissue. This will lead in time to hernia formation.
The risk factors are physical labor, obesity, ascites, constipation, pregnancies, excessive coughing, or dysuria. A female predominance is however noted with a sex ratio of 3:1 [7]. This is explained by the different distribution of risk factors according to sex. Indeed, obesity is more common in women and pregnancy is a factor noted exclusively in women. This female predominance is also due to the distension of the umbilicus associated with childbirth.
Umbilical hernias occur more often above or below the umbilicus rather than directly through the umbilicus [8]. This is why, according to the classification of the European Hernia Society, hernias whose rings are located between 3 cm on either side of the umbilicus on the linea alba, are considered as umbilical hernias (Figure 1) [9].
Localization of umbilical hernias according to the classification of the European hernia society [9].
Adult umbilical hernias are frequently asymptomatic. The most frequent reasons for consultation are intermittent pain and esthetic discomfort when the size is important [2].
Palpation helps assess the size of the neck and the reducibility of the hernia. When there is a complication, the abdominal pain is constant. The main complication is strangulation (occurrence of ischemia due to a compromised blood supply). In most cases, patients with a strangulated hernia have previously experienced incarceration seizures with spontaneous reduction.
On physical examination, palpation reveals an irreducible and painful umbilical swelling. Figure 2 shows a strangulated umbilical hernia with irreducible swelling. When the small intestines are in the hernia sac, signs of intestinal obstruction appear (vomiting, lack of gas or stool).
Non-reducible umbilical tumefaction (image of the Department of Surgery, Gaston Berger University, Saint-Louis, Senegal).
Another complication that can occur is loss of domain. It represents a chronic large irreducible hernia reducing the volume of the abdominal cavity and creating a “second abdomen” [10].
The diagnosis of umbilical hernia is most often evident on physical examination of the abdomen with tumefaction in the umbilicus.
However, the clinical presentation depends mainly on the size of the hernia (neck and sac) and the patient’s BMI. In fact, hernias with a small neck or occurring in obese subjects can go unnoticed, especially in an emergency context. In these cases, performing imaging tests is important for an accurate diagnosis.
Imaging has an important role in the definitive diagnosis. In fact, clinical examination alone cannot exclude the diagnosis of hernia [11].
Indeed, many hernias are only detectable on imaging (ultrasound or computed tomography) especially when the defect is small or the abdominal fat tissue is important. Besides, imaging can also look for other abdominal wall hernias and more accurately determine the size of the wall defect for an optimization of the treatment.
Imaging also allows to make the differential diagnosis with other, more rare conditions such as abscesses, hematomas or tumors.
Ultrasound is cost effective and efficient. A study has shown that up to 25% of the general population present umbilical hernia when ultrasound is used for diagnosis [12]. This confirms the fact that ultrasound has a much greater sensitivity in detecting umbilical hernias than clinical examination alone. On the other hand, ultrasounds are dependent on the skills of the operator and have a limited contribution when the hernias are large or even with loss of domain. In these cases, the CT scan is of great help. With sagittal and axial reconstructions, CT scan gives more precise information on umbilical hernias (Figures 3 and 4).
Axial contrast-enhanced reformatted CT image of an uncomplicated umbilical hernia with small bowel as contents (arrowhead) during Valsalva maneuver [13].
Axial contrast-enhanced reformatted CT image of an incarcerated umbilical hernia with omental fat as contents (arrow) [13].
More recently, some studies have shown that MRI has the best sensitivity and specificity of 92% and 95%, respectively, in the definitive diagnosis of abdominal wall hernias. Indeed, CT and ultrasound cannot completely rule out the presence of a hernia [14]. However, the main drawback of MRI remains the cost-effectiveness and its unavailability in resource limited context.
The treatment of umbilical hernia in adult is surgical. The preparation of the patient is very useful to decrease complications after elective umbilical hernia surgery. In fact, it is recommended smoking cessation for 4–6 weeks and weight loss to a BMI below 35 kg/m2 before surgery [15]. In fact, controlling these factors can reduce the rate of post-operative complications and improve the recovery.
All types of anesthesia are possible in umbilical hernia surgery (local, spinal or general anesthesia).
Local anesthesia is feasible in selected patients. Its main advantages lie in the reduction of complications associated with general anesthesia, the reduction of the length of hospital stay (ambulatory surgery) and its cost effectiveness [16, 17]. However, in large hernias or in obese subjects, its use can be difficult.
Rachi-anesthesia is also feasible but often requires a high block which is often incomplete [2].
Thus, general anesthesia is preferred because it allows surgery under better conditions. However, the best technique should be the one based on shared decision-making [15].
Recently, in developed countries there is an increased interest in “watchful waiting” due to the small risk of strangulation, less than 1% per year [18]. However, a study comparing watchful waiting to surgery showed that, despite no significant difference in terms of mortality in readmission, 19% of non-operated patients will require surgery in the follow up [19]. Due to the risk of complications (strangulation), a watchful waiting approach is not recommended in umbilical hernia and this approach cannot be generalized and depends on the context of care. There is a lack of evidence on the safety of this approach, especially since an adequate follow up is not always possible in resource limited context. Even if watchful waiting is chosen, only asymptomatic umbilical hernia with no esthetic compromise should be non-operatively treated [15].
Open approach is realized with different surgical techniques.
These surgical techniques depend mainly on the use or not of prosthetic material (suture repair or mesh repair).
The suture repairs most performed are simple primary closure and the technique of overlapping the fascia. This second technique was first described by William Mayo and was commonly used [8]. It consists of a plasty of the abdominal wall fascia in “vest-over-pants” (Paletot). However, with a high incidence of recurrence, this approach is less used now.
According to the Guidelines from the European Hernia Society and Americas Hernia Society, it is strongly recommended to use a mesh. In fact, it significantly decreases the rate of recurrence [15]. A randomized clinical trial showed that this rate can be reduced to 1% when mesh is used when compared to suture repair (11%) [20].
Mesh repair is now considered the “gold standard” for umbilical hernia in adults with no associated morbidity factors [21, 22]. In a selected group of patients, suture repair can be performed if the umbilical hernia defect is less than 1 cm.
The laparoscopic approach makes it possible to reduce esthetic damage by maintaining the appearance of the umbilicus and avoiding extensive dissections.
In addition, laparoscopy can diagnose other missed hernia during pre-operative procedures, evaluating all of the abdominal wall. Another advantage is the precise evaluation of the umbilical defect in order to use a mesh with the adequate size and overlap of the borders of the defect [23].
The technique consists in the placement of a mesh with a sufficient overlap (3 cm). The recommended site of the mesh placement is pre peritoneal or retro muscular due to the risk of adhesion with intra peritoneal mesh [15].
The prior primary closure of the umbilical defect is not mandatory but its realization may reduce the recurrence rate [24].
The most used mesh is polypropylene because it is cost effective and more available than others. However other types of mesh can also be used (light weight macroporous, composite or dual sides) [8].
Laparoscopic surgery is mainly suggested if the umbilical hernia is large (over 4 cm) [15]. This can decrease the risk of wound infections, post-operative pain, length of hospital stay, and other complications, mostly in patients at risk (obesity, smoking).
The use of robotic surgery can improve the results of conventional laparoscopy. Indeed, it allows additional degrees of movement, 3D visualization and better ergonomics for the surgeon. Besides, the attachment of the prosthesis to the anterior abdominal wall, which can be tedious in laparoscopy, is made even easier with the robotic approach [25]. However, longer learning curve, prolonged operative time and cost may be the main limitations of its use.
Hence, in low resource settings, open mesh repair is more feasible. This explains why “tailored surgery” should be the best approach according to the type of patient, the type of hernia, and the context of practice [26].
The additional morbidity and mortality in emergency surgery require elective surgery whenever it is possible [27]. Evaluation of the contents is mandatory to assess its viability. When there is only ischemia and recoloration after reduction, a simple reduction and parietal repair are done (Figure 5). Bowel resection is performed when there is necrosis.
Per operative image of open approach for a strangulated umbilical hernia: (A) Aspect of the unopened sac; (B) Contents of the hernia with small bowel with ischemia (yellow arrow) and omental fat (white arrow); (C) and (D) Resolution of the small bowel ischemia with recoloration (yellow arrows) (images of the Department of Surgery, Gaston Berger University, Saint-Louis, Senegal).
Both open or laparoscopic approaches are feasible but the open approach is recommended due to the possible necessity of bowel resection and the relative contra-indication of mesh use.
Considering the World Society of Emergency Surgery (WSES) guidelines, the use of mesh will depend on the contamination of the surgical field according to the Centers for Disease Control (CDC) classification. For clean (Class I) or clean-contaminated (Class II) procedures, a mesh can be used. However, for contaminated or infected wounds (Class III and Class IV), suture repair is preferred [28].
The most common post-operative complications regardless of the surgical technique are recurrence, superficial surgical site infection and chronic pain or discomfort [29].
Recurrence rate is now low (less than 1%) since the widespread use of mesh. However, mesh related complications are possible and not infrequent (seroma, adhesion, infection, migration or rejection). The removal of the mesh, if possible, should always be considered when mesh related complications occur.
The frequency of these complications is mainly related to co-morbidities, the kind of mesh, the surgical technique and the strategy used to prevent infections [30]. Hence, these complications can be prevented by patient optimization. In fact, obesity, excessive weight and smoking are the mains risk factor for the occurrence of complications [31]. Controlling these factors help reduce the rate of complications.
Umbilical hernia remains a relatively common disease in adults. Its diagnosis is clinical and imaging can be used for small defects or in patients with excessive weight. Mesh repair should be preferred for uncomplicated hernia with a defect of more than 1 cm.
Minimally invasive surgery (laparoscopy and robotic) presents important advantages in terms of cosmetic outcome, wound infections, post-operative pain and length of hospital stay.
According to the emergency, the patient characteristics, or the context, “tailored and optimized surgery” should always be used to have the best short and long terms outcomes.
“The authors declare no conflict of interest.”
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\n\nCURRENT PROJECTS
\n\nTo view current Open Access book projects that are Open for Submissions visit us here.
\n\nNot sure if this is the right publishing option for you? Feel free to contact us at book.department@intechopen.com.
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