Umbilical hernias arise when abdominal contents protrude through the umbilical ring, the natural opening in the abdominal wall at the navel. In normal development, this opening closes within a few days after birth, but closure can fail for congenital or acquired reasons. Congenital hernias are present at birth and often carry a hereditary component, while acquired hernias appear weeks after birth and are associated with infection, trauma, or increased pressure inside the abdomen. Anatomically, every hernia consists of three components: the sac, which forms the visible swelling; the contents, which may include intestine, omentum, or other organs; and the ring, the opening through which the contents pass, which may be natural or acquired.

The clinical significance of these defects varies widely. Most umbilical hernias are small, reducible, and clinically silent, causing little more than a cosmetic bulge. Larger hernias, however, can become irreducible, creating a risk of incarceration in which the herniated tissue becomes trapped, followed by strangulation, in which the blood supply to the trapped tissue is cut off. Strangulation produces acute, severe clinical signs and can be life-threatening. In breeding animals, hernias also carry an economic dimension, since they can significantly reduce both reproductive and productive performance, making timely repair a matter of practical husbandry as well as animal welfare.

Diagnosis rests on history, physical examination, and, where necessary, diagnostic imaging. For umbilical hernias, a visible swelling at the umbilicus is the typical presenting sign, and the diagnosis is usually confirmed by manually reducing the herniated mass and palpating the hernial ring, a maneuver made easier by placing the animal on its back. The condition must be distinguished from other umbilical swellings, including abscesses, hematomas, cysts, and tumors. An abscess typically shows local inflammatory signs and may discharge pus; a hematoma feels like free fluid and may yield bloody content on aspiration; a cyst fluctuates uniformly without pain or tendency to point. The pathognomonic findings for hernia are a palpable umbilical ring, a hernial sac, and reducible contents, with ultrasonography, radiography, or abdominocentesis available as supplementary tools when adhesions or swelling obscure reducibility.

In the reported case, the ram, weighing 21 kilograms and managed semi-intensively within a flock, had carried a one-month history of an enlarging umbilical swelling, with no reported trauma or prior treatment. On examination the animal was alert, with a heart rate of 74 beats per minute, a respiratory rate of 24 breaths per minute, and a rectal temperature of 39.0 degrees Celsius, all within normal physiological ranges. Palpation of the spherical swelling confirmed a distinct hernial ring, a hernial sac, and soft, non-painful contents. When the ram was positioned in dorsal recumbency, the contents reduced fully and manually into the abdominal cavity under gentle pressure. Exploratory abdominocentesis at the swelling yielded no fluid or purulent discharge, ruling out abscess and hematoma, and a diagnosis of umbilical hernia was reached. Because the animal was a year old, the hernia was classified as acquired, of unknown etiology, a finding consistent with earlier reports of acquired umbilical hernias in sheep ranging from four months to four years of age.

Surgical repair was scheduled after an overnight fast of 12 hours. Preoperative preparation followed a rigorous aseptic protocol: the swelling and surrounding region were washed with soap and water, closely shaved, and scrubbed with an antiseptic solution containing cetrimide and chlorhexidine gluconate, alternated with 70 percent isopropyl alcohol. The field was then painted with 2 percent iodine tincture in a centrifugal fashion, with concentric circles moving outward from the intended incision site, and draped with a sterile fenestrated drape secured by towel clamps. Anesthesia was achieved by local infiltration alone, using 2 percent lidocaine hydrochloride injected circumferentially around the base of the hernia at a total dose of 4 milligrams per kilogram of body weight. The surgical team deliberately avoided systemic sedation or general anesthesia to eliminate the risks of bloat, regurgitation, aspiration pneumonia, and prolonged cardiopulmonary depression, hazards particularly relevant in ruminant patients.

The operation itself illustrates the technical decisions that determine outcomes in herniorrhaphy. A single longitudinal skin incision was made over the apex of the swelling in the midline, anterior to the prepuce, and curved laterally to the right as needed, an approach chosen to avoid inadvertent injury to the preputial sheath and penile structures in this male animal. Hemostasis was maintained with direct gauze pressure and hemostatic artery forceps. Blunt dissection with closed Mayo scissors separated the hernial sac completely from the surrounding subcutaneous tissues and fascia. The sac was grasped with tissue forceps and tented upward away from the viscera, a small stab incision was made with a number 11 scalpel blade, and the surgeon’s index finger was inserted to palpate and clear any adhesions before the incision was extended. Opening the sac revealed herniated omentum and intestine, which were carefully returned to the abdominal cavity, exposing a circular hernial ring approximately 2 to 3 centimeters in diameter.

Closure began with refreshing the fibrotic edge of the ring with a scalpel blade to create a clean, viable surface for healing. To achieve a tension-free closure, the ring was enlarged with two small relief incisions, each roughly 1 centimeter long, made in opposite directions cranially and caudally. The ring was then closed with a cruciate suture pattern using size 2 silk, with all sutures placed first and tightened sequentially from the center of the defect toward its lateral margins in a centrifugal fashion. Procaine penicillin powder was applied topically over the sutured fascial site for local antimicrobial prophylaxis. Excess sac, redundant skin, and subcutaneous tissue were trimmed away, the subcutaneous layer was closed with a simple continuous pattern of size 2 polyglactin 910 to obliterate dead space and withstand abdominal wall tension, and the skin was apposed with a horizontal mattress pattern of size 2 silk for mechanical security against animal movement. The site was dressed with 2 percent iodine solution and the ram was discharged.

Postoperative management combined wound care with a three-day regimen of antimicrobials and analgesics. A combination of procaine penicillin G and dihydrostreptomycin sulfate was administered intramuscularly at 0.1 milliliters per kilogram once daily, while meloxicam was given at 0.3 milligrams per kilogram once daily for pain control. The wound was cleansed and re-dressed with iodine tincture every other day until healing was complete, and skin sutures were removed on the fifteenth day after surgery. Follow-up examinations at 30 and 60 days postoperatively found the ram in good health, gaining weight, and showing no signs of recurrence.

The choice of suture pattern is the case’s most instructive element. Commonly reported techniques for umbilical hernia repair in veterinary practice rely on interrupted and overlapping horizontal mattress patterns with non-absorbable suture material, in some studies supplemented by an additional row of simple interrupted nylon sutures. The successful use of a cruciate pattern with size 2 silk in this ram suggests that this configuration, which distributes tension across the closure while requiring less suture material and less time than layered mattress techniques, is a viable alternative for reducible hernias of similar size. The authors note that anesthetic protocol selection ultimately depends on patient temperament, hernia complexity, animal stability, and resource availability, and that local infiltration of lidocaine combined with xylazine sedation has also been reported for this procedure in sheep. The case’s principal limitation is its nature as a single report: larger prospective clinical studies with broader case series will be needed to validate long-term outcomes and compare the cruciate technique’s efficacy directly against the established mattress patterns. Until then, the case stands as a clear demonstration that timely diagnosis, careful surgical execution, and diligent postoperative care can restore a hernia-affected ram to full health with equipment and techniques accessible to field practitioners.

Subject of Research: Surgical repair of an acquired umbilical hernia in a ram using herniorrhaphy under local anesthesia

Article Title: Umbilical Hernia in a Ram and Its Successful Surgical Repair

Article References: Siyoum, G. T. (2026). Umbilical Hernia in a Ram and Its Successful Surgical Repair. Clinical Case Reports, 14(10), Article e73621. https://doi.org/10.1002/ccr3.73621

Image Credits: AI Generated

DOI: 10.1002/ccr3.73621

Keywords: umbilical hernia, ram, herniorrhaphy, veterinary surgery, sheep, cruciate suture pattern, local anesthesia, lidocaine, silk suture, small ruminants, case report, Addis Ababa University

Researchers led by Yu Zhang and Wei Cui of the Fourth Military Medical University in Xi’an, working with colleagues at Xi’an Medical University, distributed a cross-sectional questionnaire to all 109 public institutions approved by China’s Ministry of Education to offer undergraduate dentistry programs between 2021 and 2023. The questionnaire was adapted from validated frameworks used in the United Kingdom, reviewed by five subject-matter experts and pilot-tested before deployment. Forty-nine institutions returned valid responses, a participation rate of 45 percent, but the sample carried considerable weight: it included all 28 institutions holding an official discipline ranking of C-minus or above in the most recent national evaluation, and it spanned all seven major geographic regions of China.

The structural findings show a remarkable degree of consensus on how the subject is delivered. Nearly all responding institutions, 47 of 49 or 95.92 percent, teach dentoalveolar surgery not as a standalone course but embedded within a broader oral and maxillofacial surgery curriculum. Three-quarters of schools, 75.51 percent, schedule the material in the fourth academic year, positioning it after students have completed foundational biomedical coursework and general dental training but before graduation and clinical licensure.

Beneath that structural agreement, however, lies substantial variability in time commitment. For both theoretical and practical instruction, the most commonly reported duration was 10 to 20 hours, yet the actual range was dramatic: theory teaching ranged from as little as 4 hours to as many as 36 hours, while practical teaching spanned from 4 hours to more than 36 hours. That means a student at one Chinese dental school might receive nine times the hands-on surgical instruction of a peer at another institution, a disparity with potential implications for entry-level competence in procedures that carry real risks of nerve injury, fracture and infection.

The content itself follows an internationally recognizable core. Institutions consistently reported covering tooth extraction, local anesthesia, the extraction of impacted mandibular third molars, and the management of post-extraction healing and complications. These are the bread-and-butter procedures of general dental practice, and their prominence reflects the reality that most graduates will perform them daily rather than pursue surgical specialization.

Where the survey offers its most actionable insights is in the details of practical training pathways. Thirty institutions, 61.22 percent, described a progressive training sequence that moves students from instrument familiarization, through phantom-head simulation on artificial jaw models, to supervised peer-to-peer practice of local anesthesia injections. This staged approach mirrors competency-based models advocated in dental education literature, allowing students to build psychomotor skills incrementally before touching a patient. Yet simulation for more complex procedures lagged considerably: only 53.06 percent of schools provided simulation training for the surgical removal of impacted mandibular third molars, 42.86 percent for root or fractured-root removal, and just 36.73 percent for the extraction of other impacted teeth. These are precisely the procedures where inexperienced operators face the steepest learning curves and the highest complication rates.

Digital teaching tools present a similar picture of uneven adoption. Videos were nearly universal, used by 95.92 percent of institutions, and animations were employed by 79.59 percent, reflecting how inexpensive and easily deployed these passive formats have become. Interactive virtual programs, by contrast, were reported by only 24.49 percent of schools. The distinction matters educationally: passive media support observation and conceptual understanding, while interactive simulation platforms provide deliberate practice with feedback, the mechanism most strongly associated with skill acquisition in the surgical education literature.

Pedagogical innovation shows a clear hierarchy as well. Problem-based learning was the most widely adopted active-learning method, reported by 71.43 percent of institutions, followed by case-based learning at 42.86 percent and flipped-classroom teaching at 34.69 percent. These approaches ask students to reason through clinical scenarios before or instead of receiving didactic lectures, and their growing footprint suggests Chinese dental educators are engaging with international trends in health-professions education, even if penetration remains incomplete.

Assessment practices reveal perhaps the most significant gap between theory and practice in Chinese dentoalveolar surgery education. Summative theoretical examinations were nearly universal at 95.92 percent, confirming that knowledge acquisition is rigorously tested. But practical skills assessment was implemented at only 59.18 percent of institutions, and phantom-head assessment, in which students demonstrate operative technique on simulation models, at just 48.98 percent. In other words, at roughly half of Chinese dental schools, a student could complete the surgical component of their degree without ever being formally examined on their ability to perform the procedures they studied.

The authors conclude that undergraduate dentoalveolar surgery education in China has an established framework centered on tooth extraction and local anesthesia, with broad use of practical and digital teaching methods, but that marked variation persists in teaching hours, complex-procedure simulation, interactive digital tools and practical assessment. They suggest that future curriculum development may consider competency-guided learning objectives, strengthened simulation and case-based training, and more comprehensive assessment strategies, while cautioning that the educational effectiveness of such reforms requires empirical evaluation. For a country graduating thousands of dentists annually into a health system where tooth extraction remains one of the most commonly performed surgical procedures, the findings offer a data-driven baseline for national conversations about standardization, and a reminder that what happens in the simulation laboratory may matter as much as what happens in the lecture hall.

Subject of Research: Curriculum structure, simulation training and assessment in undergraduate dentoalveolar surgery education across Chinese dental schools

Article Title: Dentoalveolar surgery education in Chinese undergraduate dental schools: a national survey of curriculum structure, simulation training and assessment

Article References: Zhang, Y., Cui, W., Hu, K., Mo, J., He, F., Wang, Y., Wang, J., Zhang, W., Zhang, Z., Wang, Y., & Xue, Y. (2026). Dentoalveolar surgery education in Chinese undergraduate dental schools: a national survey of curriculum structure, simulation training and assessment. BMC Medical Education. https://doi.org/10.1186/s12909-026-10374-9

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10374-9

Keywords: dentoalveolar surgery, dental education, undergraduate curriculum, simulation training, tooth extraction, local anesthesia, China, BMC Medical Education, problem-based learning, phantom head, assessment, oral and maxillofacial surgery