Long-Term Results of a Versatile Technique for Umbilicoplasty in Abdominoplasty

Background  

Umbilical repositioning is a main step in performing abdominoplasty. The surgical aims are minimal visible scars and a natural-appearing result. Reported techniques do not completely satisfy the aesthetic targets for all types of patients. A previous study reported a versatile technique for umbilicoplasty based on an elliptical vertical incision of the umbilical skin and a double opposing “Y” incision on the abdominal flap to create a new umbilicus. This report describes the long-term results with this technique.     

Omental herniation through a 3-mm umbilical trocar site: unmasking a hidden umbilical hernia.

BACKGROUND: The incidence of umbilical hernia following laparoscopic surgery varies from 0.02-3.6%. The incidence of pre-existing fascial defects, however, may be as high as 18% in patients undergoing abdominal laparoscopic surgery. Previous recommendations have been made to close any fascial defect greater than or equal to 10 mm. Reported here is a case of herniation through a 3-mm trocar site incision and the discovery of a pre-existing fascial defect. CASE REPORT: A 32-year-old female underwent an uncomplicated laparoscopic tubal ligation using a 3-mm umbilical port. Prior to umbilical trocar removal at the completion of the case, the carbon dioxide was evacuated from the abdomen and the sleeve was withdrawn under direct vision. Neither the fascial nor skin incisions were sutured. On postoperative day two, the patient returned with omentum herniating from the 3-mm site. At surgery, a 1.5-cm pre-existing fascial defect was discovered adjacent to the trocar site. The hernia sac tracked laterally to the base of the umbilicus, and the omentum had slid into the sac and out the skin opening. CONCLUSION: As this report illustrates, herniation associated with laparoscopic trocar sites can occur with incisions as small as 3 mm. The presence of pre-existing fascial defects can cause increased morbidity in any laparoscopic surgery, and as illustrated in this report, may predispose the patient to site herniation. The detection and management of these defects is crucial in preventing postlaparoscopic complications.     

Repair of gastroschisis with preservation of the umbilicus

A simplified technique for the repair of gastroschisis without the need to excise the umbilicus or make a fascial incision has been developed. First, the abdominal wall is stretched and the viscera are reduced. Next, the skin and subcutaneous tissue are elevated from the fascia for 1.5 cm around the defect and the fascia is closed transversely with interrupted sutures. The skin is also closed transversely. The umbilical stump is left intact. Eight of nine consecutive patients with gastroschisis were able to undergo repair by this technique. The average hospital stay was 35.6 days. There were no cases of omphalitis or cellulitis of the abdominal wall, but one child has a small umbilical hernia. All have a near normal-appearing umbilicus. This simpler technique for the repair of gastroschisis is quicker and less traumatic, and gives a better cosmetic result than the conventional method.     

Umbilical restoration in abdominal dermolipectomy: A simple double-Y, double-M technique

The authors present a simple technique for restoration of the umbilicus in abdominal dermolipectomy. This procedure is represented by a double-Y cutaneous incision on the abdominal skin and by a double-M cutaneous incision on the umbilical skin. This technique restores a neoumbilicus with multiple small skin flaps and conceals the periumbilical scar at the bottom of the umbilicus. Different designs and figures are proposed to explain the procedure.     

Umbilical reconstruction using a modified inverted C-V flap with conjoint flaps

Abstract

The umbilicus is an important aesthetic feature of the abdomen. Because of its location, the umbilicus can be injured after abdominal surgical procedures. Various methods have been devised to reconstruct the umbilicus by using local flaps, purse-string sutures, or a cartilage graft, but there are no ideal methods. The authors have created a modified inverted C-V flap with conjoint flaps. A 10-year-old boy presented with deformed umbilicus because he had undergone surgical correction of an omphalocele. The drawback of the traditional C-V flap method is the transverse long abdominal scar because of the long length of the V flap. However, by using two conjoint flaps at the superior part of the C-V flap, the length of V flap can be more short and the umbilical wall can be reconstructed by rotation of two conjoint flaps. It is also good for making a sinusoidal pocket and it makes the umbilicus deeper and more natural-looking. After the operation, there were no complications like flap necrosis, infection, haematoma, and so on. The patient was satisfied with the results The patient had a more attractive umbilicus than the one with the other previous technique. This new method makes a natural-looking umbilicus with less of a transverse scar and an adequate sinusoidal pocket and umbilical wall.     

Abdominoplasty repair for abdominal wall hernias

The objectives of abdominal hernial repair are to reconstruct the structural integrity of the abdominal wall while minimizing morbidity. Current techniques include primary closure, staged repair, and the use of prosthetic materials. Techniques for abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. By incorporating these aspects into hernial repairs, the procedures are made safer and the results are improved. The medical records were reviewed of 123 consecutive patients who underwent hernial repair. Seventy-six of these patients underwent a total of 82 herniorrhaphies using an abdominoplasty approach. This included using a transverse lower abdominal incision with or without extending it into an inverted-T incision. The hernial defect was then identified and isolated. Repair was obtained with primary fascial closure and plication, primary fascial approximation and reinforcement with absorbable Vicryl mesh, or placement of permanent mesh with or without fascial approximation. Overall, 8 of 82 hernias recurred. Most complications were minor and could be managed with local wound care only. Major complications included one enterocutaneous fistula, one occurrence of skin flap necrosis requiring operative debridement and skin grafting, and one delayed permanent mesh extrusion 2 years after repair. The abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe with a low risk of complications and a low rate of recurrence. It is particularly helpful in obese patients, in patients with multiple hernias, and in those patients with recurrent hernias.     

Salvage reconstructive surgery in an adult patient with failed previous repair of an extrophy-epispadias complex. An operation with a functional and aesthetic purpose

Salvage surgical procedures after failed reconstruction for an extrophy-epispadias complex are extremely challenging. The goals are to restore continence and improve aesthetic appearance in order to provide quality of life and an improved body image to the patient. We describe the surgical steps in an adult patient who presented anal urinary incontinence and a poor body image due to the absence of an umbilicus and the presence of hypertrophic scars. He underwent a modified Mainz II reconstruction of the lower urinary tract at childhood for an extrophy-epispadias complex. Restoration of continence was achieved by the construction of a modified Mainz I pouch with a continent stoma in a neo-umbilicus. Body image improved dramatically by the construction of a neo-umbilicus, a surgical revision of the hypertrophic abdominal scars and an abdominoplasty. It is mandatory that such demanding surgery should only be attempted as a combined multidisciplinary effort with urologists and plastic/reconstructive surgeons.     

Lipoabdominoplasty without undermining

Background: The classic abdominoplasty still provides the best aesthetic results, despite many advances in abdominoplasty techniques. However, this procedure is associated with a relatively high incidence of complications. Objective: A new technique is described that combines lipoplasty with traditional abdominoplasty without undermining of the abdominal flap. Methods: Lipoplasty proceeds from the region above the umbilicus to the flanks and the region below the umbilicus. The skin below the umbilical scar is resected as in classical abdominoplasty, but a thinner fatty layer with its connective tissue, lymphatic vessels, and blood vessels is preserved. Complementary lipoplasty is performed if necessary to remove excess fat. Results: The procedure results in an improved body shape, better accommodation of the abdominal flap, and a more youthful appearance of the abdomen with less scarring and no incidence of “dog ears” or major complications. Conclusions: Lipoabdominoplasty without undermining enhances aesthetic results with fewer complications than traditional abdominal aesthetic surgery. Aesthetic Surg J 2001;21:518-526.)     

Laparoscopically assisted components separation technique for ventral incisional hernia repair

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.     

Surgical Treatment of Patent Omphalomesenteric Duct Presenting as Faecal Umbilical Discharge

A newborn infant with patent omphalomesenteric duct (POMD), who presented faecal umbilical discharge, was treated with a semicircular periumbilical incision up to the abdominal cavity. The omphalomesenteric duct was followed up to the junction with the small intestine and there resected. The abdominal wall was closed without resection of the umbilicus.

There were no postoperative complications and the aesthetic result was excellent.     

Pediatric postoperative abdominal wound dehiscence: transverse versus vertical incisions

Background: Fascial dehiscence is uncommon in children but can have serious consequences when it occurs. There are multiple risk factors for fascial dehiscence, including the type of incision used. Pediatric surgeons often use a supraumbilical transverse incision particularly in infants because of the access this incision provides to the entire abdomen. This article details the experience with fascial wound dehiscence at a large tertiary children’s hospital and focuses on problems with the types of incision used.

Study Design: This is a retrospective review of 2,785 intraabdominal operations performed over a 5-year period at Children’s Hospital and Regional Medical Center in Seattle. Risk factors for dehiscence were reviewed for each case of fascial dehiscence. Statistical analysis using chi-square was used to examine for differences in complication rates between transverse and vertical incisions.

Results: In this series, 2,442 children (88%) had transverse incisions and 343 (12%) had vertical incisions. Twelve children had abdominal fascial dehiscence postoperatively. Six cases involved transverse incisions and six involved vertical incisions. Five of the children suffered evisceration. One child died as a direct result of the dehiscence. There were multiple risk factors for dehiscence in 10 of the 12 children. Vertical incisions were found to be much more likely to dehisce than were transverse incisions, especially in children under 1 year of age (p < 0.001).

Conclusions: Vertical incisions are more apt to dehisce than transverse incisions in children, particularly babies. We recommend the use of transverse incisions whenever possible in babies less than 1 year of age, especially when other risk factors for dehiscence are present.     

A method of umbilical reconstruction

Summary A technique of umbilical reconstruction is described. This procedure uses a tubed skin flap consisting of scar tissue; a deep and cosmetically excellent umbilicus is achieved even in patients with a thin abdominal wall consisting entirely of scar tissue. This is especially suitable in the cases of deficient umbilicus with a significant vertical scar and a thin abdominal wall due to the prior trauma or surgery.     

改进的垂直切口下腹壁整形术

目的：探讨一种采用改进的垂直切口矫治腹壁纵行瘢痕和凹陷畸形的腹部整形手术方法。方法：采用经过脐周的半环形加下腹部的楔形切口，对腹壁的纵行瘢痕及多余的皮肤进行切除整形，同时行腹部吸脂手术。结果：共治疗11例，除1例局部有少量积液外，其余均恢复顺利。其中3例随访1年，腹部平坦，瘢痕细小。结论：对于下腹部有纵行瘢痕并有凹陷畸形的患者，该手术不失为一种理想的腹壁整形方法。     

经脐腹腔镜胆囊切除术16例报告

目的:探讨腹部不留瘢痕腹腔镜胆囊切除术的手术方法。方法:沿脐上缘呈"八"字形做两个5mm切口,置入5mm腹腔镜和胆囊抓钳;于脐下缘做10mm切口,置入常规器械,并由此孔取出胆囊。结果:16例手术均顺利完成,1例因炎性渗出较多,于右侧肋缘下另做戳孔放置引流管,无中转开腹及胆漏、出血等并发症发生;手术时间30～55min,平均44min。术后住院2～3d,脐部切口愈合良好,无可见瘢痕。结论:经脐腹腔镜胆囊切除术安全可行,可达到腹部无可见瘢痕的目的。     

Open Abdomen after Severe Acute Pancreatitis

Abstract The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2–3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9–12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.     

Mainz pouch with umbilical stoma]

Between March 1986 and May 1991 the Mainz pouch urinary diversion was performed in 23 patients with bladder cancer. In 12 of these 23 patients, stoma was constructed in the umbilicus. As the efferent stomal limb, the ileum was used in 10 cases and the appendix was used in 2 cases. The skin at the bottom of the umbilicus and the abdominal fascia under the umbilicus were excised round. The stomal limb was pulled through the fascial hole and the stomal margin was sutured to the skin. The cosmetic results of the umbilical stoma were satisfactory in these 12 patients. Pouch capacity ranged from 330 ml to 560 ml and good urinary continence without difficulty of self-catheterization was obtained in 11 patients. In 1 patient difficulty in catheterization occurred due to a pocket-formation in the stomal limb and the operative revision was performed. Stomal stenosis occurred in 1 patient. Acute renal failure followed by intestinal bleeding occurred in 1 patient who was cured with intensive care including hemodialysis. The results of our study show the superiority of the umbilical stoma in the Mainz pouch in regard to good cosmetic appearance, no need to use a Marlex collar, little bending of catheterization route and low incidence of complications such as parastomal hernia or nipple valve prolapse.     

Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe, and virtually scar free

Purpose

The aim of this study was to describe a new technique for the surgical management of prenatally diagnosed small bowel atresia.

Methods

Under general anesthesia, a 5-mm trocar was inserted using an open technique through an intraumbilical incision. The proximal atretic bowel end was identified using laparoscopy and mobilized toward the umbilicus using an additional 3-mm trocar inserted in the left lower quadrant. The umbilical trocar then was removed, and a ring retractor was inserted into the trocar site and used to expand the wound to deliver both atretic bowel ends. The bowel was repaired and returned to the abdomen through the umbilical wound. The umbilical fascia and skin were closed conventionally.

Results

Three patients were reviewed. Two had minimal abdominal distension, and the atretic bowel ends could be identified easily; laparoscopy-assisted surgery was successful. The third case had significant dilatation, and laparotomy was required. Postoperatively, there was minimal abdominal scarring, and the umbilicus was normal in appearance.

Conclusions

Although this experience is limited to 3 patients, this technique is simple, safe, and virtually scar free and can be applied for the treatment of neonates with prenatally diagnosed small bowel atresia, especially if there is minimal abdominal distension at birth.     

Prune belly syndrome and abdominal wall reconstruction

The prune belly syndrome was first reported by Frolich in 1839 (Frolich F, Der Mangel der Muskeln insebesondere der Setinbauchmuskeln Dissertation, 1839) and is characterized by a triad of deficient abdominal musculature, intraabdominal testes, and dilatation of the urinary collecting system. These patients who often require urological procedures and subsequent reconstruction of the abdominal wall can prove to be an interesting plastic surgery challenge. The standard techniques for abdominal wall reconstruction can be used, but these must be modified to meet the needs of each individual patient. A 3-year-old boy with prune belly syndrome is presented who was referred to the plastic surgeons for abdominal wall reconstruction. He had already undergone multiple urological procedures and had a Mitrofanoff microstoma at the umbilicus. There have been no techniques described previously to deal with the umbilical stoma. The patient underwent a two-stage reconstruction. This included plication of the fibrous abdominal wall and deepithelialization of excess skin to provide a double layer of dermis. The patient is now 17 years old and has achieved a good result. In the techniques previously described, “redundant” excess skin was excised and discarded, together with some form of plication. We feel that excess skin in prune belly patients should not necessarily be thought of as redundant and may be used as a double layer of dermis to protect and enhance the underlying abdominal wall repair.