Background and aim: Since Tan and Bianchi reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Most of these studies focused on the usefulness of such an approach in neonates. This study aims at assessing the usefulness of the circumumbilical approach for exploring the abdominal cavity of infants and older children for treating a variety of surgical intra-abdominal diseases to achieve minimally invasive surgery with excellent cosmetic results.
Patients and methods: All patients who underwent a circumumbilical skin incision for an exploratory laparotomy during the period June 2009 to October 2010 were reviewed. Age, operative procedure, conversions to standard laparotomy, complications, and follow-up data were recorded.
Results: A total of 27 infants and children with ages ranging from 3 months to 8 years underwent circumumbilical incision for abdominal exploration. The indications were as follows: nonrotational malrotation of the midgut (n=2), intussusception (n=13), complicated V–P shunts (n=4), acute abdomen that proved to be due to Meckel's diverticulitis (n=2), gastrotomy for removal of an impacted foreign body from the stomach (n=1), pyloroplasty for caustic injury of the pylorus (n=1), lymphatic mesenteric cyst (n=1), and complicated appendicitis (n=3). Conversion to a standard midline incision was necessary in one case. The complications encountered included wound infection (n=5), burst abdomen (n=1), and incisional hernia (n=2). Subsequent follow-up revealed that all incisions had healed and the scars were almost imperceptible as affirmed by parental satisfaction during outpatient clinic consultation.
Conclusion: The circumumbilical approach appears to be safe, flexible, and easily reproducible, providing adequate exposure for some abdominal surgeries even in older infants and children as it has been tried successfully in neonates. The low-complication rate and pleasing aesthetic outcome are well-appreciated by parents and operators alike.
The use of the transumbilical approach using a circumumbilical incision to perform a pyloromyotomy was first reported by Tan and Bianchi in 1986 1. This transumbilical technique has since then been adopted by many pediatric surgeons as a feasible, safe, inexpensive, and virtually scarless approach for hypertrophic pyloric stenosis. Several studies using modifications of this technique for the treatment of a variety of surgical intra-abdominal diseases in neonates and infants have been published 2–5.
However, recent studies including one from the Manchester group have focused on the usefulness of this approach in exploring the abdominal cavity and in treating most of the spectrum of surgical diseases in neonates 6–8. In this study, we assessed the usefulness of the transumbilical approach in infants, toddlers, and children suffering from a variety of surgical intra-abdominal diseases to achieve minimally invasive surgery with excellent cosmetic results.
Patients and methods
All infants, toddlers, and children who underwent a circumumbilical skin incision for an exploratory laparotomy during the period June 2009 to October 2010 were reviewed in this study. Neonates were excluded from the study. Age, sex, operative procedure, operative time, conversions to standard laparotomy, complications, and follow-up data were recorded. All parents were counseled, and an informed consent was taken in all cases. All patients were treated under general anesthesia in the operating room and were given antibiotic prophylaxis.
The umbilicus was thoroughly cleansed with chlorhexidine after standard skin preparation. The umbilicus was incised 350° on its outermost circumference, leaving a 10° skin bridge on the left side of the umbilicus. A subcutaneous plane was developed for approximately 5 cm both cranially and caudally, and then the fascia and peritoneum were opened in the midline. To provide increased exposure, the skin was stretched in all directions with vein retractors together with relaxing midline skin incisions along the lineanigra both above and below the umbilicus, as the skin represented the limiting factor in extracting the abdominal contents (Fig. 1).
The bowel was then brought through the wound onto the abdominal surface, and the standard surgical procedure was completed under full vision. The wound was closed by closing the fascia in the midline. Approximation of the subcutaneous tissue and umbilicoplasty were performed by approximating points A–Á, C–Ć, and E–Ė at the three corners of the umbilical circle with excision of the excess dog ears at the four quarters of the circle with interrupted subcuticular nonabsorbable sutures, making it a complete circle again.
During the period between June 2009 and October 2010, a total of 27 infants, toddlers, and children comprising 17 boys and 10 girls with ages ranging from 3 months to 8 years underwent treatment using the circumumbilical skin incision procedure (Table 1).
The indications for surgery are summarized in Table 2. The most frequent indication for exploration was intussusception mostly in infants below the age of 1 year
All 27 wounds except one healed with excellent aesthetic appearance, which was well appreciated by the parents (Fig. 2).
Wound infection developed in five patients, representing a total incidence of 18.5% (Table 3). One of these five patients was further complicated by a burst abdomen treated by conversion to formal midline laparotomy for better closure of the abdominal muscles. Two patients developed incisional herniae. (Table 3). The two patients with incisional herniae are still awaiting treatment. There were no incidences of missed diagnoses or misdiagnoses in this series.
The principle of applying a transumbilical approach to periumbilical surgical disease in infants and children is not new. Abdominal wall defects such as gastroschisis, omphalocele, and umbilical hernia are of course approached through the umbilicus. Similarly, epigastric hernias, urachal pathology, and omphalomesenteric duct remnants are often managed transumbilically.
The 1986 report by Tan and Bianchi 1 introduced the concept of approaching, through the umbilicus, surgical pathology elsewhere in the abdomen (i.e. pyloric stenosis). This approach has been widely adopted for pyloromyotomy. Several modifications of the original description of circumumbilical incision such as ω-shaped extension, V-Y plasty, and right-sided lateral extension have been adopted, all to address the extraction of a larger pyloric tumor 9–11.
In 2003, Soutter and Askew 2 reported on the use of transumbilical laparotomy in infants for a wide variety of surgical problems, such as malrotation, intussusception, intestinal atresia, and some other conditions. In their study they described the transumbilical approach in 13 infants (ages ranging from 1 to 9 months) and three toddlers (age ranging from 13 to 24 months), opening the door for the use of this approach in older children.
In 2005, Sauer et al. 3 described the versatility of umbilical incision in the management of Hirschsprung's disease. However, several recent studies have described the use of such an approach in neonates and concluded that virtually most surgical indications in neonates could be treated through exploring the abdominal cavity using this approach 6–8.
In this study, we were primarily concerned with the assessment of the use of the same approach with suggested modifications in infants, toddlers, and children (who passed the neonatal period) as its effectiveness in neonatal surgery has been tested and proved in previous studies.
In this study, we described 27 patients who underwent surgery using the transumbilical approach by a circumumbilical incision. The type of disease among this cohort of patients showed a wide range.
It is our belief that stretching the skin and creating relaxing vertical midline skin incisions can yield an operative field of adequate size for performing a wide variety of reductions, resections, and anastomosis. We also believe that the type of umbilicoplasty suggested in this study can well camouflage the scar within the periumbilical skin, making it barely visible after a few weeks, and becomes almost imperceptible as the child grows and gains weight, ‘folding in’ the umbilical cicatrix.
Postoperative complications were comparable to those of conventional approaches for similar operations as most of our indications for explorations were for septic or potentially septic operations 12–14. We had two incisional herniae in our series. We believe that incisional herniae can be avoided if there is good closure of the abdominal wall with particular attention to ensuring that there is no tension and no strangulation of tissues by the sutures.
Soutter and Askew 2 used a ‘transumbilical’ approach and had a complication rate of 6.8%. In the series from Toronto, including children with Hirschsprung's disease, Sauer et al.  reported a 24% complication rate, whereas the Bianchi group from Manchester 6 reported a 7.2% complication rate in 55 neonates who were subjected to the circumumbilical approach.
Although laparoscopic surgery has many advantages such as reduced postoperative pain, improved cosmesis, early mobilization and discharge with a resultant reduction in hospital costs 15–17, it could be associated with complications. In 1995, Chen et al. 13 reported a complication rate of 4% for thoracic and abdominal minimal access surgery. Laparoscopy requires considerable skill, has a prolonged learning curve, and has significant cost implications.
The circumumbilical open approach is an alternative to laparoscopy, combining safety with minimally disruptive surgery. It requires no additional equipment or particular skills and leads to an aesthetic scar. Operative time did not constitute an issue in our series. We had five cases of wound infection, which was comparable with other studies.
The infant abdomen may be uniquely suited to this approach because of its limited longitudinal axis, its relatively thin and elastic abdominal wall, and its proportionately larger umbilicus. However, our success in infants, toddlers, and older children suggests that this technique may also be suitable for this age group with a variety of intra-abdominal surgical conditions.
Conflicts of interest
There are no conflicts of interest.
1. Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg. 1986;73:399
2. Soutter AD, Askew AA. Transumbilical laparotomy in infants: a novel approach for a wide variety of surgical disease. J Pediatr Surg. 2003;38:950–952
3. Sauer CJ, Langer JC, Wales PW. The versatility of the umbilical incision in the management of Hirschsprung's disease. J Pediatr Surg. 2005;40:385–389
4. Scavarda D, Breaud J, Khalil M, Paredes AP, Takahashi M, Fouquet V, et al. Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results. Childs Nerv Syst. 2005;21:39–43
5. Lin JY, Lee ZF, Chang YT. Transumbilical management for neonatal ovarian cysts. J Pediatr Surg. 2007;42:2136–2139
6. Murphy FJ, Mohee A, Khalil B, Lall A, Morabito A, Bianchi A. Versatility of the circumumbilical incision in neonatal surgery. Pediatr Surg Int. 2009;25:145–147
7. Tajiri T, Ieiri S, Kinoshita Y, Masumoto K, Nishimoto Y, Taguchi T. Transumbilical approach for neonatal surgical diseases: woundless operation. Pediatr Surg Int. 2008;24:1123–1126
8. Takahashi Y, Tajiri T, Masumoto K, Kinoshita Y, Ieiri S, Matsuura T, et al. Umbilical crease incision for duodenal atresia achieves excellent cosmetic results. Pediatr Surg Int. 2010;26:963–966
9. Besson R, Sfeir R, Salakos C, Debeugny P. Congenital pyloric stenosis: a modified umbilical incision for pyloromyotomy. Pediatr Surg Int. 1997;12(2–3):224–225
10. Misra D, Mushtaq I. Surface umbilical pyloromyotomy. Eur J Pediatr Surg. 1998;8:81–82
11. Poli Merol ML, Francois S, Lefebvre F, Bouche Pillon Persyn MA, Lefort G, Daoud S. Interest of umbilical fold incision for pyloromyotomy. Eur J Pediatr Surg. 1996;6:13–14
12. Iwanaka T, Uchida H, Kawashima H, Nishi A, Kudou S, Satake R. Complications of laparoscopic surgery in neonates and small infants. J Pediatr Surg. 2004;39:1838–1841
13. Chen MK, Schropp KP, Lobe TE. Complications of minimal-access surgery in children. J Pediatr Surg. 1996;31:1161–1165
14. Paes TR, Stoker DL, Ng T, Morecroft J. Circumumbilical versus transumbilical abdominal incision. Br J Surg. 1987;74:822–824
15. Georgeson KE, Owings E. Advances in minimally invasive surgery in children. Am J Surg. 2000;180:362–364
16. Rangel SJ, Henry MC, Brindle M, Moss RL. Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. J Pediatr Surg. 2003;38:1429–1433
17. Yamataka A, Koga H, Shimotakahara A, Urao M, Yanai T, Kobayashi H, et al. Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe and virtually scar free. J Pediatr Surg. 2004;39:1815–1818