Circumumbilical incision for mobile unilocular abdominal cysts

Circumumbilical incision for mobile unilocular abdominal cysts

Mohammad Ahmad AI Ekrashy,MD

Department of Pediatric Surgery, Zagazig University, Egypt.

Aim: The aim of this study was to evaluate the accessibility of circumumbilical incision for excision of mobile unilocular abdominal cysts and its cosmetic results as compared with other traditional incision in pediatric abdominal surgery.

Patients and methods: Twenty patients with mobile unilocular abdominal cysts of different

origin were prospectively selected for periumbilical incision for excision of cysts. Preoperative assessment of the cyst was done either by ultrasonography  or CT for assuring of being mobile unilocular cysts and being solitary or multiple. Postoperative assessment of the cosmetic results, length of hospital stay and return to normal activity were done and were significantly different between periumbilical incision and traditional laparotomy incisions.

Results:  Periumbilical   incision  is  safe  and  provides  accepted  accessibility  for  mobile unilocular  abdominal  cysts  excision  and  reduces  postoperative  wound  complications  and hospital stay with better cosmetic results.

Introduction:

Many   abdominal   exploratory   incisions can  be  done  to  excise  mobile  abdominal cysts according to its position and relations. In infants and young children supraumbilical transverse incision is preferred as a good exploratory incision for the most of the abdomen. But in mobile pelvic masses like ovarian cysts the suprapubic Pfannensteil incision   is  the   suitable  one,   but  there 're many  medicoleagal   and  social  restrictions for  that  incision  for  virgin  females  so,  if the  periumbilical   incision  can  be  suitable for managing these cases it's considered a magical solution for these cases.

Understanding     the    detailed     anatomy of  the  umbilical  and  periumbilical   region is   important   to   assume   best   exploratory and cosmetic results. Embryologically, the umbilicus is a midline fusion of the medial aponeurotic borders of both rectus abdominis aponeuroses around the umbilical cord. This fusion may take place around the 1Oth week, after the herniated midgut returns to the peritoneal cavity.

Remember the following four anatomic entities,  which  pass  through  the  umbilical

ring in the newly born child:

Left umbilical vein (round ligament ofthe liver)

Urachus (median umbilical ligament)

Two umbilical arteries (medial umbilical ligaments).

The umbilicus is located at the center of the umbilical region.  For all practical  purposes, the umbilicus is a scar. It is not the same in all individuals. Its boundaries are the epigastric area above, the hypogastric  area below, and the right and left lumbar areas laterally.

The umbilicus is essentially at the vertical

midpoint   of  the   linea  alba.  It  marks  the junction ofthe lower end ofthe well-formed upper linea alba and the beginning of the poorly-defined lower linea alba (Skandalakis et al2004).

Umbilical Ring:

The  medial  umbilical  ligaments (obliterated umbilical arteries) and the urachus (obliterated allantoic  duct) participate  in the formation of the fibrous umbilical ring. The round ligament (obliterated umbilical vein) arises from the inferior margin of the ring and

passes superiorly in the falciform ligament.

Am-ShamsJSurg2014; 7(2):289-294

Umbilical fascia:

- In 36%,  a localized  thickening  of the transversalis  fascia in this area, named the umbilical fascia, covers the umbilical ring in toto. This fascial "buffer" can protect against the genesis of an umbilical hernia.

- In  38%  of  individuals,  the  umbilical

fascia covers only the upper part of the umbilical ring.

-In 6% of individuals, the umbilical fascia

covers  only the  lower part of the umbilical

nng.

-In 4% of individuals, the umbilical fascia is located above the ring.

- In  16%  of  individuals,  the  umbilical

fascia is absent.l

Patients and methods:

This study was carried out in our pediatric surgery unit. It was carried on twenty patients;

12 ovarian cysts, 4 of them were complicated,

4 mobile mesenteric  pedunculated  cysts and

4 urachal cysts. 16 patients were females and

4 males. The ages were ranging between two months and four years, with average age 17.2 months. Cysts were removed through circum­ infra-umbilical approach. Early postoperative events  and  complications   were  registered. After discharge from hospital regular follow up in outpatient clinic and delayed post operative complications were also registered. Only  one  case  of  seroma  was  encountered after excision of a complicated right ovarian cyst, which was managed by evacuation then compressing dressing was done over the umbilical region and cefotriaxone injection.

Another  case  with  angular  incisional hernia was encountered after excision of another simple ovarian cyst, this hernia was managed   conservatively    and   disappeared after 6 months.

Surgical       technique;      under       general

anaethesia  and  endo  tracheal  intubation,  a nearly  half   sphere   infraumbilical   incision through  skin and subcutaneous tissue, better by scalpel No 11 while skin at the expected two ends of the incision are elevated by two toothed  forceps.  Then the  umbilical  scar  is freed  of  its fascia  and the  rectus  sheath  is incised at both sides till a limit that the incised

skin allows. Insert two or more Langenbeck's retractors to allow visualization  of the abdominal  cyst. The  cyst  is fixed  between the retractors and the cyst fluidy content is aspirated by suitable sized syringe and needle and the needle is removed while an artery forceps grasps and blocks the puncture site to prevent intra peritoneal leakage of the fluid. Now the  artery  forceps  can extract  the  lax cyst extra abdominally easily and excised.

The abdominal wall is closed in mass by

continuous vicryl2/0 or 3/0 according to age. The umbilical scar is fixed to the sheath using

4/0 vicryl stitch. 3 to 4 subcutaneous inverted sutures; the skin is closed in subcuticular sutures.  Compressing  dressing  was  applied over the umbilicus for 4 to 5 days.

Various types of cysts were excised through this incision; mesenteric pedunculated cyst, right ovarian cyst and urachal cysts.

Results:

The study was carried on 20 patients with three different causes of abdominal cysts, Table (1).

Postoperative   hospital  stay  was  around

24  hours  for  all  cases,  through  this  time the patients started oral feeding and was discharged to outpatient clinic.

Postoperative   complications   were arranged in Table (2).

The seroma was evacuated andcompressive dressing was applied and parentral antibiotic resolved the condition.

The incisional hernia was angular and was

managed   conservatively    and   disappeared after around six months.

Wound appearance  was very satisfactory to parents as the wound  and umbilicus appeared normal.

Discussion:

Using circumumbilical approach for pyloromyotomy4  has  lead  to  a  realization of its potential for the management  of many routine  abdominal  operative  procedures  in the neonates as well as oncologic surgery.

It was  used  for  malrotation,   intestinal

atresia, NEC, spontaneous perforations, meconium ileus and intestinal duplication.3

Figure (1): Simple pedunculated mesenteric cyst excision through the umbilical incision.

Figure (3): Excision of urachal cyst through circumumbilical approach.

Table (1):

Figure (2): Complicated right ovarian cyst extracted through infraumbilical incision.

Figure (4):  Circum-infraumbilical incision after closure in subcuticular stitches.

Table (2):

It has the advantage of safe exposure of the abdominal contents and the ability to deliver bowel through the wound and all procedures ru·e done under full vision.

Fiona et a1 2009,3 used muscle spming procedure which doesn't require the creation of  a  subcutaneous  pocket  that's  prone  to

seroma and infection and wound drainage was not necessaty.

We have used muscle cutting  technique

transversely after creating a subcutaneous space to give a wider exposure and a non limited exploratory view to most of the abdominal contents as the incised skin is freely

mobile in all directions usmg appropriate abdominal retractors.

Good closure of the abdominal wall and good compressive dressing after subcuticular closure of skin have prevented seroma, infection and incisional hernia in all cases except one case of seroma, and one case of angular incisional hernia.

Seroma was managed by evacuation compression   and  parentral  antibiotics   and the angular incisional hernia resolved spontaneously  after around six months.

Postoperative  complications  are comparable with conventional approaches for similar operations. 3

We have closed the wound m circumferential   manner  leaving  small  skin scar  without  interruption  of  the  abdominal wall. The scar is well camouflaged within the peri umbilical skin and is much appreciated by parents.

There   is   an   appreciable   reduction   in

postoperative pain and enhanced recovery.3

Fiona et al20093 had two incisional hernias which can be avoided by particular attention that   there's    no   tension    or   strangulation of tissues by the sutures. The circum­ supraumbilical  approach is an alternative to laparoscopy combining safety and minimal disruptive  surgery. It requires  no additional equipments  or particular  skills  and leads to an aesthetic scar.3

Operative time  didn't  constitute  an issue in our study.

The  circumumbilical   incision  if  it  was

found to be inappropriate for the procedure there  are two options to solve this problem; the first is to extend  the wound  laterally to give an omega shaped incision, the second is to add another incision to fulfill the procedure like Pfannensteil incision in lower abdominal conditions and transverse supra umbilical incision in upper abdominal conditions.

Aspiration of the fluid content of the cyst

made us dispense extending the incision into Omega shape also there was no need for combination of another aesthetic incision.

In a study for Tajiri et al6 14 neonates with surgical diseases (3 hypertrophic pyloric stenoses,  3  ileal  atresias,  2 jejunal  atresias,

1 duodenal stenosis, 1 duodenal atresia, 2 ovarian cysts, 1 malrotation, and 1 segmental dilatation of ileum), were treated using a transumbilical  approach by means of a half circumumbilical  incision.  In 10 of 14 cases, the umbilicus was incised on its upper half circumference, while the umbilicus of 4 cases was incised on its lower half circumference. In one ileal atresia patient with a remarkable degree of oral intestinal dilatation, a slight additional  transverse  incision was added. In four cases (1 case with ileal atresia, 2 cases of an ovarian cyst, and 1 case with a segmental dilatation ofthe ileum), laparoscopy-assisted transumbilical   surgery  was  performed.   In all cases, no operative complications were encountered. Postoperatively, there was no wound in appearance and the umbilicus appeared to be normal.

The length of hospital stay was 24 hours

through that time the patient had started oral feeding and then he was discharged home for follow up in out patient clinic after three days for dressing.

In  a study  for  Megha  and  Jacob  2011,2

One  hundred  thirty-two  patients  underwent a laparotomy through a transverse abdominal incision   (n   = 106)   or   a  circumumbilical incision   (n  = 26).  Baseline   characteristics between groups were similar. No differences were found when comparing  operative time, postoperative days on a ventilator, narcotic infusion, time to full feeds, length of hospital stay, incidence of surgical site infection, and bowel obstruction.  Although more incisional hernias occurred in the circumumbilical incision group (38%) than the transverse abdominal incision group (6%), all hernias in the circumumbilical  group resolved without intervention, whereas 33% required surgical repair in the transverse abdominal group.

In another series for Murphy et al,5 a total of

55 neonates with a gestational age ranging from

28 to 42 weeks had 57 operative procedures. The indications were: nonrotation  of midgut in 18; intestinal atresia in 18; necrotizing enterocolitis/spontaneous perforation in 10; meconium  ileus  in  5; intestinal  duplication in  2;  patent  vitellointestinal  duct  (VID)  in

2.  No  conversion  to  a  standard  transverse

incision  was necessary in any case. However, an  omega  extension was  made  in four patients.  The complications encountered included wound infection in one; caecal perforation  in  one  and  incisional hernia  in two  cases.   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  is a safe, flexible and easily reproducible approach providing adequate  exposure for most abdominal surgeries in the neonate  resection of unilocular mobile  abdominal cysts  and  is done  very  easily  leaving  no gross  morbidity nor  any  ugly  scars.  This  incision  decreases the time of hospital stay, decreases post operative  pain  with  early  postoperative recovery and less wound  complications. The low complication rate and good aesthetic outcome  which  are much  appreciated by parents   make   the  approach   deserving trial

before doing  another traditional incision.

Reference

1-    Skandalakis J, Colborn GL, Weidman TA, Foster RS, Kingsnorth AN, Skandalakis LJ,

:Nlirilas PS: Abdominal wall and hernia. Me­ Grow Hill' access surgery, 2004; Chapter 9.

2-    Suri  M,   Langer   JC:   A   comparison  of

circumumbilical and transverse abdominal incisions for neonatal abdominal surgery. Journal of  Pediatric Surgery 2011;  46(6):

1076-1080.

3-         Murphy  FJ,  Mohee  A, Khalil  B,  Lall  A, Morabito A, Bianchi A: Versatility of  the circumumbilical incision in neonatal surgery. Pediatric Surgery Jnternational2009; 25(2):

145-147.

4-   Ali Gharaibeh KI, Ammari F, Qasaimeh G, Kasawneh B, Sheyyab M, Rawashdeh M: Pyloromyotomy through circumumbilical incision. J R Call Surg Edinb 1992;  37(3):

175-176.

5-          Murphy  FJ,  Mohee  A, Khalil  B,  Lall  A, Morabito A, Bianchi A: Versatility of  the circumumbilical incision in neonatal surgery. Pediatr Surg Jnt 2009; 25(2): 145-147.

6-   Tajiri T, leiri S, Kinoshita Y, Masumoto K, Nishimoto Y, Taguchi T: Transumbilical approach for neonatal surgical diseases: Woundless operation. Pediatr Surg Jnt 2008;

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