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Journal of Pediatric Surgery (2011) 46, 1076–1080

A comparison of circumumbilical and transverse abdominalincisions for neonatal abdominal surgeryMegha Suri, Jacob C. Langer⁎

Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8

Received 1 March 2011; accepted 26 March 2011

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Key words:Circumumbilical;Transverse abdominal;Incision;Neonatal surgery;Malrotation;Intestinal atresia;Intestinal web

AbstractPurpose: Although neonatal bowel surgery traditionally involves a transverse abdominal incision,several authors have reported that the circumumbilical incision is effective and cosmetically appealing.We report the first study comparing the circumumbilical incision to the transverse abdominal incisionfor a variety of neonatal abdominal operations.Methods: Retrospective cohort analysis comparing the circumumbilical incision to the transverseabdominal incision for neonates who underwent surgical repair of malrotation, duodenal atresia/web, orintestinal atresia/web was performed between 1999 and 2009.Results: One hundred thirty-two patients underwent a laparotomy through a transverse abdominalincision (n = 106) or a circumumbilical incision (n = 26). Baseline characteristics between groups weresimilar. 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, andbowel obstruction. Although more incisional hernias occurred in the circumumbilical incision group(38%) than the transverse abdominal incision group (6%), all hernias in the circumumbilical groupresolved without intervention, whereas 33% required surgical repair in the transverse abdominal group.Conclusions: Because of its cosmetic advantages and similar outcomes to the transverse abdominalincision, the circumumbilical incision should be considered as an alternative to the transverse abdominalapproach in neonatal surgery.© 2011 Elsevier Inc. All rights reserved.

Neonatal abdominal surgery is traditionally performedthrough a transverse abdominal incision to treat a variety ofintestinal conditions. Since the use of a circumumbilicalincision was first introduced by Tan and Bianchi [1] in 1986for Ramstedt's pyloromyotomy, several authors havesuggested that it is an effective, safe, and cosmetically

⁎ Corresponding author. Pediatric General and Thoracic Surgery, Theospital for Sick Children, Toronto, Ontario, Canada M5G 1X8. Tel.: +116 813 7340; fax: +1 416 813 7477.E-mail address: jacob.langer@sickkids.ca (J.C. Langer).

022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2011.03.032

superior approach to the standard transverse laparotomy invarious neonatal abdominal operations [2-7]. Although theseobservational studies have demonstrated that the circumum-bilical approach provides adequate exposure, reasonableoperative times, acceptable rates of wound complications,and excellent cosmetic results, no study to date has comparedthe circumumbilical approach to the traditional transverseabdominal incision for complex abdominal surgery. The aimof the present study is to compare various outcomes betweenthe circumumbilical and transverse abdominal incisions inneonatal intestinal surgery.

1077Umbilical incisions for neonatal surgery

1. Methods

A retrospective cohort analysis was performed of patientsyounger than 1 month with a diagnosis of malrotation,duodenal atresia/web, or jejunoileal atresia/web at theHospital for Sick Children, Toronto, Ontario, Canada, whounderwent a laparotomy with either a circumumbilical ortransverse abdominal incision between July 1999 and June2009. Laparotomies using a transverse abdominal incisionwere performed by all 9 staff general surgeons at the Hospitalfor Sick Children during the study period, and 2 of thesesurgeons also used circumumbilical incision. Neonates withperitonitis, free air, hemodynamic instability, or otherfindings suggesting the possibility of intestinal ischemia,necrosis, or perforation were excluded. Several patients withmalrotation who underwent first-look laparoscopy before alaparotomy were excluded from this study. Patient charac-teristics including sex, diagnosis, gestational age, birthweight, weight at surgery, length of follow-up, surgicalprocedure performed, and level of contamination at the timeof surgery were noted. Outcomes including operative time,postoperative time on ventilator, postoperative time ofnarcotic infusion, postoperative time to full feeds, andpostoperative length of stay were compared between patients

Fig. 1 Intraoperative exposure with a circumumbilical incision for a typand malrotation (C).

who underwent a laparotomy with a circumumbilical vs atransverse abdominal incision.

The circumumbilical incision was made either at thesuperior or inferior aspect of the umbilicus. The umbilicalvein or the umbilical arteries and urachus were divided. Thefascia was divided transversely, extending into the rectusabdominus muscle on both sides. If more room was needed,the skin incision was extended into an omega configuration.

Continuous variables were compared using the Student'st test, and categorical variables were evaluated using theFisher's Exact test. P b .05 was considered statisticallysignificant. This study was approved by the Hospital for SickChildren Research Ethics Board (file no. 1000014020).

2. Results

Two hundred ten charts of patients who met the inclusioncriteria for our study were reviewed. Of these, a total of 78patients were excluded, leaving 132 children in the finalstudy group. One hundred six patients (80.3%) underwent alaparotomy through a transverse abdominal incision, and 26(19.7%) had a circumumbilical incision. The transverseincision was placed in the right upper quadrant (64 patients),

e IIIb (apple-peel type) jejunoileal atresia (A), jejunoileal atresia (B),

Table 2 Patient outcomes based on incision type

Transverseabdominalincision(n = 106)

Umbilicalincision(n = 26)

P

Mean operative time ± SE,min

106 ± 4 113 ± 8 .448

Mean postoperative time onventilator ± SE, d

2 ± 0.3 2 ± 0.3 .538

Mean postoperative time onnarcotic infusion ± SE, d

3 ± 0.2 3 ± 0.4 .750

Mean postoperative time tofull feeds ± SE, d

21 ± 1 22 ± 3 .867

Mean postoperative lengthof stay ± SE, d

25 ± 2 26 ± 3 .861

Surgical site infection (%) 30 (28) 8 (31) .812Bowel obstruction (%) 15 (14) 2 (8) .523Incisional hernia (%) 6 (6) 10 (38) b.0001 ⁎

⁎ Significant result.

1078 M. Suri, J.C. Langer

left upper quadrant (2 patients), epigastrium (29 patients), atthe level of the umbilicus (3 patients), below the umbilicus (1patient), or lateral to the umbilicus on the right side (3patients). The location of the transverse abdominal incisionwas not specified in 4 cases. Of the patients who had acircumumbilical incision, 20 had the incision placed abovethe umbilicus, 1 below, and the location was unspecified in 5cases. Five patients who received a supraumbilical incisionrequired extension of the incision laterally as an omegaincision. Adequate surgical exposure was obtained with thecircumumbilical incision once the intestine was exteriorizedthrough the umbilicus (Fig. 1).

Baseline characteristics of patients who were included inthe study are summarized in Table 1. No significantdifferences were found between sex, diagnosis, level ofcontamination at the time of surgery, mean gestational age,mean birth weight, and mean weight at the time of surgery.Length of follow-up was longer in the transverse abdominalgroup as compared with the circumumbilical group (18 vs 12months, P = .013).

Mean operative time; postoperative days on the ventilator;postoperative days on a narcotic infusion; postoperative timeto full feeds; postoperative length of stay; and surgicalcomplications such as surgical site infection, bowel obstruc-tion, and incisional hernia are summarized in Table 2.

The postoperative time to reach full feeds for each patientwas calculated as the difference in days between the firstpostoperative day and the day documented in the chart as towhen the patient was tolerating a full-feed regimen. Because

Table 1 Patient characteristics based on incision type

Transverseabdominalincision(n = 106)

Umbilicalincision(n = 26)

P

Sex, female (%) 51 (48) 16 (62) .220Diagnosis (%)Rotational anomalywith volvulus

23 (22) 5 (19) .057

Rotational anomalywithout volvulus

9 (8) 1 (4)

Duodenal atresia/web 42 (40) 5 (19)Jejuno/ileal/colonicatresia/web

32 (30) 15 (58)

Level of contamination (%)I, clean 19 (18) 1 (4) .182II, clean contaminated 79 (75) 22 (85)III/IV, contaminated/dirty 8 (8) 3 (12)Mean gestationalage ± SE, d

262 ± 2 261 ± 4 .815

Mean birth weight ± SE, g 2907 ± 70 2807 ± 161 .568Mean weight at time ofsurgery ± SE, g

2846 ± 69 2926 ± 168 .659

Mean length offollow-up ± SE, mo

18 ± 2 12 ± 2 .013 ⁎

⁎ Significant result.

3 patients from the transverse abdominal incision group and1 patient in the circumumbilical incision group weretransferred to a peripheral hospital before they had reachedtheir full-feed regimen, we did not include these patients inthis part of the analysis. Consequently, the mean postoper-ative time to full feeds in the transverse abdominal andcircumumbilical groups were calculated using data from 103and 25 patients, respectively. For the same reasons, the meanpostoperative length of hospital stay in the transverseabdominal and circumumbilical groups were also calculatedusing data from 103 and 25 patients, respectively.

The occurrence of surgical site infection was similarbetween the 2 groups. Among the patients who underwent atransverse abdominal incision, 24 had simple cellulitis, 2developed a seroma, 1 developed a hematoma, and 3 patientshad a stitch abscess. In the circumumbilical group, allsurgical site infections were simple cellulitis.

Of the 15 patients (14%) in the transverse abdominalgroup who developed a bowel obstruction, 7 were managednonoperatively, whereas 8 required a laparotomy. In all caseswhere a laparotomy was necessary, the incision was madethrough the original scar. Of these patients, 6 underwent alaparotomy for adhesiolysis, whereas 2 patients also requiredrepair of an anastomotic stricture. Of the 2 children in thecircumumbilical group who developed a bowel obstruction,1 was managed nonoperatively, and the other required alaparotomy for adhesive bowel obstruction. In this case, theoriginal circumumbilical incision was extended laterally.

The only outcome that differed between groups wasthe incidence of incisional hernia (38% vs 6%, P b .001).An incisional hernia developed in 10 patients who receiveda circumumbilical incision and was documented duringtheir first postoperative visit, typically 1 to 2 months afterdischarge. Among these patients, spontaneous resolution ofthe hernia was noted within 10 months of follow-up. Sixpatients in the transverse abdominal group developed

1079Umbilical incisions for neonatal surgery

an incisional hernia, and 2 (33%) of these requiredsurgical repair.

Fig. 2 Postoperative cosmetic appearance with a supraumbilicalincision (A), supraumbilical incision with lateral omega extension(B), and transverse abdominal incision (C).

3. Discussion

The circumumbilical incision was first introduced byTan and Bianchi [1] in 1986 for Ramstedt's pyloromyot-omy. Several authors subsequently have adopted thisapproach, which appears to have similar outcomes to thestandard right upper quadrant incision as well as a superiorcosmetic result. In a retrospective cohort analysis compar-ing the circumumbilical incision using a transverse fascialincision to the transverse abdominal incision in neonateswith hypertrophic pyloric stenosis, Fitzgerald et al [8]observed similar operative time, length of hospital stay,intraoperative complications, and incidence of woundinfection. Blumer et al [9] demonstrated similar results ina retrospective comparative analysis of infants withhypertrophic pyloric stenosis. In this study, however, thefascial incision was made vertically rather than horizon-tally, and operative time was significantly longer in thecircumumbilical group as compared with the transverseabdominal group.

More recently, several authors have described the use ofa circumumbilical incision in the management of compli-cated neonatal surgical conditions including duodenal orintestinal atresias/web, malrotation, intestinal stricture,necrotizing entercolitis with perforation, meconium ileus,intestinal duplication cyst, Hirschsprung disease, andovarian cyst [2-7]. These studies have documented thatthe circumumbilical incision is an effective, safe, andcosmetically superior approach to the standard transverselaparotomy in neonatal abdominal surgery. However, nostudy to date has directly compared the circumumbilicalincision with the standard transverse abdominal incisionfor complex neonatal surgery.

In our study, we found that the circumumbilical incisionwas equivalent to the transverse abdominal approach withregard to operative time; surgical complications; postoper-ative analgesia requirements; length of hospital stay; andtime to reach full feeds in neonates undergoing surgery formalrotation, duodenal atresia/web, or intestinal atresia/web.Many surgeons eschew the circumumbilical incision on theassumption that surgical exposure may be better with thetransverse abdominal incision. However, mean operativetimes were found to be similar in both groups, supportingour experience that surgical exposure is excellent with thecircumumbilical approach. The redundancy of the umbil-ical skin, the natural hole beneath it, and the centrallocation of the umbilicus over the base of the small bowelmesentery likely contribute to the ease with whichintestinal surgery can be performed with a circumumbilicalincision. It is important to ensure that a generous fascialand muscular incision is made for adequate midgutexposure with the circumumbilical incision, and it may

be necessary to extend the cutaneous incision to an omegaconfiguration to obtain this.

Postoperative complications including surgical site infec-tion and bowel obstruction were also comparable betweenthe circumumbilical and transverse abdominal groups. The

1080 M. Suri, J.C. Langer

only significant difference observed between the 2 groupswas with regard to incisional hernias. Incisional hernias weremore common in the circumumbilical group than thetransverse abdominal group. The reason for this is unclear,but is likely because of the relative weakness of the fascia atthe umbilicus in the newborn. Despite this, none of theincisional hernias in the circumumbilical group requiredsurgical repair, whereas 33% of hernias in the transverseabdominal group required repair. This may be because of thenatural propensity of the umbilical fascia to close in the first2 years, as is seen in naturally occurring umbilical hernias[10] and in children who develop a hernia after closure ofgastroschisis [11,12].

Laparoscopy is increasingly used by pediatric surgeonsfor abdominal operations in neonates and is associated withexcellent outcomes [13-16]. Although laparoscopy is anappealing technique, it requires expensive equipment andadvanced laparoscopic skills, particularly when it is appliedto complex neonatal surgery; and most pediatric surgeons inthe world do not have the resources or expertise to use it. Forthese surgeons, the circumumbilical approach is an alterna-tive to laparoscopy because it leads to excellent cosmeticresults while achieving the same patient outcomes as thestandard transverse abdominal incision. Future prospectivestudies will be necessary to determine whether thelaparoscopic approach is associated with better cosmeticresults and patient outcomes than the circumumbilicalincision in neonatal abdominal surgery.

Our data demonstrate that the circumumbilical andtransverse abdominal incisions have similar outcomes inthe surgical management of malrotation, duodenal atresia/web, and intestinal atresia/web. Because the circumumbilicalincision provides a definite cosmetic advantage to thetransverse abdominal approach (Fig. 2), we strongly supportits use over the traditional transverse abdominal incision foropen abdominal surgery.

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