Three-flap umbilicoplasty: a novel and preliminary method of laparoendoscopic single-site transumbilical surgical approach for urachal remnants

Indications, outcomes, and complications of neoumbilical reconstruction: A systematic review

BACKGROUND AND OBJECTIVES

Neoumbilicoplasty aims to reconstruct an aesthetically pleasing new umbilicus following agenesis, malignancy, anatomical distortion, or umbilicus loss. Despite the wide variety of surgical techniques described, literature is scarce when it comes to standardized categorization of these as well as the clear definition of patients' selections, specific indications, final outcomes, and possible complications. According to available literature, this work aims to evaluate different surgical approaches, and correlate them to specific surgical needs, to simplify the surgical choice and patient management.

METHODS

A systematic review was performed in December 2020 in PubMed, Web of Science, and MedLine Ovid databases according to the PRISMA guidelines.

RESULTS

A total of 41 studies and 588 patients were finally included. On the basis of the evidence of the literature collected, we divided the studies into four groups according to the neoumbilicoplasty techniques: single suture or purse-string suture, single flap, multiple flap, and skin graft. Patients' surgical comorbidities, neoumbilicoplasty indications, and aesthetic and surgical outcomes were investigated. Direct suture and single and multiple flap techniques assured overall, satisfactory cosmetic outcomes with a low rate of surgical complications. Whereas suture-only techniques were chosen mostly by general surgeons/urologists in laparoscopic surgery, the single flap was the preferred method to reconstruct the umbilicus in open abdominal surgery or combined abdominoplasty with herniorrhaphy. Multiple flap and skin grafts were adopted in abdominoplasty-related umbilicus reconstruction, although the latter option showed impactful aesthetic and surgical complications.

CONCLUSIONS

Umbilicoplasty can assure generally pleasant aesthetic outcomes with relatively low complication rates. Indications for specific techniques correspond to different patient populations and surgical scenarios.

Laparoendoscopic single-site surgery for urachal remnant with extraperitoneal approach through a suprapubic port

INTRODUCTION

No standard procedure has been established for laparoendoscopic single-site surgery for urachal remnants (LESS-U). This study aimed to report the novel surgical techniques and initial outcomes of laparoendoscopic single-site surgery with an extraperitoneal approach through a suprapubic port for urachal remnants (spLESS).

METHODS

Fifty-five patients (median age, 27 years; range, 15-69 years) who underwent LESS-U were analyzed. To overcome the limitations inherent in the conventional procedure (LESS-U through an umbilical port: uLESS), we modified the port placement and approached via the extraperitoneal space. spLESS is a novel procedure which reduces intestinal damage caused by the extraperitoneal approach and overcomes incomplete resection of the urachal remnant, especially in the bladder dome. Three trocars are inserted into the extraperitoneal space through a suprapubic port in spLESS, and complete resection of the urachal remnant from the umbilicus to the bladder is performed with an appropriate incision line. Patient characteristics and perioperative results were retrospectively collected. Cosmetic outcomes were prospectively evaluated using self-administered questionnaires (body image and photo-series questionnaire).

RESULTS

spLESS and uLESS were performed in 43 and 12 patients, respectively. No differences were observed between the perioperative results. The cosmetic outcomes were compared between the groups using body image and photo-series questionnaires. No patient developed major complications; there was no recurrence in either group.

CONCLUSIONS

spLESS is a novel procedure which can completely resect the urachal remnant and reduce the risk of intestinal damage. spLESS is a safe, effective, and feasible procedure with high postoperative cosmesis.

Umbilical Reconstruction Techniques: A Literature Review

BACKGROUND

There are many instances in which sacrificing the umbilicus is unavoidable. Umbilical reconstruction (umbiliconeoplasty) is an important surgical procedure to complete the abdomen's reconstruction and to give again a pleasant cosmetic appearance.

OBJECTIVES

To provide a complete overview of all surgical techniques for umbiliconeoplasty described in the literature.

METHODS

PubMed database was queried using 'umbilical and reconstruction', 'umbilicus and reconstruction', 'navel and reconstruction', 'umbiliconeoplasty', 'neo-omphaloplasty' or 'umbilicaneoplasty' to select the papers dealing with the reconstruction of the umbilicus.

RESULTS

Sixty different techniques for the reconstruction of the missing umbilicus were described in 77 papers. Local skin flaps and the purse-string suture technique were the most frequently described techniques. The Three flaps technique, the Four flaps technique and the 2 Lateral rectangular pedicle lateral flaps technique were the most popular local flap techniques. Indications ranged from congenital pediatric defects to reconstruction during abdominoplasty.

CONCLUSIONS

Several surgical techniques were described for umbilicus reconstruction. While there is not a universal algorithm for the choice of the technique, the surgeon may decide which technique to use based on other surgeons' experiences reports.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Transumbilical laparoendoscopic single-site surgery versus conventional laparoscopic surgery for patients with symptomatic urachal remnants: an experience with 57 patients

PURPOSE

To evaluate the surgical feasibility and postoperative cosmesis of a novel transumbilical laparoendoscopic single-site (LESS) surgical approach involving Y-shaped incisions and three-flap umbilicoplasty in urachal remnant patients.

METHODS

Patients with symptomatic urachal remnants who underwent either conventional laparoscopic surgery (CL group, n = 21) or LESS surgery with Y-shaped incisions and three-flap umbilicoplasty (LESS group, n = 36) between May 2010 and September 2019 were retrospectively assessed. Perioperative factors and postoperative esthetic outcomes were compared between the groups using univariate and multivariate analyses. Esthetic outcomes were assessed using the body image questionnaire consisting of the body image scale (BIS) and the cosmetic scale (CS); a higher score indicated a better outcome.

RESULTS

The median operative time was greater and the insufflation time was shorter in the LESS group than in the CL group. The estimated blood loss and postoperative hospital stay and surgical site infection rate did not differ significantly between the groups. While the BIS score also did not differ significantly between the groups, the CS score was greater in the LESS group than in the CL group. Multivariate analysis revealed that the surgery type (LESS surgery) was an independent predictor of greater postoperative esthetic satisfaction.

CONCLUSION

Transumbilical LESS surgery with Y-shaped incisions and subsequent three-flap umbilicoplasty is feasible in patients with symptomatic urachal remnants. Regarding postoperative cosmesis, the higher CS score suggests that this technique is superior to CL surgery. Furthermore, the selection of this procedure was an independent predictor of good postoperative esthetic outcomes.

Surgical strategy of urachal remnants in children

A urachus is a vestigial tubular structure that connects the urinary bladder to the allantois during early embryonic development. Urachal remnants are classified as patent urachus, urachal sinus, urachal cyst, and urachal diverticulum. Ten patients with urachal remnants underwent surgery at our institution between 2015 and 2019. Six patients had a urachal sinus, and four had a urachal diverticulum. Two patients with urachal sinus underwent excision of the urachal remnant, from the umbilicus to the urinary bladder, using an umbilical approach. The other four patients with urachal sinus underwent laparoscopic surgery with excision of the urachal remnant, from the umbilicus to the urinary bladder. All patients with urachal diverticulum underwent open excision of the diverticulum through a Pfannenstiel incision. Pathologic examination of all urachal remnants showed no evidence of neoplasm and complete excision. All patients had an uneventful postoperative course and are doing well.

Outcomes of laparoscopic resection of urachal remnants followed by novel umbilicoplasty

OBJECTIVE

The purpose of the study was to report the outcomes of our modified techniques of laparoscopic urachal resection, followed by novel umbilical-plasty using dermal regenerative grafts for symptomatic urachal remnants.

METHODS

Between March 2014 and December 2016, laparoscopic urachal resection was carried out on 45 patients with complaints of urachal remnants. After extraction of the specimen and closure of the fascia at the umbilical site, a 1-cm square section of dermal regeneration sheet (TERUDERMIS®, Olympus) was suture retained between the fascia and the skin. Patient satisfaction with cosmesis was scored prospectively using the visual analogue scale (VAS). Perioperative records were reviewed to assess surgical outcomes.

RESULTS

Laparoscopic urachal resection was successfully conducted via the transperitoneal approach. Postoperative bleeding was experienced in one patient (2.2%), which was subsequently controlled laparoscopically. Infection subsided with symptomatic relief in all patients. No symptomatic recurrences were encountered. Over 80% of patients (37/45) rated the cosmetic outcome of the plasty as good to excellent, with the median scores of 8 (range 5-10).

CONCLUSIONS

Laparoscopic urachal resection is safe and curative with reasonable risk of complications. Novel umbilicoplasty using dermal regenerative graft is very simple technique and offers satisfactory cosmetic outcomes. Further follow-up and cosmesis evaluation are required.