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Key words:
Circumumbilical;
Transverse abdominal;
Incision;
Neonatal surgery;
Malrotation;
Intestinal atresia;
Intestinal web
Abstract
Purpose: 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 incision
for a variety of neonatal abdominal operations.
Methods: Retrospective cohort analysis comparing the circumumbilical incision to the transverse
abdominal incision for neonates who underwent surgical repair of malrotation, duodenal atresia/web, or
intestinal atresia/web was performed between 1999 and 2009.
Results: 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.
Conclusions: Because of its cosmetic advantages and similar outcomes to the transverse abdominal
incision, the circumumbilical incision should be considered as an alternative to the transverse abdominal
approach in neonatal surgery.
2011 Elsevier Inc. All rights reserved.
1. Methods
A retrospective cohort analysis was performed of patients
younger than 1 month with a diagnosis of malrotation,
duodenal atresia/web, or jejunoileal atresia/web at the
Hospital for Sick Children, Toronto, Ontario, Canada, who
underwent a laparotomy with either a circumumbilical or
transverse abdominal incision between July 1999 and June
2009. Laparotomies using a transverse abdominal incision
were performed by all 9 staff general surgeons at the Hospital
for Sick Children during the study period, and 2 of these
surgeons also used circumumbilical incision. Neonates with
peritonitis, free air, hemodynamic instability, or other
findings suggesting the possibility of intestinal ischemia,
necrosis, or perforation were excluded. Several patients with
malrotation who underwent first-look laparoscopy before a
laparotomy were excluded from this study. Patient characteristics including sex, diagnosis, gestational age, birth
weight, weight at surgery, length of follow-up, surgical
procedure performed, and level of contamination at the time
of surgery were noted. Outcomes including operative time,
postoperative time on ventilator, postoperative time of
narcotic infusion, postoperative time to full feeds, and
postoperative length of stay were compared between patients
1077
who underwent a laparotomy with a circumumbilical vs a
transverse abdominal incision.
The circumumbilical incision was made either at the
superior or inferior aspect of the umbilicus. The umbilical
vein or the umbilical arteries and urachus were divided. The
fascia was divided transversely, extending into the rectus
abdominus 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's
t test, and categorical variables were evaluated using the
Fisher's Exact test. P b .05 was considered statistically
significant. This study was approved by the Hospital for Sick
Children Research Ethics Board (file no. 1000014020).
2. Results
Two hundred ten charts of patients who met the inclusion
criteria for our study were reviewed. Of these, a total of 78
patients were excluded, leaving 132 children in the final
study group. One hundred six patients (80.3%) underwent a
laparotomy through a transverse abdominal incision, and 26
(19.7%) had a circumumbilical incision. The transverse
incision was placed in the right upper quadrant (64 patients),
Fig. 1 Intraoperative exposure with a circumumbilical incision for a type IIIb (apple-peel type) jejunoileal atresia (A), jejunoileal atresia (B),
and malrotation (C).
1078
Umbilical
incision
(n = 26)
16 (62)
.220
5 (19)
.057
1 (4)
5 (19)
15 (58)
1 (4)
22 (85)
3 (12)
261 4
.182
2807 161
2926 168
.568
.659
12 2
.815
.013
Table 2
113 8
.448
2 0.3
.538
3 0.4
.750
22 3
.867
26 3
.861
8 (31)
2 (8)
10 (38)
.812
.523
b.0001
Significant result.
1079
3. Discussion
1080
only significant difference observed between the 2 groups
was with regard to incisional hernias. Incisional hernias were
more common in the circumumbilical group than the
transverse abdominal group. The reason for this is unclear,
but is likely because of the relative weakness of the fascia at
the umbilicus in the newborn. Despite this, none of the
incisional hernias in the circumumbilical group required
surgical repair, whereas 33% of hernias in the transverse
abdominal group required repair. This may be because of the
natural propensity of the umbilical fascia to close in the first
2 years, as is seen in naturally occurring umbilical hernias
[10] and in children who develop a hernia after closure of
gastroschisis [11,12].
Laparoscopy is increasingly used by pediatric surgeons
for abdominal operations in neonates and is associated with
excellent outcomes [13-16]. Although laparoscopy is an
appealing technique, it requires expensive equipment and
advanced laparoscopic skills, particularly when it is applied
to complex neonatal surgery; and most pediatric surgeons in
the world do not have the resources or expertise to use it. For
these surgeons, the circumumbilical approach is an alternative to laparoscopy because it leads to excellent cosmetic
results while achieving the same patient outcomes as the
standard transverse abdominal incision. Future prospective
studies will be necessary to determine whether the
laparoscopic approach is associated with better cosmetic
results and patient outcomes than the circumumbilical
incision in neonatal abdominal surgery.
Our data demonstrate that the circumumbilical and
transverse abdominal incisions have similar outcomes in
the surgical management of malrotation, duodenal atresia/
web, and intestinal atresia/web. Because the circumumbilical
incision provides a definite cosmetic advantage to the
transverse abdominal approach (Fig. 2), we strongly support
its use over the traditional transverse abdominal incision for
open abdominal surgery.
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