4/6/2016 Umbilicoplastyinchildrenwithhugeumbilicalhernia:AkakpoNumadoGamedziKomlats,MihluedoAgbolanKomlanAnani,BoumeMissokiAzanle

TECHNICALINNOVATION
Year:2014|Volume:11|Issue:3|Page:256260

Umbilicoplastyinchildrenwithhugeumbilicalhernia
AkakpoNumadoGamedziKomlats1,MihluedoAgbolanKomlanAnani1,BoumeMissokiAzanledji1,AdabraKomlan2,GnassingbeKomla1,TekouHubert1,
1DepartmentofPaediatricSurgery,SylvanusOlympioTeachingHospital,BP57Lom,Togo
2DepartmentofGeneralSurgery,SylvanusOlympioTeachingHospital,BP57Lom,Togo
CorrespondenceAddress:
AkakpoNumadoGamedziKomlats
S/C,MGametiK.Evenyo,08BP80025Lom8
Togo

Abstract
Background:Hugeumbilicalhernias(HUH)arevoluminousumbilicalhernia(UH)thatarefrequentinblackAfricanchildren.Severalsurgicaltechniquesareusedintheirtreatmentfor
umbilicalreconstruction,buttechniquesusingskinflapsprovidebetteraestheticresults.Inthisstudy,wepresentedourtechniqueofumbilicoplastyinHUH,anditsresults.Patients
andMethods:ItisaretrospectivestudyonchildrentreatedforHUH,fromJanuary2012toDecember2013.TheUHwascalledHUHwhenitsbasisdiameter(BD)exceeds3cm.Every
HUHwascharacterisedbyitsheight,BDandmorphology.Ourtechniquewasatwolateralflapstechniquetheflapsaresymmetricalanddrawnsoastoreconstitutethedifferentparts
oftheumbilicus.Theresultswereappreciatedwithcriteria,includingtheperipheralringandthecentraldepressionoftheneoumbilicus.Results:Twelvechildrenwereconcerned(7
boysand5girls).Theirmeanagewas5yearsand6months.ThemeanBDwas5.6cm(extremes3and8cm),andthemeanheightoftheHUHwas7.45cm(extremes3and9cm).All
underwentumbilicoplasty.Inearlypostoperativeperiod,twochildrenpresentedatransitorysubcutaneoushematoma.Latecomplicationsweregranulationtissuewithtwochildren,
andcheloidscarwithone.Withameanfollowupof10months,wehad10excellentresultsandtwofairresultsaccordingtoourcriteria.Conclusion:Ourtwolateralflaps
umbilicoplastyiswelladaptedtoHUHinchildren.Itissimpleandassuresasatisfactoryanatomicalandcosmeticresult.

Howtocitethisarticle:
KomlatsANG,AnaniMAK,AzanledjiBM,KomlanA,KomlaG,HubertT.Umbilicoplastyinchildrenwithhugeumbilicalhernia.AfrJPaediatrSurg201411:256260

HowtocitethisURL:
KomlatsANG,AnaniMAK,AzanledjiBM,KomlanA,KomlaG,HubertT.Umbilicoplastyinchildrenwithhugeumbilicalhernia.AfrJPaediatrSurg[serialonline]2014[cited2016Apr
6]11:256260
Availablefrom:http://www.afrjpaedsurg.org/text.asp?2014/11/3/256/137337

FullText
Introduction

Umbilicalhernia(UH)isafrequentpathologyinchildrenitwouldbemorefrequentinblackchildren,anditsfrequencycanreach50%ofchildreninsomeAfricanregions.[1]The
treatmentofUHgenerallyconsistofsurgicalclosureoftheumbilicalringandtherefixationoftheumbilicus.[2]Hugeumbilicalhernias(HUH)arevoluminousUHfortheirtreatment,
theexcessofskinremainsaproblemtothesurgeons,afterclosureoftheumbilicalring.Torestoreanumbilicusaestheticallyneartothenaturalone,manytechniquesofumbilicoplasty
havebeendescribed.[3],[4],[5],[6]Wehereinreporttheresultsofumbilicoplastywithourtechnique,whichissimpleandpermitstoreconstitutearegularandaestheticumbilicus.

PatientsandMethods

Thisisaretrospectivestudy,carriedonfilesofchildrenaged<15yearold,treatedintheDepartmentofPaediatricSurgeryofSylvanusOlympioTeachingHospitalofLomfrom1st
January2012to31stDecember2013forHUH.WecalledHUH,everyUHwhosebasisdiameter(BD)exceeds3cm,andwhoseheightexceeds1.5cm.The[Figure1]showshowto
measuretheBDandtheheight.Wedescribedthereforetwoclassifications:
AccordingtotheBDoftheHUHwedistinguishedthreegroups:Group1:3cm<BD5cmGroup2:5cm<BD7cmGroup3:BD>7cm.AccordingtothemorphologyoftheHUH,we
distinguishedalsothreetypes:Sessile,pediculate,orhornlikeHUH.{Figure1}
Descriptionofthetechnique
Itisatechniqueoftwolateralflaps,performedundergeneralanaesthesiawithagoodmusclerelaxation.Wedrewfirst,thexyphopubicline,goingstraightoverthesummitofdeHUH.
TwopullwirewereplacedatthesummitoftheHUH,upanddowninordertomaintaintheHUHtightduringtheprocedure.SomelandmarkswereplacedontheHUHasshownby
[Figure2].ThepointsAandDwereplacedat1cmoftheHUHbasis.ThepointsB1andB2,C1andC2wereplaced,respectivelyeachinfrontoftheother,onthebasisoftheHUH,at
itsmiddlepartaccordingtoitsbasiscircumference.Onemustnotconsiderthenativeumbilicalscar,whichisdisplacedintheHUH.{Figure2}
ThesegmentsB1C1andB2C2wereequalsandcorrespondtothebasisoftheflaps.Theirlength(L)dependedonthediameter(d)oftheneoumbilicustobemade.Thetwovalues
werejoinedbythefollowingformula:[INSIDE:1].Inchildrenweusuallychoosetomakeaneoumbilicusof2cmofdiameter.Forthis,Lequalsapproximately(3.14)andwechoose3
cm.
ThepointsE1andE2,F1andF2wereplacedasneareraspossibletothexyphopubicline,inordertohaveinthebeginning,themaximalheightoftheflaps.Thedefiniteheightofthe
flaps(h)dependsonthethicknessoftheabdominalsubcutaneouspanniculus(t).Weusuallytakethisformula:H=t+0.5cm.ThesegmentsE1F1andE2F2wereequalandsymmetric
andmeasured0.5cm.Theflapssodrawnmustbeperpendiculartothexyphopubicline.
Theincisionswerenotstraight,butsemicircularorarclike.IncisionshadasuperiorconcavityfromAtoB(B1andB2)andfromBtoE(E1andE2),andinferiorconcavityfromF(F1
andF2)toC(C1andC2)andCtoD.TheincisionswerejoinedatAandDatapoint,whereastheywereroundedatB1,B2,C1andC2.Thetwolateralflapslookedliketowers
widenedtotheirbases.
Afterthisdrawing,incisionwasdoneonthemarks.Theflapswereremovedfromtheaponeurosisplanwiththeirsubcutaneouspanniculus.Inthesameway,allthelateralskinwas
dissectedwithitssubcutaneouspanniculusfromtheaponeurosisplan.Theskinwasalsoremovedfromtheaponeurosisoftheumbilicalsack,andthesackwasopenedathistop.The
excessofaponeurosiswasresectedlongitudinallythelevelofresectionwaswellcheckedinordertohavegoodandsufficienttissueforaregularandstrongnewaponeurosisplan
thatwillnotalloweventration,andthatwillprovidearegularshapetotheabdomen.Onecannoticethatthecurvatureoftheincisionsupanddownchangesafterperipheralskin

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separation[Figure3].Theheightoftheflapswasreviewedasspecifiedearlier.Theirsummitswerecorrectlysuturedonetotheother,andfixedbytwopointstotheaponeurosisplanby
2/0absorbablesuture.Theirsidesweresuturedbysubcutaneousseparatedpointsof4/0absorbablesuture,fromdepthtosurface.Afterthis,theneoumbilicuswaswelldrawn,withits
peripheralrimwellraised.Twoseparatepointswereplacedatthesuperiorandtheinferiorpartoftheneoumbilicus.Theremainderwoundisclosedwithtwoplans:Thesubcutaneous
planbyseparatedpoints,andanintradermalcontinuoussuture,bothwith4/0absorbablesuture.Thedefiniteaspectoftheumbilicoplastywasthenobtained[Figure4].{Figure3}
{Figure4}
Appreciationoftheresults
Weappreciatedtheresultsasexcellent,fairorbadaccordingtocriteriain[Table1].Inadditiontothesecriteria,wehavetheselfappreciationofthesurgeon,andtheappreciationofthe
parentsorthechild.Weaskedtheparentsorthechildhowtheyappreciatedtheneoumbilicus.Fromtheiranswers,weclassifiedtheoutcomeoftheumbilicoplastyas:
Excellent(iftheanswerwas:"Theneoumbilicuslookslikeanormalumbilicus"),Fair(iftheanswerwas"theneoumbilicusisbetterthanbefore"),andBad(iftheanswerwas"weprefer
theanterioraspectoftheumbilicus").{Table1}

Results

Duringourstudyperiod,therewere146childrenadmittedinourDepartmentwithUH,amongwhich22hadHUH.FourchildrenpresentedwithUHincarceration,butnoneofthemhad
HUH.HUHrepresented15.06%ofUHinourDepartment.Only12overthe22havebeenoperated.Thereweresevenboysandfivegirls.Theirmeanagewas5yearsand6months
withextremesof6monthsand13years.ThemeanBDwas5.6cm(extremes3and8cm),andthemedianwas5.5cm.Themeanheightwas7.45cm(extremes:3and9cm),andthe
medianwas6.5cm.TheclassificationaccordingtothegroupandthetypeofHUHispresentedin[Table2].Allthechildrenunderwentumbilicoplasty.Themeandurationofthe
operationwas73min(extremes:45and90min).Themeanhospitalisationstaywas3days(extremes:2and4days).{Table2}
Duringthepostoperativeperiod,wenoticeasubcutaneoushematoma,whichwasresorbedwithin7days.Duringthefollowup,twochildrenpresentedgranulationtissueatthe
centreoftheneoumbilicusdepression,andanotherchilddevelopedcheloidscar.Granulationtissueoccurred5and6weeksafteroperation.One(thebiggest)healedaftersurgical
resectionandgoodclosureoftheskinupontheaponeurosis.Thesecondhealedwithapplicationofnitrate2timesaweekduring3weeks.
Withameanfollowupof10months(extremes:5and20months),andaccordingtoourcriteria,wehad10excellentresult[Figure5]acandtwofairresults.Thetwofairresultswere
relatedtoflattenedneoumbilicalrim.Fortheparents(orchildren),theresultswereexcellent.{Figure5}

Discussion

ThetreatmentofHUHinchildrenincludestwoactions:Theclosureoftheumbilicalringandthereconstructionofanumbilicusclosetothenormal.Thereisoftennoproblemofhernia
incarcerationwithHUH[5]asnoticedinourseries.ThebestattitudewouldbetheoperationoftheHUHbeforetheschoolage,inordertoavoidmockeriesoffriendsatschool.The
closureoftheumbilicalringbysutureoftheaponeurosisplanisusuallyeasyanddoesn'tneedprosthesismaterial.Theproblemremainsattheumbilicoplasty.Itneedstobesimpleto
perform,toprovideacosmeticandpermanentresultwithnoexternalscar.[7]Manytechniqueshavebeendescribed,[4],[5],[6],[7],[8],[9]somemorecomplexthanothers,withvariable
results.Weaimedatdevelopingatechniqueeasytoperformwithprecision,andthatprovidessatisfactoryresults.Asimpleumbilicationoftheskinafterresectionoftheexcessofskin
[9]cannotrestorethedifferentpartsofanumbilicus.Themorphologyoftheumbilicusmustnotinfluencethedrawingoftheflaps.Theflapsmustbedrawnperpendicularlytothexypho
ombilicalline,andmustnotfollowthedirectionoftheHUH.
Theumbilicalrim
Itdeterminesthecosmeticaspectoftheumbilicus.Itgivestotheneoumbilicus,itsdiameter(d).Itisraisedwithyoungchildrenandbecomelittleflattenedwhentheabdominal
panniculusthickens.ThecurvatureofourincisionsespeciallyatpointsB1,B2,C1,C2[Figure2]permittedustoraisetheumbilicalrim[Figure4]and[Figure5]b.Inaddition,theheight
offlapsmustpassthethicknessoftheabdominalpanniculusbyabout0.5cm.Theregulationoftheflapsheightaccordingtothethicknessofabdominalpanniculusisveryimportant:
Shortflapsleadtodepressedriminotherhand,toolongflapscanleadtoexuberantrimthatwillnotbecosmetic.Wehadnodepressedorexuberantriminourseries.Other
techniques[4],[6]trytoreconstitutearaisedrimbutitcanbeirregularorincomplete.Inourtechnique,symmetricflapswithequalheightandequalbasispermittohaveregularand
completerim.Thediameteroftheumbilicalrimdependsonthewidthoftheflapsattheirbasis(L).Weusuallychoose3cmfortheLinchildren,inordertohaveanumbilicalrimof2
cm.Onecanchoosetocreateaneoumbilicuswitharimmoreor<2cmlarge,accordingtotheageandthemorphologyofthechild.Inthatcase,theformulamustbeused.
Thecentraldepressionoftheumbilicus
Itisthesecondelementconstitutingtheumbilicus.Itsdepthgivestotheumbilicus,itsparticularity.Withoutthisdepression,wecannothaveanumbilicus.Inourtechnique,thefixationof
theflap'ssummittotheaponeurosisplanpermitstocreatethisdepression.Othertechniquesofumbilicoplasty[4],[5],[6],[7],[8],[10]dothatfixationwiththesamepurpose.
Theaddedscar
Theavoidanceofanaddedscaristheverychallengeofallthetechniquesofumbilicoplasty.Thesurgeonmustcreateaneoumbilicusclosetothenormal,withoutaddedscarif
possible.Theabsenceornot,andthelengthoftheaddedscar(LAS)isrelatedtotheBDoftheHUH.The"lazyM"andomegaflapstechnique[5]canpermittohaveaneoumbilicus
withoutaddedscarbutonlyinUHwithreducedBD,<3cm.Withthedoublehalfconeumbilicoplasty,[11]after3cmoffascialdefect,thecosmeticresultwillbediscussedbecausethe
neoumbilicalrimwillbetoolarge.ThetechniqueofIkedaetal.[12]isadaptedforUHthatBDisbetween2and2.5cmitcannotprovidegoodresultwithwhatwecallHUH.WithHUH,
eveninGroup1,therewillbeanaddedscar,evenwiththe"lazyM"andomegaflaps.Theothertechniques[4],[6],[8]asoursletanaddedscarwhoselengthdependontheBDofthe
HUH.Wenoticedinourseriesthathowlongwastheaddedscar,theresultswereexcellentforchildrenandparents,andtheypreferredtheneoumbilicuswithaddedscartotheHUH.
Withaneoumbilicusof2cmofdiameter(d),ifweconsider1cmaddedupand1cmaddeddownduringthedrawing,theLAScanbecalculated:LAS=BDd+1+1=BD2+2=
BD.
Thus,theLASequalstheBD,andthislengthisdistributedapproximatelyforhalfupandhalfdowntheneoumbilicus.Hence,moreistheBD,morewillbetheLAS,becausetheexcess
ofskinthatmaybeexcisedbeginsatthebasisoftheHUH.TheLASisindependenttothemorphologyoftheHUH.OurclassificationinthreegroupsaccordingtotheBDpermitsusto
knowhowlongwillbetheLAS.Themaximumcaremustbegiventotheclosureoftheincision,inordertoletascarlessvisibleaspossibleonemustavoidskintransfixingseparate
points,anduseintradermalcontinuoussuture.WeareworkingtoimproveourtechniqueinordertoreducetheLASatleastinGroup1HUH.
Postoperativecomplications
Subcutaneoushematomacanoccurinearlypostoperativeperiod(onecaseinourseries).Itregressesspontaneously.Othercomplicationslikeparietalinfectionin5%anderythema
offlapsin29.2%werefoundbyKanekoandTsuda.[6]Thelatecomplicationsthatweencounteredwerecheloidscar(onecase)andgranulationtissue(twocases).Cheloidscar
reducesthecosmeticaspectoftheneoumbilicusbutispreferredtoHUH.Ifthepatienthassomecheloidscarbeforeumbilicoplasty,subcutaneousinjectionofcorticoidintheedgeof
incisionjustafterhealingofthewoundcouldhelptoavoidit.Asforgranulationtissue,theyareduetoinsufficientclosureofskinatthesummitoftheflapsbeforetheirfixationtothe
aponeurosis.Intheirstudy,TakasuandWatanabe[4]theyhavefounditatthecentreoftheneoumbilicusin9%,andinthegapbetweenadjacentskinflapsin4%ofcases.Acorrect
closureofthesummitandthegapbetweentheflapspermitstoavoidthem.
Postoperativeeventrationmustnotbeenfound.

Conclusion

Ourumbilicoplastyisasimpleandprecisetechnique,whichprovidesexcellentaestheticresult.Amongthemultipletechniquesdescribed,itiswelladaptedtoHUHoftenencountered

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withAfricanchildren.Agoodapplicationofthetechniquepermitstoavoidpostoperativecomplications.Despitetheaddedscar,theresultsareexcellent.Nevertheless,thesurgeon
mustlookhardforthewaytoreducetheLAS.

Acknowledgements

WethankM.DonaldAKLASSOUforthedrawings.

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