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Journal of Pediatric Surgery (2011) 46, 10761080

www.elsevier.com/locate/jpedsurg

A comparison of circumumbilical and transverse abdominal


incisions for neonatal abdominal surgery
Megha 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

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.

Neonatal abdominal surgery is traditionally performed


through a transverse abdominal incision to treat a variety of
intestinal conditions. Since the use of a circumumbilical
incision was first introduced by Tan and Bianchi [1] in 1986
for Ramstedt's pyloromyotomy, several authors have
suggested that it is an effective, safe, and cosmetically
Corresponding author. Pediatric General and Thoracic Surgery, The
Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8. Tel.: +1
416 813 7340; fax: +1 416 813 7477.
E-mail address: jacob.langer@sickkids.ca (J.C. Langer).
0022-3468/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2011.03.032

superior approach to the standard transverse laparotomy in


various neonatal abdominal operations [2-7]. Although these
observational studies have demonstrated that the circumumbilical approach provides adequate exposure, reasonable
operative times, acceptable rates of wound complications,
and excellent cosmetic results, no study to date has compared
the circumumbilical approach to the traditional transverse
abdominal incision for complex abdominal surgery. The aim
of the present study is to compare various outcomes between
the circumumbilical and transverse abdominal incisions in
neonatal intestinal surgery.

Umbilical incisions for neonatal surgery

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

M. Suri, J.C. Langer

left upper quadrant (2 patients), epigastrium (29 patients), at


the level of the umbilicus (3 patients), below the umbilicus (1
patient), or lateral to the umbilicus on the right side (3
patients). The location of the transverse abdominal incision
was not specified in 4 cases. Of the patients who had a
circumumbilical incision, 20 had the incision placed above
the umbilicus, 1 below, and the location was unspecified in 5
cases. Five patients who received a supraumbilical incision
required extension of the incision laterally as an omega
incision. Adequate surgical exposure was obtained with the
circumumbilical incision once the intestine was exteriorized
through the umbilicus (Fig. 1).
Baseline characteristics of patients who were included in
the study are summarized in Table 1. No significant
differences were found between sex, diagnosis, level of
contamination 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 abdominal
group as compared with the circumumbilical group (18 vs 12
months, P = .013).
Mean operative time; postoperative days on the ventilator;
postoperative days on a narcotic infusion; postoperative time
to full feeds; postoperative length of stay; and surgical
complications such as surgical site infection, bowel obstruction, and incisional hernia are summarized in Table 2.
The postoperative time to reach full feeds for each patient
was calculated as the difference in days between the first
postoperative day and the day documented in the chart as to
when the patient was tolerating a full-feed regimen. Because
Table 1

Patient characteristics based on incision type


Transverse
abdominal
incision
(n = 106)

Sex, female (%)


51 (48)
Diagnosis (%)
Rotational anomaly
23 (22)
with volvulus
Rotational anomaly
9 (8)
without volvulus
Duodenal atresia/web
42 (40)
Jejuno/ileal/colonic
32 (30)
atresia/web
Level of contamination (%)
I, clean
19 (18)
II, clean contaminated
79 (75)
III/IV, contaminated/dirty
8 (8)
Mean gestational
262 2
age SE, d
Mean birth weight SE, g 2907 70
Mean weight at time of
2846 69
surgery SE, g
Mean length of
18 2
follow-up SE, mo
Significant result.

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

Patient outcomes based on incision type


Transverse Umbilical P
abdominal incision
(n = 26)
incision
(n = 106)

Mean operative time SE, 106 4


min
Mean postoperative time on
2 0.3
ventilator SE, d
Mean postoperative time on
3 0.2
narcotic infusion SE, d
Mean postoperative time to
21 1
full feeds SE, d
Mean postoperative length
25 2
of stay SE, d
Surgical site infection (%)
30 (28)
Bowel obstruction (%)
15 (14)
Incisional hernia (%)
6 (6)

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.

3 patients from the transverse abdominal incision group and


1 patient in the circumumbilical incision group were
transferred to a peripheral hospital before they had reached
their full-feed regimen, we did not include these patients in
this part of the analysis. Consequently, the mean postoperative time to full feeds in the transverse abdominal and
circumumbilical groups were calculated using data from 103
and 25 patients, respectively. For the same reasons, the mean
postoperative length of hospital stay in the transverse
abdominal and circumumbilical groups were also calculated
using data from 103 and 25 patients, respectively.
The occurrence of surgical site infection was similar
between the 2 groups. Among the patients who underwent a
transverse abdominal incision, 24 had simple cellulitis, 2
developed a seroma, 1 developed a hematoma, and 3 patients
had a stitch abscess. In the circumumbilical group, all
surgical site infections were simple cellulitis.
Of the 15 patients (14%) in the transverse abdominal
group who developed a bowel obstruction, 7 were managed
nonoperatively, whereas 8 required a laparotomy. In all cases
where a laparotomy was necessary, the incision was made
through the original scar. Of these patients, 6 underwent a
laparotomy for adhesiolysis, whereas 2 patients also required
repair of an anastomotic stricture. Of the 2 children in the
circumumbilical group who developed a bowel obstruction,
1 was managed nonoperatively, and the other required a
laparotomy for adhesive bowel obstruction. In this case, the
original circumumbilical incision was extended laterally.
The only outcome that differed between groups was
the incidence of incisional hernia (38% vs 6%, P b .001).
An incisional hernia developed in 10 patients who received
a circumumbilical incision and was documented during
their first postoperative visit, typically 1 to 2 months after
discharge. Among these patients, spontaneous resolution of
the hernia was noted within 10 months of follow-up. Six
patients in the transverse abdominal group developed

Umbilical incisions for neonatal surgery

1079

3. Discussion

be necessary to extend the cutaneous incision to an omega


configuration to obtain this.
Postoperative complications including surgical site infection and bowel obstruction were also comparable between
the circumumbilical and transverse abdominal groups. The

The circumumbilical incision was first introduced by


Tan and Bianchi [1] in 1986 for Ramstedt's pyloromyotomy. Several authors subsequently have adopted this
approach, which appears to have similar outcomes to the
standard right upper quadrant incision as well as a superior
cosmetic result. In a retrospective cohort analysis comparing the circumumbilical incision using a transverse fascial
incision to the transverse abdominal incision in neonates
with hypertrophic pyloric stenosis, Fitzgerald et al [8]
observed similar operative time, length of hospital stay,
intraoperative complications, and incidence of wound
infection. Blumer et al [9] demonstrated similar results in
a retrospective comparative analysis of infants with
hypertrophic pyloric stenosis. In this study, however, the
fascial incision was made vertically rather than horizontally, and operative time was significantly longer in the
circumumbilical group as compared with the transverse
abdominal group.
More recently, several authors have described the use of
a circumumbilical incision in the management of complicated neonatal surgical conditions including duodenal or
intestinal atresias/web, malrotation, intestinal stricture,
necrotizing entercolitis with perforation, meconium ileus,
intestinal duplication cyst, Hirschsprung disease, and
ovarian cyst [2-7]. These studies have documented that
the circumumbilical incision is an effective, safe, and
cosmetically superior approach to the standard transverse
laparotomy in neonatal abdominal surgery. However, no
study to date has directly compared the circumumbilical
incision with the standard transverse abdominal incision
for complex neonatal surgery.
In our study, we found that the circumumbilical incision
was equivalent to the transverse abdominal approach with
regard to operative time; surgical complications; postoperative analgesia requirements; length of hospital stay; and
time to reach full feeds in neonates undergoing surgery for
malrotation, duodenal atresia/web, or intestinal atresia/web.
Many surgeons eschew the circumumbilical incision on the
assumption that surgical exposure may be better with the
transverse abdominal incision. However, mean operative
times were found to be similar in both groups, supporting
our experience that surgical exposure is excellent with the
circumumbilical approach. The redundancy of the umbilical skin, the natural hole beneath it, and the central
location of the umbilicus over the base of the small bowel
mesentery likely contribute to the ease with which
intestinal surgery can be performed with a circumumbilical
incision. It is important to ensure that a generous fascial
and muscular incision is made for adequate midgut
exposure with the circumumbilical incision, and it may

Fig. 2 Postoperative cosmetic appearance with a supraumbilical


incision (A), supraumbilical incision with lateral omega extension
(B), and transverse abdominal incision (C).

an incisional hernia, and 2 (33%) of these required


surgical repair.

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.

M. Suri, J.C. Langer

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