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Keywords:

  • umbilicoplasty;
  • operative reconstruction;
  • umbilicus;
  • patent urachus

INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. CASE REPORT
  4. DISCUSSION
  5. INFORMED CONSENT
  6. REFERENCES

The concept of ‘umbilicoplasty’ emphasises the cosmetic function of the umbilicus as a central structure of the body beyond a simple foetal remnant and focuses on the aesthetic aspects of reconstructive surgery. A protruding umbilicus is considered ‘unattractive and undesirable’ by some patients [1]. Therefore, one aim is to form an inverted umbilicus by resection of the umbilical scarification [1]. Another aim, especially in female patients, is to form a ‘scarless’ and ‘natural-appearing umbilicus’ with a ‘longitudinal deep depression’[2]. Many attempts have been made to establish standardised criteria to define the appearance of an aesthetically pleasing umbilicus. From a study of 147 female participants, it was concluded that the T- or vertically shaped umbilicus with superior hood or shelf is a desirable goal in umbilical reconstruction, as it scored highest in aesthetic appeal [2]. Beyond cosmetic aspects, the crucial function of the umbilicus to ‘seal off’ the abdominal wall from the outer environment has to be restored to avoid urinary discharge and recurrent infections.

We present a new technique for operative reconstruction of the umbilicus in a 6-week-old girl with a patent urachus.

CASE REPORT

  1. Top of page
  2. INTRODUCTION
  3. CASE REPORT
  4. DISCUSSION
  5. INFORMED CONSENT
  6. REFERENCES

At 38-weeks gestation a 3455 g and 50 cm tall girl was delivered (Apgar scale: 9, 10, 10) by caesarean section due to a 50 × 8 cm giant umbilical cord. Postnatal clinical, laboratory and pathological examination lead to the diagnosis of an open patent urachus with urinary leakage into the umbilical cord and subsequent development of a giant oedema [3]. However, the infant's development was normal and there were no other malformations. A visible connection between the dome of the urinary bladder and the umbilicus was not detectable on postnatal ultrasonography. The umbilical cord was clamped, but urinary discharge persisted and, at 6 weeks of age, the child underwent surgical repair of the patent urachus with subsequent aesthetic and functional umbilicoplasty.

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Figure 1 The umbilicus with the open patent urachus is excised with a circular skin incision and subsequent 3 cm caudal elongation of the incision. (a) After removal of the urachus, the peritoneum and transversalis fascia are closed by a continuous suture (b).

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Figure 2 The cranial skin is then fixed at a point, as cranial as possible, down onto the transversalis fascia with a single suture and a 1-cm free skin edge.

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Figure 3 Redundant skin is resected, sutured to the crescent-shaped deeply fixed middle flap, to create a new umbilicus. After closure of the longitudinal skin incision, the central flap is fixed directly to the cranial edge of the longitudinal suture followed by a transverse suture to create the new umbilicus. The final result was an inverted, natural-looking umbilicus with longitudinal deep depression and minimal skin incision.

DISCUSSION

  1. Top of page
  2. INTRODUCTION
  3. CASE REPORT
  4. DISCUSSION
  5. INFORMED CONSENT
  6. REFERENCES

Several techniques for either new construction or reconstruction of the umbilicus have been invented, developed and modified during the past 30 years, including various different techniques. Indications for umbilicoplasty include: congenital abdominal wall defects, e.g. gastroschisis, omphalocele, cloacal exstrophy or exstrophy-epispadias complex, or secondary destruction of the umbilicus due to umbilical hernia, laparotomy, abdominoplasty, inflammatory or neoplastic diseases [4–6]. The former demand new construction, whereas the latter necessitate reconstruction of the umbilicus. Furthermore, a patent urachus with persistent urinary leakage from the umbilicus requires surgical repair and reconstruction of the umbilicus. Reports of umbilicoplasty after resection of a patent urachus are few, with only two other published cases [7].

Persistent urachal remnants can present at any age and with various clinical manifestations [8]. Urachal cysts, urachal sinus and a patent urachus are the most common and may present with urinary discharge [9]. If urinary discharge persists after clamping of the umbilical cord, a patent urachus can be suspected clinically, and complete surgical removal of the urachus is mandatory to avoid complications. Although most urachal anomalies remain asymptomatic, they predispose to recurrent infections and, rarely, adenocarcinomas of the bladder may arise in adulthood from a persistent vesicourachal diverticulum at the bladder dome [9]. The surgical approach implies open preparation and complete resection of the urachus from the urinary bladder and primary closure of the bladder dome [8]. In the present case, umbilicoplasty followed resection of the urachus. With the optimal time or preferred method for surgical reconstruction of a patent urachus remaining unclear, we developed a new technique for aesthetic and functional umbilicoplasty, providing a successful method for cases of patent urachus requiring surgical repair. Our technique is derived from two methods developed by Hanna and Ansong [5] in 1984 and Cervellione et al. [10] in 2008, respectively, for umbilicoplasty in bladder exstrophy. We modified both techniques to meet our constellation of patent urachus. The longitudinal incision between the former umbilicus and urinary bladder was necessary for complete removal of the urachus.

Our technique is easy to perform, without major complications and achieves excellent cosmetic results.

INFORMED CONSENT

  1. Top of page
  2. INTRODUCTION
  3. CASE REPORT
  4. DISCUSSION
  5. INFORMED CONSENT
  6. REFERENCES

Written informed consent was obtained from the patient's mother. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. CASE REPORT
  4. DISCUSSION
  5. INFORMED CONSENT
  6. REFERENCES