Operative Technique in Plastic Surgery – Kevin C.Chung

in the midline.
■ If umbilical sparing abdominoplasty is being done, the side with the
umbilicus should be anterior.
■ Horizontal mattress sutures are used to align the fascia.
■ At this time, excess skin is excised bilaterally.
■ Monfort Approach
■ Access to the abdomen is created using two fascial incisions to the epigastric
arteries.9 If urological correction is to be done concurrently, these incisions
expose the genitourinary system (TECH FIG 1A).
■ Once the intra-abdominal portion is completed, the lateral fascia is closed by
overlapping the central remaining fascia to decrease abdominal wall laxity
bilaterally (TECH FIG 1B).
TECH FIG 1 • A. Lateral fascial incisions are made in
the Monfort repair, which provides access to the
abdominal cavity if urologic corrections are needed. B.
The lateral fascia is closed by overlapping the central
remaining fascia to decrease abdominal wall laxity

bilaterally.
■ Closure
■ The skin and subcutaneous tissues are closed in two layers (TECH FIG 2).
■ A drain is placed in the subcutaneous tissue and maintained to suction to
prevent formation of seromas.
■ The nasogastric tube is removed prior to extubation.
TECH FIG 2 • The skin is finally reapproximated in the
midline, and closed in two layers.
PEARLS AND PITFALLS

Intraoperative
monitoring
■ It is important to monitor airway pressures during abdominal wall
reconstruction to identify abdominal compartment syndrome.
Laparoscopy
■ Laparoscopic abdominoplasty has been described and has been
proposed to result in decreased rates of intra-abdominal adhesion
formation. The fascia at the level of the anterior rectus muscle is
plicated intra-abdominally, and then tacked to the medial fascial
wall to reduce laxity.10
POSTOPERATIVE CARE
■ Pain control, initially with intravenous analgesia.
■ Subcutaneous drains are maintained to suction until drain output decreases,
thereby minimizing the risk of seroma formation.
■ An abdominal binder should be worn for 8 to 10 weeks postoperatively.
■ Close monitoring of respiratory status is needed, as patients can develop
respiratory distress in the postoperative period and may require intubation.
COMPLICATIONS3
■ Continued abdominal wall laxity.
■ Necrosis of skin flaps; close attention to blood supply of the flaps should be
done to maintain adequate perfusion.
■ Long-term complications can be related to urological complications.
■ Overall mortality of prune belly is about 20% and is usually related to renal
complications.
REFERENCES
1. Denes FT, Arap MA, Giron AM, et al. Comprehensive surgical treatment of
prune belly syndrome: 17 years’ experience with 32 patients. Urology.
2004;64(4):789-793.
2. Routh JC, Huang L, Retik AB, Nelson CP. Contemporary epidemiology and
characterization of newborn males with prune belly syndrome. Urology.
2010;76(1):44-48.
3. Lesavoy MA, Chang EI, Suliman A, et al. Long-term follow-up of total
abdominal wall reconstruction for prune belly syndrome. Plast Reconstr Surg.
2012;129(1):104e-109e.
4. Jennings RW. Prune belly syndrome. Semin Pediatr Surg. 2000;9(3):115-120.

5. Papantoniou N, Papoutsis D, Daskalakis G, et al. Prenatal diagnosis of prune-
belly syndrome at 13 weeks of gestation: case report and review of literature. J
Matern Fetal Neonatal Med. 2010;23(10):1263-1267.
6. Noh PH, Cooper CS, Winkler AC, et al. Prognostic factors for long-term renal
function in boys with the prune-belly syndrome. J Urol. 1999;162(4):1399-
1401.
7. Zugor V, Schott GE, Labanaris AP. The Prune Belly syndrome: urological
aspects and long-term outcomes of a rare disease. Pediatr Rep. 2012;4(2):e20.
8. Ehrlich RM, Lesavoy MA. Umbilicus preservation with total abdominal wall
reconstruction in prune-belly syndrome. Urology. 1993;41(3):231-232.
9. Monfort G, Guys JM, Bocciardi A, et al. A novel technique for reconstruction
of the abdominal wall in the prune belly syndrome. J Urol. 1991;146(2 (Pt
2)):639-640.
10. Levine E, Taub PJ, Franco I. Laparoscopic-assisted abdominal wall
reconstruction in prune-belly syndrome. Ann Plast Surg. 2007;58(2):162-165.

65
CHAPTER
Gastroschisis and
Omphalocele
Jamie C. Harris and Fizan Abdullah
DEFINITION
Gastroschisis
■ Gastroschisis is the most common congenital abdominal wall defect in the
newborn period. This results from failure of the intestines to return back into
the abdomen during development around week 10 of gestation.
■ The abdominal wall defect is usually less than 4 cm in diameter and is more
commonly located to the right of midline.
Omphalocele
■ Omphalocele is the second most common abdominal wall defect, 1/5000 live
births.
■ This is characterized by a large defect, greater than 4 cm, and is covered by a
membrane of peritoneum.
■ This can contain intestines, as well as liver, spleen, and gonads. Unlike
gastroschisis, omphalocele has a high rate of associated anomalies, including
chromosomal abnormalities and cardiac defects.
DIFFERENTIAL DIAGNOSIS
■ Ruptured omphalocele can be distinguished from gastroschisis based on the
size of the defect (greater than 4 cm), as well as contents other than intestines
in the defect.
■ An umbilical cord hernia will be smaller than omphalocele, and does not
contain abdominal organs.
■ Pentalogy of Cantrell is a rare constellation of ectopia cordis, omphalocele,

sternal cleft, anterior diaphragmatic hernia, and intracardiac defect.
■ In ectopia cordis, the defect is located at the midline of the sternum and
contains the heart.
Patient History and Physical Findings
■ Prenatal history
■ Often, abdominal wall defects are diagnosed on prenatal screening. Maternal
serum and amniotic fluid demonstrates elevated alpha fetoprotein (AFP).
■ Amniotic fluid demonstrates elevated acetylcholinesterase.
■ There is a higher specificity of elevated AFP for gastroschisis compared to
omphalocele.
■ Postnatal history and physical (FIG 1)
■ For both defects, birth history as well as patient stabilization from a
cardiopulmonary standpoint should be completed first.
■ Initial inspection should be done to determine:
• The presence of a covering membrane (indicating omphalocele) (FIG 1A).
• The viability of the intestines, evidence of necrosis, atresias, or perforation.
• Contents in the defect, including liver, gonads, and other intra-abdominal
organs.
• If these are seen without a covering membrane, ruptured omphalocele
should be considered.
■ Full cardiopulmonary exam should be done to determine if there are audible
murmurs appreciated, which suggest an underlying cardiac defect.
■ Examination of the rest of the body to examine for any associated anomalies
should be done.
• Omphalocele is associated with multiple different syndromes including
Beckwith-Wiedemann (omphalocele, macroglossia, and gigantism), and
trisomy 13, 18, and 21.1
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ Prenatal ultrasound
■ Gastroschisis
• Prenatal ultrasound will demonstrate intestines within the amniotic fluid,
outside of the abdomen.
• This is most commonly seen around 20 weeks of gestation.2
• Anomalies, most commonly intestinal atresias, can also be identified on

prenatal ultrasound. Bowel dilatation greater than 14 mm is predictive of
atresias.1
■ Omphalocele
• Intestinal contents will be seen outside of the abdomen.
• The sac can be visualized on ultrasound, helping distinguish from
gastroschisis.
• Additionally, liver can be visualized in the defect.
• This is seen around 18 weeks of gestation.
• Evaluations of other associated anomalies, including cardiac, can be done
on prenatal ultrasound as well.
■ Postnatal echocardiogram
■ The rate of cardiac anomalies in omphalocele is higher (14%–47%) than in
gastroschisis (3%–33%).3
■ Common cardiac anomalies that are seen are ventricular septal defect, atrial
septal defect, and tricuspid atresia. A complete cardiac evaluation for
omphalocele should be done in the perinatal period.
SURGICAL MANAGEMENT
Preoperative Planning
■ Gastroschisis
■ There are two management strategies for gastroschisis:
• Delayed closure with silo placement, allowing for reduction of the
abdominal contents over the following days
• Immediate reduction with closure at birth
FIG 1 • A. Omphalocele presents with a membrane

covering and the umbilicus originating from this
membrane. B. Gastroschisis presents with a defect in
the abdominal wall without a membrane covering the
extruded intestines.
■ Many studies monitor intra-abdominal pressures for signs of abdominal
compartment syndrome to guide decisions on immediate vs delayed
closure.3,4
■ When the diagnosis is known prenatally, delivery should be done at a hospital
in which pediatric surgeons can be present.
■ The current guidelines have shown no difference in outcomes between
vaginal delivery and cesarean section for gastroschisis. Delivery modality
should be at the discretion of the obstetrician. Additionally, older gestational
age is associated with less complications, where 37 weeks is considered
term.5
■ Immediately after birth, the intestines should be covered with sterile moist
towels to minimize fluid losses. Intravenous access should be started to
replace losses.
■ Assessment of the viability of the bowel should be done.
• If any atresias are noted, this should be documented. These are generally
repaired 4 to 6 weeks after birth to allow the intestinal inflammation
gastroschisis to decrease.
• Atretic segments of intestine, if not compromised, are reduced into the
abdomen.
■ If necrotic or perforated intestines are encountered, termed complex
gastroschisis, these are resected and enterostomies are created.
■ An orogastric tube should be placed at birth to aid in bowel decompression
to facilitate reduction into the abdominal cavity.
■ Omphalocele
■ When the diagnosis is known prenatally, delivery should be done at a hospital
in which pediatric surgeons can be present.
■ Surgical repair is dependent upon the size of the omphalocele. For giant
omphaloceles with loss of abdominal domain, primary closure is generally not
attempted. These are often complex and require a level of creativity to close.
Closure methods that are used include promoting sac granulation by treating
with topical agents such as diluted betadine, xeroform, or bacitracin to allow

the peritoneal sac to become firmer and more durable.
• Skin flaps and grafts, such as Gore-Tex mesh, can be used to cover the sac,
and negative pressure wound VAC used to promote granulation.
■ If the omphalocele is not a giant omphalocele, primary closure of the small
omphalocele can be done.
Positioning
■ Gastroschisis
■ The patient is positioned in the supine position, with the arms at the patient’s
side.
■ The abdomen should be prepped and draped into the operative field.
■ The surgeon is positioned on the right of the patient, while the assistant is on
the left.
■ Omphalocele
• The patient is positioned in the supine position, with the arms at their sides.
• Antiseptic prep is used and should include the entire abdomen up to the
chest.
• Reduction of the sac contents into the abdomen is performed at this point.
T E C H N I Q U E S
■ Repair of Gastroschisis
Immediate Reduction
■ If primary closure is feasible at the time of birth, the umbilical cord can be
used to elevate the abdominal cavity to reduce the intestines within the
cavity.
■ Once the intestines are returned to the abdominal cavity, closure of the defect
can be managed in a similar fashion with both methods.
Delayed Closure With Silo Placement
■ The infant is placed supine6 (TECH FIG 1).
■ The silo bag can either be spring loaded, which is placed below the fascia, or
sutured to the fascia.
■ The intestines are maintained in the silo.

■ It is important to maintain upward traction on the silo to maintain bowel
orientation and minimize any twisting or kinking of the mesentery to
minimize the risk of ischemia.
■ Once secured, serial reduction of the intestine within the silo is done, and
complete reduction is usually accomplished within 2 to 3 days of life.
■ Often, the silo can be placed with light sedation to minimize the need for
general anesthesia in an infant.
Closure
■ Sutured closure of the defect is done after the intestines are reduced to the
abdomen.
■ The fascia is then closed using either a purse-string or interrupted suture
closure.
■ The skin is closed using a running subcuticular stitch.
■ Alternatively, sutureless closure has been demonstrated to be a viable option
for closure7,8 (TECH FIG 2).
■ The umbilical cord remnant is cut to fit over the fascial defect.
■ The remnant is then secured in place using Tegaderm or adhesive tape to
reinforce the defect.
■ Tegaderm or tape is maintained for 3 days postoperatively and is then
removed.
■ The defect closes circumferentially around the umbilical cord.

TECH FIG 1 • Initial management of gastroschisis
involves placing a spring-loaded silo below the fascia
and the intestines are suspended. This is serially
reduced over the next few days until the abdominal
contents are completely reduced and closure can be
completed.
Primary Closure of Omphalocele
■ The sac is incised circumferentially at the level of the skin.
■ Any remaining herniated intestinal contents are completely reduced into the
abdomen, monitoring airway pressures as they are reduced.
■ After reduction, the sac is excised and the fascia is closed primarily.
■ The fascia can be closed with either interrupted fascial sutures or running
fascial closure.
■ If the defect is large, primary fascial closure is not feasible and temporary
closures or mesh closures can be considered.9
■ Once the fascia is closed, the subcutaneous tissue is closed in layers.
■ A running subcuticular suture is used to close the skin.
■ Generally, drains are not used following skin closure.
TECH FIG 2 • Sutureless closure. A. The intestines
are reduced completely into the abdominal cavity. B.
The umbilical cord remnant is then placed over the
defect and (C) secured in place with Tegaderm.

PEARLS AND PITFALLS
Gastroschisis
■ 5%–8% of gastroschisis patients have intestinal atresia; therefore,
careful running of the bowel should be done whenever feasible.
■ Gastroschisis defects placed in a silo bag can typically be reduced
over 24–72 hours.
Omphalocele
■ For patients with omphalocele, maintaining the membrane and not
allowing it to rupture is paramount, as the membrane? provides
significantly more tissue to adequately cover the defect.
■ Surgical options for closure and/or temporary surgical silo are
used only if it is not possible to preserve the peritoneal sac in
omphalocele, or if the sac ruptures.
POSTOPERATIVE CARE
■ Gastroschisis
■ During intestinal reduction, observation for signs of abdominal compartment
syndrome including elevated airway or bladder pressures, as well as
decreasing urine output should be monitored.
■ Return of bowel function is very slow in gastroschisis, and postoperative
parenteral nutrition is necessary to support the infant until oral intake can be
instated.
■ If atresias are present, resection and primary anastomosis can be completed
once intestinal inflammation has decreased. This usually takes place 4 to 6
days after birth.
■ Omphalocele
■ Airway pressures as well as bladder pressures should be monitored for signs
of abdominal compartment syndrome.
■ If granulation of the sac is the initial method of closure, close inspection of
defects within the sac should be done regularly.
■ Management of associated anomalies should continue to be done, as these are
what cause the largest morbidity in this group.
COMPLICATIONS
■ Most often, complications associated with gastroschisis have to do with
prematurity rather than the surgical repair.2

■ Similarly, complications associated with omphalocele are most often related to
the associated anomalies.
■ Gastroschisis has a high rate of necrotizing enterocolitis (NEC), and the
surgeon should be cognizant of this if bloody stools or abdominal distention
occur in the perioperative period.
■ Overall survival rates in gastroschisis are 90%; overall survival rates in
omphalocele are 70% to 95%.
REFERENCES
1. Lakshminarayanan B, Lakhoo K. Abdominal wall defects. Early Hum Dev.
2014;90:917-920.
2. Mortellaro VE, St Peter SD, Fike FB, et al. Review of the evidence on the
closure of abdominal wall defects. Pediatr Surg Int. 2011;27:
391-397.
3. Gamba P, Midrio P. Abdominal wall defects: prenatal diagnosis, newborn
management, and long-term outcomes. Semin Pediatr Surg. 2014;23:283-290.
4. Boutros J, Regier M, Skarsgard ED, et al. Is timing everything? The influence
of gestational age, birth weight, route, and intent of delivery on outcome in
gastroschisis. J Pediatr Surg. 2009;44:912-917.
5. Pastor AC, Phillips JD, Fenton SJ, et al. Routine use of a SILASTIC spring-
loaded silo for infants with gastroschisis: a multicenter randomized controlled
trial. J Pediatr Surg. 2008;43:1807-1812.
6. Kidd JN Jr, Jackson RJ, Smith SD, et al. Evolution of staged versus primary
closure of gastroschisis. Ann Surg. 2003;237:759-764.
7. Sandler A, Lawrence J, Meehan J, et al. A “plastic” sutureless abdominal wall
closure in gastroschisis. J Pediatr Surg. 2004;39:738-741.
8. Emami CN, Youssef F, Baird RJ, et al. A risk-stratified comparison of fascial
versus flap closure techniques on the early outcomes of infants with
gastroschisis. J Pediatr Surg. 2015;50:102-106.
9. Marven S, Owen A. Contemporary postnatal surgical management strategies
for congenital abdominal wall defects. Semin Pediatr Surg. 2008;17:222-235.

66
CHAPTER
Management of the Open
Abdomen
Alexander F. Mericli and Charles E. Butler
DEFINITION
■ The phrase “open abdomen” is used to describe a defect in the abdominal wall
that exposes the viscera.
■ There are several challenging clinical scenarios that can necessitate leaving the
abdominal cavity opened or that can result in an open abdomen (FIG 1):
■ Damage control laparotomy after trauma
■ Excessive visceral edema as seen in severe abdominal sepsis
■ Following a decompressive laparotomy for management of abdominal
compartment syndrome
■ Strategies involving a planned relaparotomy (second look for intestinal
ischemia)
■ Staged abdominal wall reconstruction after fascial dehiscence and
evisceration
■ The central tenant of open abdomen management is the construction of a
temporary abdominal closure until definitive abdominal wall reconstruction
can be performed.
■ When one is confronted with a clinical situation that requires an open
abdomen or results in an opened abdomen, there is a number of reasons why it
may be prudent to stage the abdominal reconstruction with a temporary
abdominal closure:
■ Decreases tension on the musculofascial abdominal wall and prevents
abdominal compartment syndrome
■ Reduces risk of evisceration
■ Facilitates regaining access to the abdominal cavity
■ Reduces lateral retraction of the skin, subcutaneous tissue, muscle and fascia

■ Ideally, it facilitates a delayed primary abdominal wall closure.
ANATOMY
■ The abdominal wall is a layered structure consisting of muscle and fascia.
FIG 1 • Various clinical scenarios commonly managed
using the technique of temporary open abdomen. From
left to right: open abdomen after postsurgical
evisceration; multiple enterocutaneous fistulae; open
abdomen associated with abdominal sepsis; open
abdomen after damage control laparotomy. © Charles
E. Butler, MD.
■ The paired rectus abdominis muscles comprise the central portion, ensheathed
in the fascia of the anterior and posterior rectus sheaths.
■ The rectus muscles are flanked on either side by the oblique family of
muscles: the external oblique, followed by the internal oblique, followed by the
transversus abdominis.
■ Above the arcuate line (approximately at the level of the anterior superior iliac
spine), the anterior rectus sheath is made up by contributions from the external
oblique aponeurosis and internal oblique; the posterior rectus sheath is made up
by the internal oblique, transversus, and transversalis fascia.
■ Below the arcuate line, there is no posterior sheath, only transversalis fascia is
below the rectus muscle (FIG 2).
PATHOGENESIS
■ The scientific rationale for the creation and maintenance of an open abdomen
is centered on the phenomenon of intestinal edema and decreasing the impact
of the inflammatory cascade.

■ The intestine is a highly vascularized structure with a rich network of arteries,
veins, capillaries, and lymphatic vessels. In pathologic states, such as after an
abdominal trauma, after abdominal surgery, or in abdominal sepsis, a decrease
in clearance of fluid from the extracellular space can result in swelling of the
intestinal wall several times the normal diameter, potentially interfering with
perfusion of the bowel.
■ Multiple inflammatory cells are present within the bowel wall and peritoneal
membrane.
■ In the postsurgical abdomen, the trauma abdomen, and in abdominal sepsis,
there is a profound local inflammatory response, which quickly progresses to
systemic inflammatory response syndrome (SIRS), which can easily contribute
to multiple organ dysfunction syndrome (MODS).

FIG 2 • Cross-sectional anatomy of the abdominal wall
superior and inferior to the arcuate line.
■ Premature closure of the abdomen can exacerbate the inflammatory response
and accelerate these syndromes as well as contribute to abdominal
compartment syndrome.1
■ Utilizing the open abdomen technique is associated with survival rates up to
80% after abdominal trauma, severe intra-abdominal sepsis, and acute
evisceration.2–5
Abdominal Compartment Syndrome
■ Abdominal compartment syndrome is a syndrome of uncontrolled intra-
abdominal hypertension. Any factor that raises intra-abdominal pressure can
contribute to abdominal compartment syndrome, including free blood and
clots, bowel edema, vascular congestion, excessive crystalloid resuscitation,
intraperitoneal packing, and nonsurgical bleeding, acidosis, hypothermia, and
postoperative ileus.
■ Normal intra-abdominal pressure is 0 to 5 mm Hg and can easily be quantified
by measuring bladder pressure.
■ Abdominal compartment syndrome is defined as a sustained bladder pressure
of 20 mmHg or greater with dysfunction of 1 or more organ systems (ie, heart,
lungs, kidneys, neurologic, etc.) OR a sustained bladder pressure of greater
than 25 mmHg without organ dysfunction.
■ Once diagnosed, emergent abdominal decompression is indicated. Typically,
organ function returns to normal after decompression, but a mortality rate of
50% has been recorded, secondary to ongoing MODS.6
NATURAL HISTORY
■ There are numerous physiologic changes that accompany an open abdomen.
These changes are not insignificant and can contribute to substantial morbidity;
however, the potential for morbidity of an intentional open abdomen is
outweighed by the possible complications that could ensue, should the
abdomen be closed prematurely.
■ Fluid balance
■ A significant amount of peritoneal fluid is lost through an open abdomen,
typically 1 L/h for a 70 kg person.

■ If a closed suction system is used as part of the temporary abdominal closure,
such as negative pressure therapy, then this fluid loss can be quantified and
therefore accurately replaced.
■ Maintenance of normothermia
■ The large cutaneous defect oftentimes present with an open abdomen impairs
the body’s thermoregulatory system.
■ The loss of peritoneal fluid exacerbates heat loss through convection.
■ Frequent temperature monitoring, forced air warming blankets, and a
warmed room are all techniques that can be employed to counteract this
effect.
■ Protein loss
■ Peritoneal fluid is protein rich, with 2 g protein/L.7 This must be replaced
through diet or enteral feeds in order to maintain nitrogen balance.
■ Fistula
■ With the open abdomen, the bowel is at risk for injury. Patients with a fresh
bowel anastomosis are at greatest risk.8
■ Whenever possible, the viscera should be covered by the omentum for an
additional layer of protection.
FIG 3 • Anterior and lateral views of a patient with
abdominal loss of domain. The rectus and oblique
muscles have retracted laterally overtime. The exposed
viscera is skin grafted in anticipation of delayed
abdominal wall reconstruction. © Charles E. Butler, MD.
■ Loss of domain
■ The creation of an open abdomen places the patient at risk for losing

abdominal domain as the musculofascial abdominal wall retracts laterally
over time (FIG 3).
■ Methods of temporary abdominal closure are designed to prevent this
situation by keeping the fascia as medial as possible.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Although it is most commonly the decision of the general or trauma surgeon, it
is helpful for the plastic surgeon to understand the factors that are involved in
deciding whether a patient should be managed with an open abdomen.
■ Trauma/damage control
■ Preoperative predictors: penetrating torso trauma with hypotension, need for
resuscitative thoracotomy, blunt abdominal trauma with intraperitoneal
hemorrhage, and hypotension
■ Intraoperative predictors: development of a coagulopathy, intraoperative
exsanguination requiring greater than 10 units of packed red blood cells, pH
less than 7.2, base deficit greater than −6 in patients older than 55 years or
greater than −15 in patients younger than 55 years, temperature less than
34°C, and/or estimated blood loss greater than 4 L2.
■ Abdominal compartment syndrome
■ Patients with sustained intra-abdominal pressure greater than 20 mm Hg with
onset of new organ dysfunction
■ Patients with acutely increased intra-abdominal pressures greater than 25 mm
Hg without acute organ dysfunction should be considered for prophylactic
decompression.
■ Patients at high risk for development of abdominal compartment syndrome:
those requiring greater than 15 L crystalloid or 10 units of packed red blood
cells, patients with increased peak inspiratory pressures greater than 40 mm
Hg upon fascial closure.2
■ Planned relaparotomy
■ Management of intestinal ischemia potentially requiring repeat bowel
resections
■ Severe abdominal sepsis necessitating repeated debridements, such as in
pancreatic necrosis or intra-abdominal abscesses
■ Acute postoperative evisceration
■ Fascial dehiscence in the acute or subacute postoperative period can result in
evisceration. Given that this often occurs during the inflammatory stage of
wound healing, visceral edema and friable, inflamed abdominal wall soft

tissue may preclude immediate fascial reapproximation.
IMAGING
■ Computed tomographic imaging of the abdomen and pelvis are imperative for
surgical planning and preoperative evaluation. FIG 4 demonstrates images
from a patient with an open abdomen and associated lateral musculofascial
retraction (loss of domain) (left) as well as a patient with an incisional ventral
hernia after laparotomy (right).
SURGICAL MANAGEMENT
■ A variety of surgical techniques for temporary abdominal closure are
available, ranging from a skin-only closure to the more sophisticated ABThera
System (KCI, San Antonio, TX).
■ The ideal temporary closure contains the viscera, minimizes skin maceration
and damage to the underlying bowel or fascia, and facilitates durable fascial
reapproximation. Although there are advantages and disadvantages to each
technique (Table 1), the method of temporary abdominal closure is largely
dependent upon surgeon preference.
Preoperative Planning
■ Preoperatively, a full history should be obtained and physical exam should be
performed.
■ A basic laboratory panel should be obtained and preoperative CT scan should
be performed.
FIG 4 • Computed tomography images from a patient
with an open abdomen and associated lateral

musculofascial retraction (loss of domain) (left) as well
as a patient with an incisional ventral hernia after
laparotomy (right).
Table 1 Temporary Abdominal Closure Techniques

Materials/Technique
Advantages
Disadvantages
Skin-only
closure
Suture; staples
Inexpensive;
fast; minimizes
fluid and heat
loss
100% hernia
rate; high risk of
evisceration; risk
of abdominal
compartment
syndrome
Silo technique
“Bogota” bag; 3 L IV
bag; suture; drains;
bag secured to edges
of fascia to contain
viscera within “silo”
Inexpensive;
visualization of
intra-abdominal
contents;
minimizes fluid
and heat loss
Risk of
evisceration; loss
of domain; poor
fluid
management
Absorbable
synthetic mesh
Polyglactin 910 mesh,
suture; mesh placed
as bridge between
fascial edges
Absorbable, can
apply skin graft
once granulation
tissue forms
over mesh
100% ventral
hernia rate; risk
of
enterocutaneous
fistula and
evisceration
Bioprosthetic
mesh
Acellular dermal
matrix; mesh placed
as bridge between
fascial edges
Incorporates;
low risk of
infection or
extrusion in
contaminated
settings; can be
skin grafted
once granulation
tissue forms
Expensive;
extremely high
ventral hernia
rate at 5 years if
used in bridging
format
Nonabsorbable
synthetic mesh
Polypropylene;
polytetrafluoroethylene
patch; patch anchored
to fascia laterally and
serial plication of the
Extends the life
span of the
temporary
abdominal
closure;
Fascial trauma;
adhesions;
enterocutaneous
fistula formation;
compartment

patch at the midline
progressively
medializes the fascial
edges
inexpensive;
limits loss of
domain
syndrome
possible if
plication too
aggressive
Patch
Wittmann patch
(Starsurgical, Inc.,
Burlington, WI); two
pieces of mesh
approximated to
lateral fascial edges,
two pieces latch onto
each other similar to
Velcro; mesh is
sequentially tightened
Limits loss of
domain; high
rate of primary
fascial
approximation;
allows for
extended open
abdomen
Requires multiple
fascial
manipulations;
requires special
equipment;
adhesions can
occur to
undersurface of
mesh
Vacuum pack
closure
Nonadherent sheet
placed over bowel,
followed by surgical
towels, drains, and
iodoform-impregnated
occlusive dressing;
wall suction
Inexpensive;
ability to monitor
fluid losses;
temperature
control
Poor control of
domain;
theoretical
potential for
massive
exsanguination.
Enterocutaneous
fistula formation
Commercial
negative
pressure
system
V.A.C. Therapy (KCI,
San Antonio, TX)
Plastic-encased
sponge
designed to be
placed in
contact with the
viscera;
prevents
adhesions; fluid
management;
temperature
control;
minimizes
visceral edema;
high rate of
success with
primary fascial
reapproximation
if used in
Theoretical
potential for
massive
exsanguination.
Enterocutaneous
fistula formation;
expensive

conjunction with
fascial retention
sutures
T E C H N I Q U E S
■ Fascial Closure Techniques
■ Fascial closure techniques use an interposition graft material sutured to the
abdominal fascia to bridge the laparotomy defect.
■ These techniques can utilize absorbable synthetic materials such as
polyglactin 910 mesh, bioprosthetic mesh such as Strattice (Acelity, Inc.),
Surgimend (TEI biosciences, Inc.), or nonabsorbable synthetic materials such
as the Wittmann Patch (Starsurgical, Inc.), expanded polytetrafluoroethylene,
or polypropylene mesh.
■ Initially, the mesh material should be loose in order to allow for visceral
edema.
■ As the edema resolves, the mesh is either serially excised, plicated, or
advanced (Wittmann patch) to facilitate fascial approximation during
reexploration.
■ Typically, the patient is taken to the operating room every 48 hours for
repeated washouts, reexplorations, and mesh tightening until the fascia can be
reapproximated primarily.
■ These techniques provide a mechanism to limit or reverse the loss of domain
that occurs with an open abdomen. Therefore, fascial closure techniques
should be considered when the open abdomen is likely to be prolonged
greater than 1 week.
■ Fascial closure techniques do require suturing to the abdominal fascia, which
may increase the risk of fascial injury.
Fascial Approximation Anticipated During Present Hospital
Admission
■ Fascial closure technique if the possibility of fascial approximation is
anticipated during hospital admission: Wittmann Patch (Starsurgical, Inc.)
■ Intraperitoneal drains are placed.

■ Patch sutured to fascial edges on either side of laparotomy.
■ Material has hooks and eyes similar to Velcro, which facilitates repeated
openings and reclosures (TECH FIG 1).
TECH FIG 1 • Artistic rendition of the Wittmann patch
for management of the temporary open abdomen in
situations where fascial approximation is anticipated
during present hospital admission. Note the hooks and
loops on the opposing pieces of mesh allowing
sequential fascial medialization.
■ The rate of primary closure for this method is 78% to 100%.9
■ The rate of fistula is 2%.9
Delayed Fascial Approximation Anticipated
■ Fascial closure technique if fascial approximation is likely not possible
during initial hospital admission: bridged polyglactin 910 mesh or bridged

bioprosthetic mesh
■ Intraperitoneal drains are placed.
■ Mesh is fixed to the fascial using polydioxanone sutures, bridging the
fascial defect (TECH FIG 2A).
■ The mesh is covered with a moist dressing and changed twice daily.
■ The mesh is evaluated for redundancy on a daily basis; if redundancy is
present, the pleating is plicated in the midline at the bedside with running
absorbable suture.
■ If the fascial edges are able to be approximated to within 2 to 4 cm of each
other before the formation of granulation tissue overlying the mesh, then
the patient is returned to the OR for delayed primary fascial
reapproximation.
TECH FIG 2 • A. Abdominal wall closure with bilateral
component separation and bridged bioprosthetic
mesh. B–D. Series of photographs demonstrating
temporary abdominal closure with a split-thickness
skin graft. From left to right: Due to visceral edema,
fascial approximation is not possible. A bridging mesh
is placed and granulation tissue forms over the mesh.
Skin grafts are placed over the mesh and granulation
tissue. © Charles E. Butler, MD.
■ If granulation tissue forms over the mesh before fascial reapproximation is
possible, then a skin graft is applied and delayed reconstruction is planned
for 6 to 12 months following the injury (TECH FIG 2B–D).
■ In this scenario, bioprosthetic mesh may have several advantages over
polyglactin 910, including a greater tensile strength and structural support

of the abdominal wall comparatively. The disadvantages include expense
and difficulty to plicate at the bedside. Therefore, if a biologic is used, it
should be inset with sufficient tension. Similarly, it too can be skin grafted
once granulation tissue has formed.
Negative Pressure Wound Therapy for Temporary Abdominal
Closure
■ Negative pressure stimulates cell division, angiogenesis, and cell
proliferation.10,11
■ Negative pressure for temporary abdominal closure was first described by
Barker and colleagues.12 They described a system in which a fenestrated
plastic draped was placed in contact with the viscera, followed by surgical
towels and drains; this middle layer was then covered by a bioocclusive
adhesive sheet (Ioban). The drains were then connected to the wall suction
at −150 mm Hg. Using this system, the authors achieved a primary fascial
reapproximation rate of 55.4%. Fistula rate was 4.5%. The authors describe
that within 7 to 10 days, the bowel would adhere to the abdominal wall,
preventing primary reapproximation. Therefore, if definitive abdominal
wall closure could not be achieved within 7 to 10, then the bowel should be
skin grafted and definitive closure planned for 6 to 12 months.
■ There are now several commercially available options for negative pressure
management of the open abdomen. The most studied and popular system is
the VAC System by KCI, Inc. (San Antonio, TX).
■ The VAC System consists of an inner plastic-encased sponge designed to be
in direct contact with the viscera. The plastic interface protects the bowel,
prevents adhesion formation, and is perforated to allow drainage of peritoneal
fluid.
■ Next, a macroporous polyurethane sponge is then applied over the inner
layer and is in direct contact with the overlying fascia and subcutaneous
tissues.
■ Fascial retention sutures can then be placed, if desired, to further medialize
the fascial edges.
■ The entire construct is then covered with an occlusive dressing and the
machine is set to −125 mm Hg (TECH FIG 3).
■ The patient is returned to the operative room every 2 to 3 days for irrigation,
debridement, negative pressure dressing change, and further fascial
medialization.

■ Primary fascial closure rates using this system average 67%9 but can
achieve 100% with the adjunctive use of fascial retention sutures.13
■ Fistula rate is 2.9%.
TECH FIG 3 • Negative pressure therapy for
management of the open abdomen. A sterile
fenestrated plastic drape is placed over the exposed
viscera, followed by a macroporous sponge, and
covered with an occlusive plastic dressing. © Charles
E. Butler, MD.
PEARLS AND PITFALLS
Physiologic rationale
for temporary
abdominal closure?
■ Premature closure of the abdomen can exacerbate the
inflammatory response and accelerate SIRS and MODS
as well as contribute to abdominal compartment
syndrome
■ Utilizing the open abdomen technique is associated with
survival rates up to 80% after abdominal trauma, severe
intra-abdominal sepsis, and acute evisceration
When to consider
temporary abdominal
closure?
■ Laparotomy for intra-abdominal trauma
■ Abdominal compartment syndrome
■ Abdominal sepsis
■ Planned relaparotomy

■ Acute evisceration
What are the two main
methods of temporary
abdominal closure?
■ Progressive fascial closure techniques
■ Negative pressure wound therapy
Postoperative care
■ Intensive fluid management due to insensible losses
associated with open abdomen
■ Nutrition and protein intake
■ Return to the operating room every other day for repeat
debridement, dressing change, and integral fascial
advancement
POSTOPERATIVE CARE
■ Because of the physiologic derangement that is associated with the clinical
conditions necessitating an open abdomen, these patients often require
intensive care.
■ Postoperatively, the focus should be on resuscitation, fluid and electrolyte
management, and nutrition. There is a multitude of information available on
these topics, a review of which is outside the scope of this chapter.
■ Time interval for repeated debridements
■ Regardless of the technique of temporary abdominal closure, the patient is
typically returned to the operating room every 2 or 3 days.
■ There are no data to support a specific interval, and every clinical situation is
different.
■ A shorter interval between episodes of general anesthesia may be
physiologically challenging for the patient, whereas a longer period will
allow for the formation of intestinal adhesions, increasing the risk for enteral
injury.
■ Nutrition
■ Assuming there are no contraindications (enteral anastomosis, ileus), enteral
nutrition can and should continue during the period of open abdomen and
temporary abdominal closure.
■ Because of the necessary repeated trips to the operating room, it can be
difficult to meet nutritional requirements; therefore, a combination of both
enteral and parenteral nutrition is prudent.
■ Neuromuscular blockade

■ A short course of neuromuscular blockade may decrease fascial edge
retraction and be a useful adjunct to negative pressure devices.
■ In one study, 192 open abdomen patients were divided into two groups: one
receiving a continuous infusion of a neuromuscular blocker for greater than
24 hours and one receiving standard care.
■ The patients receiving the neuromuscular blockade were more likely to
achieve primary fascial closure by 7 days (93% vs 83% P < .024) and had no
increase in pneumonia.14
■ Antibiotics
■ There is no evidence for prophylactic administration of antibiotics in patients
with open abdomens other than the typical perioperative prophylactic
antibiotic dosing.
■ Antibiotic use and duration should be determined by the treatment
appropriate for the primary abdominal pathology (ie, abdominal sepsis,
abscess, etc.).
■ Sedation and analgesia
■ There are no studies regarding optimal pain control or sedation in patients
with an open abdomen.
■ Epidural anesthesia has been shown to reduce intra-abdominal pressure and
pain control in patients with open abdomen due to abdominal compartment
syndrome.15
OUTCOMES
■ Once the indication for open abdomen has resolved, a delayed primary
abdominal wall reconstruction should be performed as soon as possible.
■ Delayed primary closure of the abdominal wall is most possible if performed
within 8 days of initial open abdomen.16,17 A recent study of the damage
control population demonstrated that delayed primary abdominal closure is
only possible in 65% of patients.9
■ If negative pressure temporary closure is combined with fascial retention
sutures, a 100% primary repair rate can be achieved.13
■ In situations where delayed primary abdominal closure cannot be obtained, a
bridged biologic or synthetic absorbable mesh repair is performed, followed by
skin grafting over the mesh once granulation tissue has formed. This controlled
ventral hernia is then repaired 6 to 12 months later.18
■ In certain clinical scenarios, the iatrogenic creation of a ventral hernia with

skin graft coverage is not in the patient’s best interest. For instance, in the
oncologic population, a durable soft tissue reconstruction must be established
expeditiously so that the patient can proceed with adjuvant radiation and
chemotherapy.
■ In these situations, adjunctive abdominal wall reconstruction techniques can
oftentimes be employed to achieve primary fascial reapproximation in the
acute setting.
■ These techniques are covered in other chapters and include component
separation, the use of inlay mesh, and various autologous flaps.
COMPLICATIONS
■ The open abdomen leads to fluid and electrolyte derangements that must be
actively monitored and corrected. The prolonged open abdomen, bowel
fistulization, and loss of abdominal domain can complicate management. The
main goal of temporary abdominal closure is fluid management and
minimizing the loss of domain.
■ Methods of temporary abdominal closure are associated with a bowel
fistulization rate of 2% to 4.5%. Factors that increase the likelihood of fistula
are abdominal sepsis, bowel anastomosis, and negative pressure therapy in
direct continuity with a new bowel anastomosis.
■ If using a “fascial closure technique,” primary fascial approximation should be
achieved within 7 to 12 days; otherwise, the formation of intestinal adhesions
may necessitate a delayed closure approach at a later date.
■ If using a modern negative pressure technique, such as the ABThera System,
primary fascial approximation can be achieved over a longer period of time, up
to 30 days.
■ Temporary abdominal closure techniques result in primary fascial
approximation in 65% to 100% of patients. In the 35% of patients where
primary fascial approximation is not possible, then either a delayed closure
approach is taken (skin grafting followed by abdominal closure at a later date
after the resolution of inflammation), an adjunctive abdominal reconstruction
technique is utilized (component separation, flap), or some combination of
both.
REFERENCES
1. Malbrain ML, Deeren D, De Potter TJ. Intra-abdominal hypertension in the
critically ill: it is time to pay attention. Curr Opin Crit Care. 2005;11:156-171.

2. Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of
the open abdomen. World J Surg. 2012;36:497-510.
3. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: an
approach for improved survival in exsanguinating penetrating abdominal
injury. J Trauma. 1993;35:375-382.
4. Ivatury RR, Nallanthambi M, Rao PM, et al. Open management of the septic
abdomen: therapeutic and prognostic considerations based on the APACHE II.
Crit Care Med. 1989;17:511-517.
5. Garcia-Sabrido JL, Tallado JM, Christou NV, et al. Treatment of severe intra-
abdominal sepsis and/or necrotic foci by and “open-abdomen” approach:
zipper and zipper-mesh techniques. Arch Surg. 1988;123:152-156.
6. Balough Z, McKinley BA, Holcomb JB, et al. Both primary and secondary
abdominal compartment syndrome can be predicted early and are harbingers of
multiple organ failure. J Trauma. 2003;54:848-859.
7. Cheatham ML, Safcsak K, Brzezinski SJ, Lube MW. Nitrogen balance,
protein loss, and the open abdomen. Crit Care Med. 2007;35:127-131.
8. Ramsay PT, Mejia VA. Management of enteroatmospheric fistulae in the open
abdomen. Am Surg. 2010;76:637-639.
9. Boele van Hensbroek P, Wind J, Dijkgraaf MG, et al. Temporary closure of
the open abdomen: a systematic review on delayed primary fascial closure in
patients with an open abdomen. World J Surg. 2009;33:199-207.
10. Ingber D. In search of cellular control: signal transduction in context. J Cell
Biochem Suppl. 1998;30-31:232-237.
11. Chen SZ, Li J, Li XY, Xu LS. Effects of vacuum-assisted closure on wound
microcirculation: an experimental study. Asian J Surg. 2005;28(3):211-217.
12. Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack technique of
temporary abdominal closure: a 7-year experience with 112 patients. J Trauma.
2000;48:201-207.
13. Cothren CC, Moore EE, Johnson JL, et al. One hundred percent fascial
approximation with sequential abdominal closure of the open abdomen. Am J
Surg. 2006;192:238-242.
14. Abouassaly CT, Dutton WD, Zaydfudim V, et al. Postoperative
neuromuscular blocker use is associated with higher primary fascial closure
rates after damage control laparotomy. J Trauma. 2010;69:557-561.
15. Hakobyan RV, Mkhoyan GG. Epidural analgesia decreases intraabdominal
pressure in postoperative patients with primary intra-abdominal hypertension.
Acta Clin Belg. 2008;63:86-92.

16. Miller PR, Thompson JT, Faler BJ, et al. Late fascial closure in lieu of ventral
hernia: the next step in open abdomen management. J Trauma. 2002;53:843-
849.
17. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of
vacuum-assisted fascial closure after open abdomen: planned ventral hernia
rate is substantially reduced. Ann Surg. 2004;239:608-614.
18. Bee TK, Croce MA, Magnotti LJ, et al. Temporary abdominal closure
techniques: a prospective randomized trial comparing polyglactin 910 mesh
and vacuum-assisted closure. J Trauma. 2008;65:
337-342.

67
CHAPTERUmbilicoplasty
Sergey Y. Turin, Chad A. Purnell, and Gregory A. Dumanian
DEFINITION
■ Reconstruction of the umbilicus is an essential part of restoring the natural
aesthetic of the abdomen.
■ It is the focal point of the anterior abdominal wall, helps define the middle
abdominal sulcus and if absent or malformed, will draw attention to the
abdomen.1
■ We present two simple techniques for creation of a neoumbilicus.
■ One is to be used for patients with vertical midline incisions.
■ The other is for patients undergoing abdominoplasty when the umbilical
stalk cannot be maintained.
■ Umbilicoplasty for a scarred umbilicus after a standard abdominoplasty will
also be discussed.
ANATOMY
■ The umbilicus is generally described as a depressed circular indentation
approximately 1.5 to 2 cm in diameter positioned in the midline of the
abdomen at the level of the superior iliac crests2 (FIG 1A).
■ The vertical position has also been variably described as 30% to 47% of the
way up between the symphysis pubis and the xiphoid.3,4
■ The aesthetic ideal of the female umbilicus has been described as T or vertical
in shape with a superior hood or shelf.1 Protrusion, transverse orientation, or
excessive size are rated as less attractive. There is a linear depression running
from the xiphoid to the umbilicus, and this compares to the smooth contour of
skin without a depression from the umbilicus to the symphysis pubis.
Surrounding the umbilicus is a zone of decreased fat approximately 3 cm in

diameter total, and this fat thickens to its maximum dimension for the ventral
abdomen over the anterior rectus fascia.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Past surgical history, including prior transection of the umbilical stalk at the
time of an umbilical hernia repair, must be obtained. Prior laparoscopy
umbilical portal sites can be the cause of incisional hernias and scar formation
around the umbilicus.
■ A reversed sit-up maneuver should be done for evaluation of rectus diastasis.
■ Significant abdominal hirsutism should be appreciated preoperatively and is a
relative contraindication to umbilicoplasty, as hair-bearing skin is placed deep
against the abdominal wall and could create an iatrogenic pilonidal cyst.

FIG 1 • A. Location of umbilicus. B. T-shaped umbilicus.
C. Aesthetic abdominal contour with supraumbilical
depression.
SURGICAL MANAGEMENT
Preoperative Planning
■ The decision-making process for umbilicoplasty begins in the operating room
after repair of the rectus muscles in the midline. The critical issue is whether or
not the umbilical stalk remains vascularized and attached to the abdominal
wall. For midline laparotomies, there is typically skin excess, and we find it
easier to discard a marginal umbilical stalk and simply reconstruct it with
pumpkin-teeth flaps.
■ Patients undergoing an abdominoplasty where the stalk will not remain viable
will need to be counseled that the reconstructed umbilicus with local flaps is
not as aesthetic as the umbilical stalk that they currently have.
Positioning
■ The patient is positioned in the usual supine position. The entire abdomen
from xiphoid to pubis should be prepped to allow accurate determination of the
midline and landmarks for appropriate umbilicus positioning.

T E C H N I Q U E S
■ Umbilicoplasty in the Setting of a Midline Incision
Video p8-c067
■ Once the abdominal wall is reapproximated in the midline, we assess the
amount of skin redundancy and if the umbilical stalk is still connected to the
abdominal wall. In the majority of abdominal wall reconstructions, the skin is
redundant and requires removal to decrease dead space and improve healing.
The markings for what we term “pumpkin-teeth” flaps are made at the time
of this vertically oriented skin excision (TECH FIG 1A–C).
TECH FIG 1 • Markings for “pumpkin-teeth” flaps as
00:00 / 00:00

final step in abdominal wall reconstruction.
■ Vertical lines from the xiphoid to the pubis are drawn to outline the midline
skin to be excised. Rectangular flaps 2 cm in height and 2 cm wide are drawn
and preserved in the desired location of the neoumbilicus. The flaps are
excised fairly thinly, with minimal dermal fat remaining attached. After
incising these pumpkin teeth, the full-thickness vertical incision for the
length of the abdominal skin closure is then completed.
■ We also perform a small amount of excision lipectomy just superior to the
site of the neoumbilicus to allow for a depression in that area—this provides
an aesthetically pleasing contour to the umbilicus.
■ As the closure progresses, two 3-way sutures between the edges of the flaps
and the final planned position of the neoumbilicus on the abdominal wall are
placed and then tied using a 3-0 polydioxanone suture. The remaining dermal
sutures are then placed in standard fashion, “folding in” these pumpkin-teeth
skin flaps as the neoumbilicus (TECH FIG 2).
TECH FIG 2 • Postoperative result for “pumpkin-teeth”
flaps.
■ De Novo Umbilicoplasty Without a Midline

Incision
■ For situations when the native umbilicus is removed and there is no vertical
midline incision but still some laxity in the transverse plane, we present a
variation on the technique described above (TECH FIG 3A).
■ Two laterally based rectangular flaps are incised, and the fat deep to this
entire area for a diameter of 3 cm is excised. These rectangular flaps are then
sewn down to the abdominal wall with 3-0 polydioxanone sutures.
■ For closure of the donor site, again A is brought to A prime, and B is brought
to B prime. This creates excessive tissue above and below the neoumbilicus,
which is handled as two separate W-plasties. The hashed triangles are
excised, and point C and C prime are sewn down to the abdominal wall to
create a circular depression (TECH FIG 3B–E).
TECH FIG 3 • A. Umbilicoplasty design showing the
initial H-shaped incision; excision of the redundant
triangles of skin (shaded in); final closure design. B.
Skin incised and approximated in midline, excess skin
excised as W-plasties. C. Skin flaps tacked down to
abdominal wall. D. Result at the end of the surgical
procedure. E. Postoperative result.

■ Umbilical Stenosis After Abdominoplasty
■ The goal of this umbilicoplasty is to bring the abdominal skin down to
healthy umbilical stalk remnants (TECH FIG 4).
■ In the office, the pinhole umbilicus opening is probed to ensure that a viable
umbilicus stalk exists deep. The area around the scarred pinhole umbilicus
opening is injected with 10 cc of xylocaine with epinephrine.
■ The circular umbilical scar is excised.
■ A 3-cm ring of fat is excised, especially superiorly, both to assist in local
closure as well as to better identify the viable umbilicus stalk.
■ The stalk is freed of scar tethering it to the abdominal wall and is mobilized
superficially. The inferior aspect of stalk is opened in the Heineke Mikulicz
fashion to enlarge the circular suture line.
■ The closure is performed in one layer with 5-0 polypropylene sutures to the
abdominal skin.
TECH FIG 4 • Umbilical stenosis after full
abdominoplasty.
PEARLS AND PITFALLS
Patient
selection
■ Umbilicoplasty is not to be performed in hirsute skin, as this will
bring hair-bearing skin deeply and create an iatrogenic pilonidal
sinus.

Technical
considerations
■ These procedures require a transverse excess of skin. If the skin
is tight transversely, the umbilicoplasty will be pulled open.
■ Umbilicoplasties tend to drain for 1–2 weeks after creation.
■ Optimal appearance will include a depression of fat in the
midline from the umbilicus to the xiphoid (see FIG 1C).
Scarred
umbilicus
■ Treatment of a scarred umbilicus after abdominoplasty will
require pressure on the circular scar with a marble or equivalent
daily to stretch and maintain patency of the stalk.
Stenosis of
the
neoumbilicus
■ This may occur after insetting the umbilicus in an
abdominoplasty or with a de novo umbilicus. Stenting is the first-
line management options and can be accomplished with daily use
of a Vaseline-impregnated gauze bolster or even a firm noise-
reducing ear plug for the 1–2 months following reconstruction.5
Umbilicus
malposition in
sagittal or
coronal planes
■ This occurs especially when skin is extremely redundant as in
cases of massive weight loss. Preoperative placement of staples
10 cm from the midline aids in having the final skin closure in the
midline.
POSTOPERATIVE CARE
■ We encourage the patients to gently wash these closures with soap and water
twice daily and to cover them with a dry gauze for cleanliness.
OUTCOMES
■ Creation of a neoumbilicus at the time of a midline hernia repair is reliable and
significantly improves appearance. Pumpkin-teeth flaps tack the skin down to
the abdominal wall as an ultimate “quilting” suture to help limit seroma
formation. The only complications have been excessive hair growth in males,
and one female patient where the umbilicus lost its depth due to a lack of
transverse skin laxity.
COMPLICATIONS
■ Drainage has on occasion lasted for several weeks after umbilicoplasty.
Although difficult to quantify, on occasion, there has been restenosis of the
scarred umbilicus after umbilicoplasty.
REFERENCES
1. Craig SB, Faller MS, Puckett CL. In search of the ideal female umbilicus.
Plast Reconstr Surg. 2000;105:389.

2. Dini G, Ferreira L. A simple technique for umbilicus dilatation. Plast Reconstr
Surg. 2006;117:336-337.
3. Dubou R, Ousterhout D. Placement of the umbilicus in an abdominoplasty.
Plast Reconstr Surg. 1978;61:291.
4. Gallo J. Vertical relocation of the umbilical scar in abdominoplasty of Bozola
and Psillakis Group IV cases—standardization of procedures. Br Rev Plast
Surg. 2014;29:1.
5. Parnia R, Ghorbani L, Sepehrvand N, et al. Determining anatomical position
of the umbilicus in Iranian girls, and providing quantitative indices and
formula to determine neo-umbilicus during abdominoplasty. Indian J Plast
Surg. 2012;45(1):94-96.

68
CHAPTER
Section XVIII: Perineum
Hypospadias Repair
Christopher D. Morrison and Earl Y. Cheng
DEFINITION
■ Hypospadias is defined as a ventrally located meatus proximal to its expected
orthotopic location.
■ Hypospadias is often associated with chordee, an abnormal ventral curvature
of the penis.
■ The prevalence of hypospadias is estimated at 1 per 200 to 300 live births, and
the prevalence appears to be increasing.1,2
ANATOMY
■ The hypospadiac meatus can be located anywhere along the course of the
urethra:
■ Posterior/proximal: perineal, scrotal, penoscrotal
■ Middle: along the shaft of the penis
■ Distal/anterior: subcoronal, glandular
■ In general, a more proximal hypospadiac meatus is associated with a more
significant degree of chordee.
■ The glans can vary in size, and the urethral plate can range from grooved to
completely flat.
■ In most cases, the prepuce does not extend ventrally, resulting in a
noncircumferential dorsal hooded foreskin.
■ The skin overlying the ventral aspect of the urethra can be dysplastic or
insufficient, leading to ventral tethering of the penis.
■ The corpus spongiosum diverges laterally or is completely atretic, which can
result in a urethra that is only covered by a very thin layer of ventral skin.

PATHOGENESIS
■ Hypospadias results from the incomplete development of the penis and urethra
between 8 and 14 weeks gestation.
■ Tubularization of the urethra is thought to be androgen mediated, and
disruption of this process results in a hypospadiac meatus.3
■ Both genetic and environmental factors have been associated with
hypospadias.4
■ Hypospadias is heritable and can be associated with several syndromes (less
than 10% of cases).
■ Over 20 genes have been implicated in the pathogenesis of hypospadias.
■ Environmental factors such as maternal medication/drug use, maternal age,
maternal obesity, and placental insufficiency have been associated with
hypospadias and may account for the rising prevalence of hypospadias.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Hypospadias is typically recognized at the time of birth during newborn
examination.
■ Newborn circumcision (if desired) is contraindicated in the setting of
hypospadias because the foreskin may be needed for surgical repair of the
hypospadias.
■ History
■ A complete prenatal and family history should be performed to identify
possible contributing factors.
■ If possible, ask the parents about the direction and strength of the patient’s
urinary stream, as well as the curvature of the penis with erections. A
downward deflected urinary stream or significant curvature of the penis may
affect the patient’s urinary and sexual function later in life.
■ Exam
■ Penile exam:
• Location and appearance of the meatus
• Quality and depth of urethral plate
• Size and configuration of the glans
• Degree of chordee
• Integrity of the ventral skin
• Amount of dorsal hooded foreskin available
■ A careful scrotal and inguinal exam should be performed to look for other

abnormalities such as cryptorchidism, hydrocele, or hernia.5
■ If a patient also has undescended testicles (unilateral or bilateral), it is
important to consider the possibility of a disorder of sex development (DSD).
• If undiagnosed, a DSD condition such as congenital adrenal hyperplasia
(CAH) can be life threatening.
• These patients should undergo an endocrine workup and karyotype.
• Approximately 20% to 30% of patients with hypospadias and
cryptorchidism will have a karyotype abnormality.3
• The most common DSD seen in patients with hypospadias and
cryptorchidism is mixed gonadal dysgenesis.
IMAGING
■ Proximal hypospadias can be associated with renal anomalies. However,
routine imaging is not performed in most cases of hypospadias. If the patient
has a severe proximal hypospadias, one could consider obtaining a renal
ultrasound.
NONOPERATIVE MANAGEMENT
■ For patients with distal/anterior hypospadias in which the urinary stream is
relatively straight and there is no significant chordee, surgical correction is
generally considered optional and is usually performed more for appearance
and psychosocial reasons rather than for correction of a functional need.
■ There is controversy among some urologists as to whether correction of distal
hypospadias confers long-term benefits for patients.
■ A 1995 study of 500 men found great variability in the meatal location.
Thirteen percent of these men had anterior hypospadias with no functional
compromise, and two-thirds of these patients were unaware of their
hypospadiac condition.5
■ In contrast, a 2014 study examined the self-reported outcomes for patients
who had uncorrected hypospadias and found that these patients were more
likely to have worse voiding symptoms, more penile curvature making sexual
intercourse difficult, and worse satisfaction with the appearance of their
penis.6
SURGICAL MANAGEMENT
■ Multiple different surgical techniques have been described for distal
hypospadias, including the MAGPI and the Mathieu repair. However, the

tubularized incised plate (TIP) urethroplasty, as described by Snodgrass, is the
technique that is now most commonly performed by hypospadias surgeons. It
is suitable for patients with a sufficiently healthy and wide (greater than 7 mm)
urethral plate and less than 30-degree chordee.
■ Midshaft hypospadias is often approached similarly to distal hypospadias;
however, it tends to be associated with more significant chordee.
■ If there is less than 30-degree chordee and the urethral plate is sufficiently
healthy and wide, a TIP urethroplasty can be performed.
■ If there is less than 30-degree chordee but the urethral plate is too narrow,
hypospadias repair can be performed using a transverse preputial island flap
or an inner preputial inlay graft.
■ Proximal hypospadias repair presents a greater challenge for several reasons:
■ There is a longer length of urethra that must be tubularized.
■ The urethral plate may be narrow, fibrotic, or even nonexistent.
■ There tends to be a more significant degree of chordee.
Preoperative Planning
■ If diagnosed at the time of birth, most urologists will delay treatment until the
child is 6 months of age to decrease potential anesthetic risks.
■ Ideally, the surgery should be performed prior to the child being old enough
to remember the surgery.
■ Many advocate hypospadias repair between 6 and 12 months of life.7
■ Historically, hormonal stimulation with testosterone, dihydrotestosterone, or
human chorionic gonadotropin was given preoperatively to increase penile
length, glans circumference, and vascularity as this was thought to aid in
surgical correction.
■ However, there is now concern that hormonal stimulation may affect normal
wound healing and may lead to an increased risk of postoperative
complications.8
■ Nevertheless, hormone stimulation is still felt to be beneficial in more severe
cases of hypospadias.
Positioning
■ After the induction of general anesthesia, if possible, a caudal anesthetic block
is recommended for perioperative pain control.
■ The patient is positioned supine for the surgery.

Approach
■ The operative approach varies based on the following:
■ Location of the hypospadiac meatus
■ Severity of chordee
■ Characteristics (width, depth, and health) of urethral plate
■ Quality of penile shaft and dorsal hood skin
■ Surgeon preference/experience
■ The main components of a hypospadias repair consist of the following:
■ Evaluation and correction of chordee
■ Urethroplasty
■ Glanuloplasty
■ Skin coverage
■ Hypospadias repair is typically performed with the use of 2.5 times surgical
loupes or with an operating microscope.
■ Hypospadias repair can be either a one- or two-staged repair. The decision to
perform a one- or two-stage repair depends primarily on the degree of chordee
and the health of the urethral plate.
■ If the chordee can be corrected with dorsal plication and the urethral plate is
healthy and wide, a TIP urethroplasty should be performed.
■ If the chordee can be corrected with dorsal plication but the urethral plate is
NOT healthy and wide, the surgeon can perform either a one-staged preputial
onlay island flap urethroplasty or a two-staged inner preputial inlay graft with
subsequent tubularization.
■ If division of the urethral plate is required for correction of chordee, this
should be performed during the initial stage. The urethroplasty should be
performed in a second stage at least 6 months later.
■ An algorithm for intraoperative decision-making during hypospadias repair is
presented in FIG 1.

FIG 1 • Algorithm for hypospadias repair.
T E C H N I Q U E S
■ Tubularized Incised Plate Urethroplasty for Distal
Hypospadias Repair
■ Examination Under Anesthesia
■ Prior to beginning the surgery, examine the anatomy.
■ Visually inspect the meatus.
■ Calibrate the meatus with bougies and examine the ventral penile skin
overlying the urethra.
■ If the urethra and overlying skin is too thin, it may be necessary to perform a
cutback procedure to healthier tissue and perform a more proximal
hypospadias repair.
■ Examine the urethral plate for width, depth, and overall health.

■ Initial Approach (TECH FIG 1)
■ Place a 4-0 Ethibond suture longitudinally at the tip of the glans for
retraction purposes.
■ Make a reverse chevron incision on the dorsum of the penis to preserve the
mucosal collar flaps.
■ Working laterally to medially, carefully elevate the ventral skin off of the
urethra. (Avoid incising into the urethra. If necessary, it is better to buttonhole
the overlying skin than to incise into the native urethra.)
■ Deglove the penis down to the penopubic and penoscrotal junction.
■ Induce an artificial erection and evaluate degree of chordee by constricting
the corpora cavernosa at the base of the penis with a tourniquet device (ie,
rubber band, dental roll, and hemostat) and injecting saline through a small-
gauge butterfly needle into the corpora cavernosa.
TECH FIG 1 • Initial incisions. A. Reverse chevron
incision to preserve mucosal collars (arrows). B.
Elevation of skin off of urethra behind hypospadiac
meatus (arrow). C. Example of thin ventral urethra
(arrow) that will require cut back.
■ Correction of Chordee With Dorsal Plication
■ In most cases of distal hypospadias, degloving of the penis alone will
adequately straighten the penis.
■ In cases in which residual chordee remains that is less than 30 degrees, this
can be corrected with dorsal plication (TECH FIG 2).

■ Dorsal plication will shorten the penis and should be avoided in patients
with a small phallus.
TECH FIG 2 • Dorsal plication. A. Artificial erection to
assess chordee (less than 30 degrees). B. Dorsal
incision at 12 o’clock (arrow; between neurovascular
bundles). C. Plication suture (arrow) with 3-0 Ethibond
suture. D. Corrected chordee following dorsal
plication.
■ Make an incision in Buck fascia at the 12 o’clock position over the dorsal
vasculature.
■ Place a 3-0 or 4-0 Ethibond suture (Ethicon Inc., Somerville, NJ) parallel to
the shaft, ensuring not to injure the neurovascular bundles laterally.
■ Imbricate Buck fascia over the plication suture using interrupted 6-0 PDS.