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V. V. da SilvaJúnior et al.
is also very well used in patients with excess adipose panicle to decrease tension at these xation
points and to reduce the risk of rupture or dehiscence of the points, which is the main cause of
shallow navel [31].
The surgical thread used may have an inuence on the end result of this reconstruction and
some studies describe several options for dermis
xation, such as nylon, prolene, ethilon, vycril,
ranging from 2, 3, 4 to 50. However, 70% of the
studies prefer the use of nylon because it is nonabsorbable and 40% describe the xation of the
dermis in the rectal fascia [20].
There are situations where a very large umbilical hernia, especially in pregnancy, causes the
umbilical fundus adhesions to be broken or
become too loose to the point of losing all depth.
In this case, the risk of necrosis of this umbilical
skin or shallow nal aspect of the navel is most
likely. In this case, the total amputation of the
stump and the reconstruction of a new navel are
indicated.
28.2.2.3 Umbilical Tunnel
Reconstruction Technique:
Belly Button like aTunnel
The navel is considered a tube for some authors
and its correction is based on the purpose. There
are techniques for each type of belly button,
which differ in depth and diameter, and they
attempt to simulate the side walls of the belly button [33, 34].
In very thin patients who do not have enough
skin in the umbilical area, even using the bottom
of the navel to try to get deeper, shallow navel
cannot be avoided. In this case, the umbilical wall
should also be reconstructed to simulate a greater
depth. Thus, local aps are used. However, there
is the inconvenience of leaving apparent scars.
Therefore, it would be more indicated in patients
with light skin and less likely to develop hypertrophic scars.
Tunneled neo-navel surgery is based on the
making of V-shaped aps from a midline incision,
two upper and two lower aps. The idea is to simulate the umbilical tube wall tissue with an upper
and lower ap, which rotates in the opposite
direction against each other. The third ap should
have the most central epithelialized portion to
cross under one of the aps and be xed to the
central portion to simulate the bottom of the navel.
The fourth ap is excised. The drawback is the
risk of the middle scar becoming apparent from
the poor skin quality of the patient. But it is a
well-indicated technique in cases of navel amputation, as it becomes more predictable and highly
reproducible (Figs.28.1, 28.2, 28.3, and 28.4).
Some authors have described techniques for
making this tunnel with local aps xed between
Fig. 28.1 Umbilicoplasty technique for reconstruction in
cases of total amputation of the umbilicus. Flap marking
and skin incision for making the new umbilicus
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Fig. 28.2 Making of V-shaped aps from a midline incision, two upper and two lower aps. The idea is to simulate the umbilical tube wall tissue with an upper and lower
ap, which rotate in an opposite direction against each
other. The letter “A” ap crosses to opposite side. The letter “C” ap should have the most central depithelialized
portion to cross under letter “D” ap and be xed to the
central portion to simulate the bottom of the navel. The
letter “B” ap is excised
473
them and the bottom in the rectus abdominis aponeurosis [35].
28.2.2.4 New Approach (Associate
Old Stump
withNeoumbilicoplasty
Technique)
We describe this technique as hybrid because it
associates the xation of the abdominal ap dermis in aponeurosis, as in the technique we
described in 2013 [31] and the utilization of the
remaining umbilical stump.
The umbilical stump is xed in the aponeurosis of the rectus abdominis, especially in cases of
shallower appearance. A vertex-shaped portion is
appended with a vertex to the umbilical center in
the position between 12 and 2 o’clock and the
lower second between 6 and 8 o’clock. The
abdominal ap is degreased in the portion that
will rest on the old stump. In this degreased
region, six nylon 2.0 xation points are made up
to the rectum aponeurosis, causing the stump to
be covered by the skin of the abdominal ap. The
points are in the following positions: 12, 2, 4, 6,
8, and 10 h. After all closure of the abdominal
wall, the skin is inserted, making two small
V-aps, which will be tted and sutured within
the triangular designs (Fig.28.5).
This technique proved to be much more effective in relation to aesthetic results, depth, and hidden scars compared to neoumbilicoplasty without
utilization of the stump (Table28.1).
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Fig. 28.3 Skin marking, incision, and confection in the new umbilicus in a 40-year-old patient
V. V. da SilvaJúnior et al.
ab
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c
Fig. 28.4 Postoperative. (a) 10days. (b) 60days. (c) 90days
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Fig. 28.5 (1)
Preparation of four
triangular aps in a
detached abdominal
ap. (2) Excision of A
and D and exposure of
the umbilical stump with
amputation of two
triangular segments
where aps B and C will
be sutured. (3) Final
appearance of the suture
of aps B and C to the
umbilical stump
V. V. da SilvaJúnior et al.
Table 28.1
umbilicoplasty
Techniques Benets Disadvantages
Incision in the
abdominal ap and
direct suture in the
remaining stump
Navel without scars Natural
Stump making with
local aps
Neoumbilicoplasty
with remaining stump
Comparison between different techniques of
Easy
execution
result,
without
scar
Natural
result
Natural
result
Apparent scar,
less natural
result
Risk of shallow
navel
Apparent scar in
the
periumbilical
region, difcult
to perform
Runtime
increase
28.3 Postoperative Care (Wound
Dressing)
Subclinical local infection can be a limiting factor for the nal result and for the increased risk of
suture dehiscence. For this reason, antibiotic
ointment and gauze are used on the navel at the
end of the surgery, and it is maintained for
15days, when the use of silicone gel starts twice
a day for 4months. The early use of orthoses is
avoided so as not to force the scar and break the
suture, which are started after 30 days. As a
result, a lower rate of these complications was
observed.
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28.4 Outcomes andPrognosis
The use of new techniques associating the construction of a tunnel over a remaining umbilical
stump proved to be much more effective in relation to the aesthetic, depth, and hidden scarring
results in relation to neoumbilicoplasty without
using the stump. In techniques that did not use
the remaining umbilical stump, the navels were
shallow, and there were high rates of reoperation
to make it deeper.
The making of new navels or the correction of
umbilical complications can be performed under
local anesthesia in an isolated procedure.
28.5 Complications
The incidence of seroma can also increase the
risk of dehiscence of the stitches when it drains
through that region. Therefore, the points of
adhesion of the ap on the abdominal wall are
important to reduce this incidence. The infection
rate can be decreased with the use of local antibiotic ointments. Keeping the measurement of the
new umbilical design between 1.8 and 2.0cm is
important to avoid wide and ugly navels.
Techniques that do not use the anterior umbilical
stump tend to result in shallow and unlit navels.
Those that do not x the abdominal ap around
the stump may result in hypertrophic scars and
stigmatized navels similar to a cacimba.
28.6 Conclusions
Regarding the shape and quality of a beautiful
belly button, Lee and Craig’s conclusions were
that it should have a vertical, oval design. In studies by Malic etal. and Lesavoyh etal., it was concluded that the upper navel hook is preferred by
patients and is a desired component in a beautiful
navel [20]. In addition, apparent scarring, stenosis, dehiscence, shallow, and misplaced navels
are the challenges to come up with a perfect technique that brings natural results.
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Abdominal Wall Restoration
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CarlotaTuero, PabloMarti, GabrielZozaya,
andCarlosSánchezJusticia
29
29.1 Umbilical Hernia
29.1.1 Introduction
Umbilicus is located in the midline, halfway
between the xyphoid process and the pubic symphysis. It is the remainder of the insertion of the
umbilical cord and it is a weakness point in the
abdominal wall. It is protected in the lower part
by the obliterated uracus and the medial umbilical ligaments and in the upper part by the round
hepatic ligament. The limits are the two rectus
sheaths on both sides, the umbilical fascia posteriorly and the linea alba anteriorly [1].
Umbilical hernia is located at or near the
umbilicus in a range from 3cm above and 3cm
below [2]. It is a common entity with higher prevalence in women than in men, with a 3:1 ratio [3].
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_29.
C. Tuero (*)
Department of Surgery, Hospital García Orcoyen,
Estella, Navarra, Spain
e-mail: Ctuero@unav.es
P. Marti · G. Zozaya · C. S. Justicia
Department of Surgery, University Clinic of Navarra,
Pamplona, Navarra, Spain
e-mail: Pamartic@unav.es; Gnzozaya@unav.es;
Csjusticia@unav.es
Furthermore, there is a peak around the age of 40,
which may be related to pregnancy [4].
The main risk factor is the increase in the
intra-abdominal pressure, so this entity is more
frequent in obese patients, cirrhotic, abdominal
tumors or in multiparous women [1, 5]. In the literature, there is an incidence rate of umbilical
hernia among pregnancy of 0.08% [6].
29.1.2 Patient Selection andTiming
29.1.2.1 Patient Selection
Patient selection is important in order to reduce
or even avoid postoperative complications.
Certain comorbidities such as tobacco use, obesity, diabetes, and malnutrition are related to
postoperative complications and should be modied before surgery.
Tobacco impairs wound healing and increases
the risk of infection; so, nonsmoking during the
last 4weeks before surgery reduces the infection
rate. Malnutrition should also be avoided with
protein repletion before the intervention.
Obesity and diabetes impair tissue perfusion
and immune response; patients ought to lose
weight before surgery and keep a strict control
of glycemia to reduce postoperative complications [7].
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_29
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29.1.2.2 Timing: Umbilical Hernia
Before, During andAfter
Pregnancy
There is still no consensus about the perfect timing for surgery in a pregnant woman or planning
pregnancy. Surgeons usually recommend oneyear lapse between the hernia intervention and
pregnancy. There is no evidence support, however, if an early pregnancy increases the rate of
recurrence [8].
In a pregnant woman, when the hernia is small
and asymptomatic, it may be better to postpone
the surgery until she gives birth [8]. Unlike, when
the hernia is symptomatic, some studies describe
a high rate (58%) of complications (strangulation
or incarceration), so they recommend elective
surgery before complications appear and before
delivery, with low risk. The most frequent complication is surgical site infection, but the main
disadvantage is the scant data regarding recurrence rate [9, 10].
After childbirth, elective repair is possible
8weeks postpartum, but it is better to wait one
year for the patient to recover and return to normal body weight. If the woman would like to
have more children, surgery can be postponed for
a longer time [8] (Table29.1).
Another option that has been described is
repairing the umbilical hernia during the cesarean section. It is an optimal therapeutic option
that takes more time than performing only the
cesarean, but it is safe, there is no additional pain,
neither more morbidity, and avoids readmission.
However, there is still little report experience
about recurrence [9, 11, 12] and some studies
describe scarce aesthetic results and high incidence of complications such as skin necrosis,
wound infection, seroma, and hematoma; so, further studies are needed [13].
There is also hesitance about the use of mesh
reparation during pregnancy, because there is
high risk of lateral mesh detachment or inadequate overlap of the hernia defect. Furthermore,
the mesh may restrict the elasticity of the abdominal wall leading to associated pain [14]. A study
made by Oma etal. found no differences in the
recurrence rate between mesh repair and simple
suture repair in women who underwent surgery
before pregnancy. They hypothesized that as the
pregnancy progresses, the tension on the hernia
repair increases. This tension may cause mesh
detachment or migration and explain the lack of
mesh benet. Besides, they also concluded that
umbilical hernia repair was associated with a
greater risk of recurrence compared with epigastric hernia repair [15].
29.1.3 Preoperative Evaluation
29.1.3.1 Physical Examination
Umbilical hernias may appear as an umbilicus
bulge that causes abdominal pain or discomfort
(Fig. 29.1). This bulge increases with Valsalva
maneuver and decreases with the decubitus.
The neck of the hernia is usually narrower
than the content with a high risk of strangulation
or incarceration; so, these hernias are related to a
higher morbidity and mortality than groin hernias. Men are more likely to present an umbilical
incarcerated hernia, meanwhile in women, the
typical presentation is an easily reducible mass.
When there is an incarcerated hernia, the patient
presents a large bulge, which is impossible to
reduce into the abdomen. Bowell obstruction
symptoms are usually associated. An emergent or
urgent surgical intervention is required [16]. If
there is evidence of intestine suffering and we
Table 29.1 Algorithm of treatment
Type Planning pregnancy During pregnancy After pregnancy
Small, asymptomatic
hernia
Large/symptomatic
hernia
Irreducible hernia Emergency repair and wait
Repair 1year after childbirth Repair 1year after
Repair and wait 1year until
pregnancy
1year until pregnancy
childbirth
Repair in second
trimester
Emergency repair Emergency repair and wait
Repair 1year after childbirth
Repair after childbirth
1year until pregnancy
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481
eral anesthesia may be associated with regional
one after the procedure in order to avoid postoperative pain. When we perform laparoscopic
repair of the abdominal wall, general anesthesia
is required.
Regional anesthesia is rapid and starts acting
between 5 and 15min but shows some disadvantages like increasing the risk of urinary restriction
and delaying ambulation.
Regarding general anesthesia, when performing abdominal wall surgery, we need to avoid
coughing during extubating. Some centers, when
the surgery is nearly to end, change the endotraqueal tube and place a laryngeal mask instead,
which is well tolerated. Sometimes, after general
anesthesia, we can perform a TAP, which is a
regional blockage, in order to avoid postoperative
pain and achieve an early recovery diminishing
narcotic requirement [17].
Fig. 29.1 Umbilical bump
need to perform an intestinal resection, mesh
placement after hernia repair is still in doubt due
to the high infectious rate.
Larger umbilical hernias are related to skin
erythema, necrosis, or ulceration [3].
29.1.3.2 Diagnosis
The diagnosis is easy and usually performed
through clinical exploration. The increase in the
abdominal pressure helps the diagnosis;, however, in certain patients, such as obese or when
the hernia is small, an ultrasound or a CT is
needed.
29.1.4 Anesthetic Considerations
Hernia repair is a very common procedure,
because elective repair after diagnosis is advised.
There are numerous anesthetic considerations
regarding this intervention, depending on the
medical status of the patient. Surgery may be performed with regional anesthesia with or without
sedation or general anesthesia. Furthermore, gen-
29.1.5 Surgical Technique
29.1.5.1 Patient Positioning
The patient is placed in supine position in the
operating room table and secured to avoid any
shifting although no angulation of the able is
needed. The arms are usually open in the form of
a cross. The surgeon is located in the right side of
the patient and the rst assistant on the opposite
one. When there is a laparoscopic approach, the
surgeons are also placed at both sides of the
patient and the television on his/her feet.
29.1.5.2 Procedures Step by Step
There are mainly two repairing options: tissue
suture and prosthetic repairs and they can be performed through laparoscopic or open approach.
1. Open Technique
The beginning of the open repair is very
similar. It consists in a periumbilical incision,
curvilinear or vertical, and a posterior subcutaneous dissection (Fig.29.2). Afterward, the
hernia sac is identied and dissected to its
attachments and later reduced or resected
(Figs.29.3 and 29.4). Once the sac is removed,
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