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The Scarless Umbilical Port Insertion (SUPI) Technique for Laparoscopic Surgery in Children

Caroline Mary Smith, Thomas Tsang

Department of Paediatric Surgery, Jenny Lind Children’s Hospital, Norfolk and Norwich University Hospital, Norwich, UK


Correspondence:

Caroline Mary Smith

Department of Paediatric Surgery

Norfolk and Norwich University Hospital

Colney Lane, Norwich, NR4 7UY, UK

Phone: 07545499988

Fax: 01603 287584

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Abstract

Background: Despite widespread adoption of laparoscopic surgery in children, there is no evidence as to the optimum camera port insertion technique. In this study, we aim to analyse outcomes following a transumbilical technique of camera port insertion in children which is scarless, and compare these to port site complication rates as described in the literature.

Materials and methods: This is a retrospective analysis of a single surgeon series. Patients were identified from a prospective surgical log over a 4 year period. Primary outcomes were surgical site infection requiring intervention and incisional hernia. Data analysis was through descriptive techniques.

Results: Two-hundred and ninety two children were included. In 3 the scarless umbilical port insertion (SUPI) technique was not possible. There were no intraoperative complications. The series showed 0.4% wound infection rate requiring drainage and 2 incisional hernias that resolved spontaneously.

Conclusion: This is the largest series to assess outcomes of a specific camera port technique. We would recommend the SUPI technique in all children undergoing minimal access surgery. This study shows that outcomes are favourable to published camera port insertion complication rates, with advantages in cosmesis.

Keywords: minimal access surgery, children, camera port

 

Introduction

Miniaturisation of working instruments and improved affordability has led to widespread application of laparoscopic surgery in children [1]. Minimal access surgery (MAS) has the advantages of improved view and exposure, decreased postoperative pain and hospital stay in some procedures [2] and improved cosmesis.

There are multiple techniques for camera port insertion. Many paediatric surgeons use supraumbilical or infraumbilical camera port site incision due to concerns regarding postoperative wound site infection or trocar site hernia following transumbilical insertion, but this technique leaves a discernible scar. Transumbilical camera port insertion leaves no scar, but anecdotally has higher rates of complication. There are no papers in the literature describing outcomes following specific umbilical port insertion technique.

We describe a scarless umbilical port insertion (SUPI) technique. We hypothesise this technique has primary outcomes of wound infection and incisional hernia rate comparable to those reported in the literature.

Materials and methods

We performed retrospective data analysis of a single surgeon’s case series observing early and late outcomes following the scarless umbilical port insertion (SUPI) technique. All children undergoing laparoscopic surgery over a 4 year period, January 2008 to August 2012, were identified from a prospectively maintained database. All procedures with intention to treat were included in analysis. Exclusions included procedures where the SUPI technique was not attempted due to an unsuitable umbilicus, where optimal camera placement was not at the umbilicus and following conversion. All parents were consented specifically for transumbilical camera port insertion. Approval was given by the hospital clinical governance department. Outcomes were defined as surgical site infections requiring intervention and postoperative incisional herniation. Early complications were considered as within 30 days of surgery. Follow up was of a minimum of 2 years to ensure there were no cases of late incisional hernia.

SUPI technique is performed in all neonates, infants and children. After meticulous cleaning of the umbilicus with 10% povodine (Fig. 1A), the central ‘axle’ of the umbilicus is incised with an 11mm straight blade with extension caudally and cranially within the scar of the umbilicus (Fig. 1B and 1C). The wound is deepened in the midline plane and transversalis and umbilical fascias are divided under direct vision. Once the fascia is divided the peritoneum is visualised, picked up and opened ensuring underlying bowel and omentum have dropped away (Fig. 1D). A 5mm or 11mm port with trocar, depending on the size of the child, is inserted through the ring and pneumoperitoneum established. We fix the port with a 2/0 polyglactin 910 (Vicryl TM Ethicon, US) (Fig. 1E). Following the procedure the umbilical ring is closed, with the fascia ring brought together vertically with 4/0 Vicryl suture or stronger depending on the size of the patient. The umbilical scar tissue is then opposed with 4/0 polyglactin 910 (Vicryl) suture (Fig. 1F). Steristrips (3M, US) are used for dressing.

Figure 1 - The Scarless Umbilical Port Insertion Technique (SUPI)

Fig 6-1a Fig 6-1b

A. Umbilicus cleaned, with meticulous attention

to hygiene

B. Identification of central ‘axle’ of umbilicus
Fig 6-1c Fig 6-1d

C. Incision made cephalocaudally adherent

to the midline

D. Fascial ring identified and stretched. Peritoneum picked up and opened.
Fig 6-1e Fig 6-1f

E. Port inserted tied in place with 2.0 Vicryl.

Umbilical ring closed with 4.0 Vicryl once the

port is removed

F. Scarless post-operative appearances

Results

Two hundred and ninety two children were identified as having undergone urological, pelvic and gastrointestinal laparoscopic surgery, as described in Table 1. In three children SUPI was not possible due to significant scarring at the umbilicus or infected umbilicus, making SUPI feasible in 99% of laparoscopic operations in children. Five children were excluded: two cases of extension of umbilical incision for mini-laparotomy, two cases of conversion to open, and one where the camera port was not placed umbilically.

Table 1 - Frequency of laparoscopic procedures performed during study period, January 2008 to August 2012

Procedure

 

 Frequency

n=292

 

Inguinal hernia repair

 

115

Appendicectomy

58

Pyloromyotomy

33

Gastrostomy

24

Fundoplication

15

Impalpable testis

9

Orchidopexy

8

Antegrade Colonic Enema/ Chait’s tube insertion

7

Diagnostic Laparoscopy

4

Cholecystectomy

3

Meckel’s & Duplication cyst

3

Ovarian pathology

3

Varicocele

2

IBD stricture

2

Pull-through for Hirschsprung’s Disease

2

Heller cardiomyotomy

2

Lysis of adhesions

1

Colopexy

1

Outcome data was gathered in 284 children where SUPI was performed successfully. Demographics were as follows: median age was 24 months (interquartile range 0-132 months), mean age - 5 years, 76% were male, median weight was 6.8 kg (range 1.7 - 91kg).

Eighty percent of children had 5mm ports and 20% 11mm inserted. There were no operative complications of the SUPI technique. Difficulties were found in one case due to an elongated umbilical stump, but insertion was successful.

Two children were noted to have small umbilical hernias at the time of operation. Both children had no operative complications, and following standard polyglactin 910 (Vicryl) fascial repair neither developed postoperative complication.

One child developed a wound infection, requiring oral antibiotics and drainage and three children developed minor wound infections which responded to topical antibiotics. In two children incisional umbilical hernias were noted postoperatively, but all resolved spontaneously. No child required operative management of postoperative incisional hernia.

Discussion

The umbilical defect closes following physiological intestinal embryological herniation in the majority of children but the reminders of its embryological past remain in its anatomic relations. At the umbilical ring the circumferential confluence of abdominal wall fascia and skin result in a shallow region, allowing easy access to the abdominal cavity (Fig. 2). The absence of subcutaneous fat and muscle at the umbilicus means the dissection plane remains bloodless to the peritoneum if the midline is adhered to.

Figure 2 – Transverse schematic diagram of the abdominal wall at the umbilicus

Figure 6-2

There are concerns that transumbilical peritoneal entry increases the risk of developing a wound infection or incisional hernia, and has therefore this route has been avoided by many paediatric surgeons. In our series two children had transient postoperative incisional herniae, of tonouchi type 3 [3], where small volume omentum or small bowel protrudes into the defect. All resolved without surgical repair. Previous series have shown incisional herniation rates between 0.3% and 1.4% [1, 4- 6] some requiring surgical closure. The specific umbilical camera port technique was not described. Incisional hernias have been reported at 3 mm, 5 mm and 10 mm trocar sites [7 - 9]. We support recommendations to close the fascia in port sites cases.

In the present series we report a 0.4% infection rate requiring systemic antibiotic treatment. This is favourable to the literature, where rates are reported between 0.5% and 1.4% [4, 6]. Unfortunately classification of surgical contamination level data for each procedure was not available. A single previous paper has described transumbilical camera insertion in children with a 2% infection rate [10]. In a 5-year single centre study, where a ‘sub-umbilical’ technique was performed in children with weight under 5 kg, the rate of infection were found to be 7% [11].

Conclusion

We feel that the SUPI technique has distinct advantages when compared to other camera port insertion techniques. Technical advantages include bloodless entry into the abdominal cavity to maximise visualisation of the working areas and an efficient and ergonomic entry procedure to lessen operative time. SUPI is feasible in 99% of neonates, infants and children. Our data shows if attention is made to cleaning, haemostasis and fascial closure the rates of both infection and incisional herniation requiring treatment, 0.4% and 0% respectively, are favourable to those described for paediatric trocar sites and leave the child with no abdominal wall camera port scar.

Acknowledgements

Thank you to the contribution of the staff of the Medical Illustrations Department at the Norfolk and Norwich University Hospital.

 

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