Umbilical Hernia Repair in Conjunction With Abdominoplasty: A Surgical Technique to Maintain Umbilical Blood Supply

Abdominoplasty is one of the most common aesthetic procedures performed in the United States. One of the primary indications for the procedure is skin and fascial laxity, which is often found in multiparous women.1, 2, 3, 4, 5 A frequently-encountered problem associated with the occurrence of fascial laxity or diastasis is abdominal wall hernias. In fact, hernias are often diagnosed on clinical examination or are encountered intraoperatively during an abdominoplasty. One of the most common locations for a hernia to occur is in the umbilical and periumbilical area. The identification of an umbilical or periumbilical hernia while performing an abdominoplasty provides the plastic surgeon an opportunity to surgically correct the fascial defect, which in many cases significantly contributes to the overall appearance of the anterior abdomen. However, undertaking such a repair is not without potential consequences.

Traditional surgical techniques for performing an abdominoplasty include skin incisions circumferentially around the umbilicus, resulting in complete detachment of the umbilicus from the anterior abdominal flap. As a result, the umbilicus maintains its only blood supply from the underlying fascial attachments via the umbilical stalk. Standard repair of umbilical hernias involves fascial incisions immediately adjacent to the abdominal wall defect and extensive dissection in preparation for repair. Because of this extensive dissection, the blood supply to the umbilicus is primarily derived from the surrounding attached skin via the subdermal plexus. Therefore, abdominoplasty and umbilical hernia repair, when performed simultaneously using the traditional aforementioned techniques, can potentially compromise the vascular supply to the umbilicus, resulting in tissue necrosis.3, 4, 5, 6, 7, 8 This increased risk has lead many surgeons to either avoid repair of these hernias or perform a two-stage procedure for correction. We present a simplified surgical technique that avoids any fascial incisions immediately adjacent to the umbilicus, thereby maintaining maximal blood supply to the umbilical stalk and minimizing the risk of umbilical necrosis.

Surgical technique 

The abdominal flap was elevated and the umbilicus was dissected from the anterior abdominal wall flap while leaving intact the fascial attachments of the umbilical stalk at its base. The abdominal flap was raised at the level of the anterior sheath to the xyphoid centrally and the costal margins laterally. The fascial plication was marked based on the degree of anterior fascial laxity. A 3- to 4-cm midline longitudinal laparotomy incision was then made through the linea alba, beginning 2 cm inferior to the umbilical stalk. The fascial defect was identified and the hernia reduced from the undersurface of the umbilicus either in the pre- or intraperitoneal space. The hernia was then repaired with interrupted, nonabsorbable monofilament sutures (Figure 1, A-D). The midline laparotomy fascial incision was then closed with running monofilament suture. Plication of the rectus fascia was then performed using the previous markings, which allowed for symmetrical placation of the anterior sheath. Excess abdominal skin was excised in the normal fashion and the umbilicus delivered through a midline incision. In most cases, it is secured to the underlying fascia at the three, six, and nine o'clock positions.

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Figure 1. A, Umbilical hernia. B, Midline infraumbilical incision through the linea alba. C, Marking of the umbilical hernia. D, Repair of umbilical hernia with interrupted monofilament suture.

Results 

A retrospective analysis was performed on 17 patients over a six-year period. All patients had umbilical or periumbilical hernia repairs with simultaneous abdominoplasty using the aforementioned surgical technique. The average length of follow-up was 3.5 years (range, three months to eight years).

Conclusions 

Historical concerns regarding circulatory compromise of the umbilicus as a result of simultaneous repair of such hernias with abdominoplasty were found to be unwarranted with respect to the described procedure. None of the patients have experienced a recurrence of their umbilical hernia or necrosis of their umbilicus. Furthermore, the overall aesthetics of the umbilicus have been improved.