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ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 3  |  Page : 127-130
 

Positioning the umbilicus in african newborns with large anterior abdominal wall defects


Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria

Date of Web Publication4-Jul-2018

Correspondence Address:
Dr. Olakayode Olaolu Ogundoyin
Department of Surgery, College of Medicine, University of Ibadan, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_201_17

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   Abstract 


Objective: We tried to determine the normal position of the umbilicus in African newborns with a potential application in aesthetically acceptable umbilical reconstruction.
Subjects and Methods: The study involves a cross-sectional study of 896 healthy neonates who underwent clinical abdominal examination and measurement of the distances between the xiphoid process and the umbilicus (XU), xiphoid process and the pubis (XP), umbilicus and the pubis (UP), umbilicus and the anterior superior iliac spine (UASIS), abdominal girth (AG), and inter anterior superior iliac spines (IASIS) distance. The gestational age at delivery, age at measurement, sex, AG measured across the umbilicus, birth weight (BW), body length, and body mass index of the newborns were recorded. The measurements were used to determine the location of the umbilicus and Pearson's correlation analysis performed to determine the relationships of the recorded neonatal parameters with the measurements.
Results: The mean XP was 11.97 ± 2.09 cm, XU = 7.94 ± 2.74 cm, UP = 4.26 ± 1.21 cm, UASIS = 5.79 ± 1.04 cm, and IASIS = 10.25 ± 1.54 cm. The BW, length, and AG significantly correlated with the distance between the XU, umbilicus and pubis, umbilicus and anterior superior iliac spine as well as the distance between the two anterior superior iliac spines.
Conclusion: The position of the umbilicus is dependent on the selected participants' characteristics. We suggest that a UP: XU ratio of 0.55 should be used to position the umbilicus during umbilical reconstruction in African neonates.


Keywords: African newborns, position, umbilical reconstruction, umbilicus


How to cite this article:
Ogundoyin OO, Olulana DI, Lawal TA. Positioning the umbilicus in african newborns with large anterior abdominal wall defects. J Indian Assoc Pediatr Surg 2018;23:127-30

How to cite this URL:
Ogundoyin OO, Olulana DI, Lawal TA. Positioning the umbilicus in african newborns with large anterior abdominal wall defects. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2019 Dec 15];23:127-30. Available from: http://www.jiaps.com/text.asp?2018/23/3/127/235898





   Introduction Top


The repair of congenital defects of the anterior abdominal wall in the newborns and umbilical hernias with a large defect in infancy and childhood is associated with construction of the umbilicus. However, good aesthetic outcome of the repair is dependent on the location of such umbilical scar. The position of the umbilicus varies. It, however, lies between the third and the fourth lumbar vertebrae corresponding to the midpoint of the line joining the two anterior superior iliac spines in healthy adults but may be lower in infants.[1],[2] It was generally thought that the umbilicus is located in the midline but Rohrich et al.[3] have clearly demonstrated that it is not located in the midline for all humans. Therefore, a good cosmetic outcome will not consider only the midline location of the umbilicus, as this landmark alone may not be enough in achieving acceptable cosmesis, but its relationship with some other anatomical landmarks. The construction of the umbilicus following the repair of large anterior abdominal wall defects is often difficult because of the size of the defects, which may make its eventual position to be too high or too low on the anterior abdominal wall. Ultimately, the eventual position of the umbilicus may not be acceptable to the parents as it significantly affects the cosmetic appearance and symmetry of the anterior abdominal wall of the neonate. To overcome this, various studies have tried to develop different techniques and formulae that could be adopted in positioning the umbilicus during umbilicoplasty in the adult population.[4],[5],[6],[7],[8] This study, therefore, tried to determine the normal position of the umbilicus that will preserve the anterior abdominal wall esthetics in African neonates and also guide surgeons during the repair of congenital defects of the anterior abdominal wall in the newborns and umbilical hernias with large defects.


   Subjects and Methods Top


This was a cross-sectional study of 896 healthy newborn infants delivered at three large tertiary hospitals within Ibadan metropolis in Nigeria, from January to December 2014. These hospitals are known for delivering standard obstetric care and account for the majority of hospital deliveries within the metropolis. Informed consent was obtained from the mothers of all individual participating newborns included in the study with strict adherence to ethical guidelines of Helsinki Declaration of 1975 as revised in 2000. Ethical approval was obtained from our Institutional Ethical Review Committee before the study commenced.

Excluded from this study were neonates with chromosomal anomalies and congenital defects of the anterior abdominal wall, including omphalocele, bladder, and cloacal exstrophy. Neonates with abdominal masses and distension from any cause as this may interfere with the symmetry of the abdomen and neonates whose mothers refused to give consent to carry out an examination of the abdomen on them were also excluded from the study. The gestational age (GA) at delivery, age at measurement, sex, abdominal girth (AG) measured across the umbilicus, birth weight (BW), body length (BL), and body mass index (BMI) of the newborns were recorded. The babies were placed in supine position and linear measurements of the distance between the xiphoid process and umbilicus (XU), the xiphoid process and the pubis (XP), the umbilicus and the pubis (UP), the umbilicus and the anterior superior iliac spines (UASIS), the distance between the two inter anterior superior iliac spines (IASIS), and the AG measured across the umbilicus were performed using a measuring tape. The following ratios were also calculated; XP: UP, UP: XU, and UASIS: IASIS. Analysis of the data was carried out using the IBM Statistical Package for Social Sciences (SPSS) Version 21, Chicago, U.S.A. Descriptive analysis of the participants' demography and their measured parameters were performed while Pearson's correlation analysis was performed to determine the relationships between the recorded parameters and the various measurements.


   Results Top


A total of 896 healthy neonates were recruited into the study, 55.4% were boys and 44.6% were girls. The mean age was 1.71 ± 3.27 days, mean GA was 39.71 ± 12.55 weeks, the mean BW was 3.11 ± 1.13 kg, mean BL was 47.75 ± 3.77 cm, the mean AG was 30.23 ± 2.92 cm, and the mean BMI 12.64 ± 4.33. The mean distances were XP = 11.97 ± 2.09 cm, XU = 7.94 ± 2.74 cm, UP = 4.26 ± 1.21 cm, UASIS = 5.79 ± 1.04 cm, and IASIS = 10.25 ± 1.54 cm. The mean of the ratios obtained were XP: XU = 2.91 ± 0.35, UP: XU = 0.55 ± 0.17, and UASIS: IASIS = 0.57 ± 0.17.

There was a significant correlation between the BW and BL with all the measured distances but no significant relationship was found between them and GA. However, there was a positive and significant correlation between the age at examination and XU (r = 0.076, P = 0.026) and IASIS (r = 0.086, P = 0.012) but a negative and significant relationship with the BMI (r = −0.100, P = 0.003). Furthermore, the AG correlated significantly with XU (r = 0.225, P = 0.000), UASIS (r = 0.221, P = 0.000), IASIS (r = 0.347, P = 0.000), and BMI (r = 0.109, P = 0.001) [Table 1].
Table 1: Relationship of subjects' anthropometric characteristics with the measurements

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   Discussion Top


The appearance and location of the umbilicus are of cosmetic significance to parents of neonates and infants with large anterior abdominal wall defects. This may also be relevant to an umbilical hernia, a common condition in the pediatric population in Africans and African Americans [9] with a typical incidence in Nigeria of 91% in children under the age of 6 years.[10] In addition to this cosmetic significance, Onal et al.[11] suggested that it gives good postoperative recovery when a well-situated umbilicus is used for the laparoscopic procedure in neonates and infants as postoperative pain will be reduced. We observed that the ratio of the distance between the UP to that of xiphoid process to the umbilicus (UP: XU) of 0.55 ± 0.17 varies from 0.61 obtained in a previous study from Turkey [11] and 60% of the distance measured from the xiphoid process to the pubis as obtained by Williams and Brain.[12] The difference in the values may be related to the relatively higher incidence of an umbilical hernia with large defects in the African population as the various umbilical measurements (XU, UP, and UASIS) were taken from the edges of the umbilical defect. Therefore, we suggest that a well-located umbilicus in African neonates following a repair of congenital anterior abdominal wall defects and an umbilicus with a large defect should have a UP: XU ratio of 0.55. Applying the method used by Abhyankar et al.[13] in a study conducted on a set of adult female Indian volunteers to determine the position of the umbilicus in neonates and infants, the XP: UP ratio was found to be 2.91 ± 0.35 and the UASIS: IASIS ratio was found to be 0.57 ± 0.17. If two arcs are drawn using each of the anterior superior iliac spine as the center with a radius 0.57 times the distance between the two anterior superior iliac spines, the position of the umbilicus can be considered to be the point of intersection of these arcs at the surgical closure of the anterior abdominal wall defect.

It was also observed that the neonatal anthropometric measurements (BW, BL, and AG) were significantly related to all the measured parameters suggesting that the measurements increase with increasing body size, but the ratios remained the same. This is similar to the findings by Duduković et al., in which the ages of the adults used and their anthropometric measurements significantly influenced the position of the umbilicus.[8] However, the insignificant relationship between the AG and UP may reflect the relative increase the length of XU with increasing AG compared to UP.

Although it has been demonstrated that the umbilicus is not located at the midline for all participants,[3] the determination of the position of the umbilicus in this study was carried out with reference to the midline. We believe that it is easier to make use of the midline as the habitus,[14] the shapes of the abdomen and the pelvis in neonates and infants who are still growing are different compared to those of adults.


   Conclusion Top


The umbilicus is an essential part of the abdomen, and the aesthetics of the abdomen depends on the ability of the surgeon to position the umbilicus correctly during the closure of defects of the anterior abdominal wall in neonates and infants. We suggest that an umbilicus positioned with UP: XU ratio of 0.55 should be adopted during umbilicoplasty for an African neonate. This study has, therefore, provided a guide for surgeons to position the umbilicus during the repair of large congenital defects of the anterior abdominal wall and umbilical hernias with large defects in neonates and older children in the African population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Donnabella A. Anatomical reconstruction of the umbilicus. Rev Bras Cir Plást 2013;28:119-23.  Back to cited text no. 1
    
2.
Harold E. The abdomen and pelvis. In: Clinical Anatomy: Applied Anatomy for Students and Junior Doctors. Oxford: Blackwell; 2006. p. 55-158.  Back to cited text no. 2
    
3.
Rohrich RJ, Sorokin ES, Brown SA, Gibby DL. Is the umbilicus truly midline? Clinical and medicolegal implications. Plast Reconstr Surg 2003;112:259-63.  Back to cited text no. 3
    
4.
Mowlavi A, Huynh PM, Huynh DC, Wilhelmi BJ. A new technique involving a spherical stainless steel device to optimize positioning of the umbilicus. Aesthetic Plast Surg 2012;36:1062-5.  Back to cited text no. 4
    
5.
Martinez-Teixido L, Serra-Mestre JM, Serra-Renom JM. A new technique for creating a neo-umbilicus in abdominoplasty. J Plast Reconstr Aesthet Surg 2017;70:1760-7.  Back to cited text no. 5
    
6.
Parnia R, Ghorbani L, Sepehrvand N, Hatami S, Bazargan-Hejazi S. 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;45:94-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Danilla S, Bonasic S. Anatomical localization of the umbilicus: A statistical analysis. Plast Reconstr Surg 2007;119:1123-4.  Back to cited text no. 7
    
8.
Duduković M, Kisić H, Baez ML, Bulić K, Veir Z, Cvjetičanin B, et al. Anatomical prediction for surgical positioning of the umbilicus in a croatian population. Ann Plast Surg 2015;75:135-9.  Back to cited text no. 8
    
9.
Cilley RE. Disorders of the umbilicus. In: Grosfeld JL, O'Neill JA, Fonkalsrud EW, Coran GA, editors. Pediatric Surgery. Philadelphia: Mosby Elsevier; 2006. p. 1143-56.  Back to cited text no. 9
    
10.
Rakotomalala JH, Poenaru D, Mayforth DR. Disorders of the umbilicus. In: Ameh E, Bickler S, Lakhoo K, Nwomeh B, Poenaru D, editors. Pediatric Surgery: A Comprehensive Text for Africa. Philadelphia: Lippincott Williams and Wilkins; 2010. p. 352-7.  Back to cited text no. 10
    
11.
Onal E, Turan O, Karabulut R, Hirfanoglu I, Turkyilmaz C, Sonmez K, et al. Where should the normal position of the umbilicus be in the neonate? Eur J Pediatr Surg 2010;20:339-40.  Back to cited text no. 11
    
12.
Williams AM, Brain JL. The normal position of the umbilicus in the newborn: An aid to improving the cosmetic result in exomphalos major. J Pediatr Surg 2001;36:1045-6.  Back to cited text no. 12
    
13.
Abhyankar SV, Rajguru AG, Patil PA. Anatomical localization of the umbilicus: An Indian study. Plast Reconstr Surg 2006;117:1153-7.  Back to cited text no. 13
    
14.
Srinivasan J, Soueid A. Where to position of the umbilicus during abdominoplasty? – Look at the root! J Plast Reconstr Aesthet Surg 2009;62:e536-7.  Back to cited text no. 14
    



 
 
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    Abstract
   Introduction
   Subjects and Methods
   Results
   Discussion
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    References
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