Novel technique and outcomes of umbilical reconstruction during cytoreductive surgery; a multi-centre study

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While the absence of the umbilicus can be aesthetically undesirable for patients, umbilical reconstruction is rarely performed due to the perceived complexity and increased risk of wound infections [ 1 ]. This study aims to evaluate the outcomes, cosmetic results, and patient satisfaction of umbilical reconstruction during cytoreductive surgery. Methods Consecutive patients from a prospectively maintained database who underwent cytoreductive surgery with umbilical excision and reconstruction were evaluated. Our technique for umbilical reconstruction involved recreating the subcutaneous fat space and fashioning umbilical skin flaps that anchor to the anterior fascia. Outcomes assessed included postoperative infection rate, wound dehiscence, seroma formation, wound appearance, and patient satisfaction. Results Umbilical reconstruction was performed on 50 patients, with 12 (24%) experiencing wound-related complications. Of these, 8 patients (16%) had superficial wound infections, while 1 patient (2%) developed a deep wound infection. Three patients (6%) required local wound drainage, though none needed surgical revision. There were no reports of wound seromas, skin necrosis, wound widening, or umbilical stenosis. All patients reported satisfaction with the outcome of their reconstruction. Conclusion Our novel technique for umbilical reconstruction during cytoreductive surgery did not negatively impact wound healing outcomes. Recreating the umbilicus improved cosmetic results and patient satisfaction, enhancing body image for those undergoing major abdominal surgery. This approach should be considered for patients undergoing major laparotomies that necessitates umbilical excision. Umbilicus Umbilical reconstruction abdominal aesthetics cytoreductive surgery Figures Figure 1 Figure 2 Figure 3 1. Introduction Cytoreductive surgery (CRS) is the mainstay treatment for removal of macroscopic disease in peritoneal malignancies. Complete cytoreduction, achieved through a combination of extensive disease excision and delivery of heated intraperitoneal chemotherapy (HIPEC), has been shown to improve survival in peritoneal surface malignancies [ 2 – 4 ]. To facilitate the removal of all disease, cytoreductive surgery traditionally entails a midline laparotomy and careful resection of involved organs and involved peritoneal surfaces [ 5 ]. The umbilicus is hypothesized as a frequent haven for tumour deposits. Sakata et al found 30% of patients undergoing CRS had disease involving the umbilicus and thus advocated for routine umbilical excision [ 1 ]. The infiltration of tumour at the umbilicus can originate from previous diagnostic or staging laparoscopies with port sites acting as a conduit of disease spread, or alternatively, the result of direct spread of disease [ 6 ]. Therefore, the risk of incomplete cytoreduction remains a concern if umbilical excision is not performed. Routine excision of the umbilicus is performed in some centres as standard practice for patients with peritoneal surface malignancies. Crucially, there are body image and cosmetic implications for patients requiring umbilical excision. Patients often perceive the absence of the umbilicus as aesthetically displeasing and may experience significant psychological distress as a result. The umbilicus serves as a noticeable and essential landmark on the abdomen and therefore affects one’s overall appearance and body confidence [ 7 , 8 ]. Plastic surgeons have recognised both the importance of umbilical appearance and necessity of reconstruction when excised, and therefore have published numerous reconstructive techniques [ 7 – 10 ]. However, a suitable method specifically applicable in the context of CRS and peritoneal malignancy has not yet been described. The aim of this study is to describe a novel technique of umbilical reconstruction during CRS and evaluate postoperative would complications and patient satisfaction. 2. Method A review of prospectively collected data was conducted on consecutive patients undergoing CRS and HIPEC requiring concurrent umbilical excision between January 2021 and December 2023, at the two largest peritoneal malignancy units in Australia. Written consent was obtained from all patients, and ethics approval was granted by the Human Research Ethics Committee of both Local Health Districts. Patient data collected included age, body mass index (BMI), preoperative skin height (measured on preoperative CT scans from skin to fascia at the iliac crest), smoking status, diabetes, and intraoperative PCI score. Surgical technique The same reconstruction technique was performed for all patients. We utilise a standardised laparotomy approach marking the xiphisternum, pubic bone, and midline. An elliptical incision is made at the midline to incorporate the umbilicus with the creation of semioval skin flaps at the level of the umbilicus for later reconstruction (Fig. 1 A). Entry into the abdomen is made with a combination of diathermy and sharp dissection, and an elongated elliptical wedge of fascia is taken to include the umbilicus. This allows for spread of tension at the time of closure of both fascia and skin. CRS is then performed. Prior to HIPEC, a 2 cm wide subcutaneous dissection is performed at the fascia to expose the anterior sheath and allow for the fascia to be submerged into the HIPEC fluid. Closure of the fascia is performed using a continuous 1 PDS® (polydioxanone) suture in a standardised manner ensuring that the surgical knots are not placed at the level of the umbilical reconstruction. In patients with a large amount of subcutaneous fat, the fat is removed at the semioval flaps. Two 1 Vicryl® (polyglactin 910) mattress sutures are placed at the cranial and caudal aspect of the vertices of the semioval flaps as well as the fascia and tied down to anchor what will be the base of the umbilical reconstruction (Fig. 1 B). Further 1 Vicryl sutures are placed at the cranial and caudal base of the semioval flap on either side and the skin is reapproximated, thus creating a conical shaped umbilical reconstruction (Fig. 1 C). A 1 Vicryl suture on a 48mm needle is then passed parallel to the skin plane in the subcutaneous fat from the cranial apposition suture and removed at the caudal end, ensuring a semicircular path. This is repeated on the other side and tied slowly to narrow the aperture of the neo-umbilicus for cosmesis (Fig. 1 D). The remainder of the wound is closed in two layers; continuous Vicryl subdermal stitches then staples or Monocryl® (poliglecaprone 25) sutures in continuous fashion. No further sutures are placed at the neo-umbilicus to allow for drainage. An alginate dressing is fashioned into a ball and placed in the neo-umbilicus to facilitate drainage and bolster the reconstruction. Outcomes The primary outcome measured was the rate and type of wound complication associated with this umbilical reconstruction technique. This included common wound-related complications such as inflammation, dehiscence and both superficial and deep wound infections. We additionally assessed for wound stenosis and widening at the umbilicus. Secondary outcomes were post operative complications and patient satisfaction using a modified version of the Patient and Observer Scar Assessment Scale (POSAS) [ 11 ]. Statistical analyses were performed using IBM SPSS software version 24 (IBM corporation, New York, USA). Descriptive statistics included mean, percentage, standard deviation (SD) and range. Multivariant analysis was performed to compare between patients with and without complications. 3. Results A total of 50 patients with peritoneal surface malignancy underwent umbilical reconstruction during CRS using our novel technique. The mean age was 56.4 years (SD 11.2, range 30 to 85) with a mean BMI of 27.3 kg/m 2 (SD 8.24). A summary of patient baseline and operative characteristics is provided in Tables 1 and 2 . Wound classification was considered “clean” or “clean-contaminated” in 48 (96%) patients, and mesh was used for abdominal wall reconstruction in four (8%) patients. Table 1 Characteristics of patients who had umbilical reconstruction with cytoreductive surgery Patient characteristics Number of patients (%) a,b Age, mean (SD), years 56.4 (11.3) Sex Male 13 (26) Female 37 (74) Origin of primary cancer Appendiceal 27 (53) Colorectal 13 (23) Other (e.g. ovarian, mesothelioma) 10 (23) ASA score 1 0 2 3 (6) 3 42 (84) 4 5 (10) BMI, mean (SD), kg/m² 27.3 (8.32) Pre-operative skin height, mean (SD), mm 23.0 (10.3) Smoking status Current smoker 2 (4) Ex-smoker 2 (4) Non-smoker 46 (92) Diabetes, n (%) Yes 6 (12) No 42 (84) a Data are presented as no. of patients (%) unless otherwise stated. Percentages may not total 100 because of rounding. b SD, standard deviation; ASA, American Society of Anesthesiology; BMI, body-mass index. Table 2 Operative characteristics of patients who underwent umbilical reconstruction with their cytoreductive surgery Operative characteristics Number of patients (%) a, b PCI score, median (interquartile range) 14 (6–24) CC score 0 45 (90) 1 3 (6) 2 2 (4) Wound classification Clean 8 (16) Clean-contaminated 42 (84) HIPEC None 2 (7) Mitomycin 41 (82) Cisplatin 2 (4) Oxaliplatin 3 (6) Mitomycin + cisplatin 2 (4) Use of mesh 4 (8) Operative time in minutes, mean (SD) 626 (188) a Data are presented as no. of patients (%) unless otherwise stated. Percentages may not total 100 because of rounding. b PCI, peritoneal cancer index; CC, completeness of cytoreduction A total of 12 (24%) of patients experienced wound-related complications (Table 3 ). Four patients showed signs of wound inflammation, two of whom subsequently developed superficial surgical site infections requiring antibiotic treatment. The other two patients did not require any treatment. Eight patients in total experienced superficial surgical site infections requiring antibiotic treatment. Two of these patients required bedside drainage of the wounds resulting in minor wound dehiscence. One patient experienced a deep surgical site infection requiring antibiotics and washout of their wound performed at the bedside. All complications observed were classified as either Grade I or Grade II according to the Clavien-Dindo classification scale. None of the patients experience wound seroma, skin necrosis, widening of the wound or umbilical stenosis. Additionally, no patients required radiological interventions for their wound, nor did any require a return to the operating theatres for wound revision procedures. The median hospital length of stay for all patients was 19 days (range 5–47). Table 3 Perioperative Characteristics and Complications in Patients with Wound Complications. Patient no. Age (y) Sex BMI (kg/m 2 ) Skin height (cm) PCI Smoking status Complication 1 62 M 31.2 26 8 Never Deep SSI 2 69 F 29.5 18 10 Never Superficial SSI + wound dehiscence 3 53 M 34.9 18 5 Never Superficial SSI + wound dehiscence 4 46 F 28.3 37 16 Never Superficial SSI 5 50 F 28.7 17 39 Ex-smoker Inflammation 6 52 F 23.6 23 26 Ex-smoker Inflammation + superficial SSI 7 30 F 23.6 27 33 Never Inflammation + superficial SSI 8 75 F 23.3 29 4 Never Superficial SSI 9 61 M 27.2 38 18 Never Inflammation 10 46 F 34.3 30 16 Never Superficial SSI 11 46 M 26.7 27 16 Never Superficial dehiscence 12 61 F 29.0 8 25 Never Superficial SSI BMI, body-mass index; PCI, peritoneal cancer index; SSI, surgical site infection At routine follow up at six weeks postoperatively, all patients expressed satisfaction with their umbilical reconstruction and did not wish to pursue any further revisional surgery for their umbilical appearance. 72% of patients who completed the POSAS satisfaction survey reported being very satisfied with their umbilical reconstruction, while the remaining 28% were moderately satisfied. Notably, none of the patients expressed dissatisfaction with their scar. The cohort of patients who developed wound-related complications had similarly high patient satisfaction scores as those without complications. Figures 2 and 3 provide a chronological demonstration of patients undergoing the umbilical reconstruction over a six-week period. When comparing individuals who experienced wound complications with those who did not, preoperative factors such as age, preoperative skin height, BMI, and PCI score demonstrated no significant impact on the occurrence of wound complications (Table 4 ). None of the patients who underwent mesh repairs experienced any wound complications. Additionally, the presence of diabetes did not increase their risk of wound-related complications in our study population. Table 4 Comparison of pre-operative factors for patients with and without wound complications Variable Wound complication No wound complications p-value Age, mean in years 54.3 57.1 0.45 BMI, mean 28.3 26.9 0.61 Skin height, mean in cm 24.9 22.4 0.46 PCI score, median 11.0 16.0 0.19 Wound clean-contaminated 33 9 0.33 4. Discussion Although numerous techniques for umbilical reconstruction have been described in the literature, this series of 50 patients is the first to present a simple and reproducible method of umbilical reconstruction during CRS where excision of the umbilicus is of oncological importance [ 7 , 8 ]. Our technique is novel due to its ease, applicability, and ability to be performed concurrently with CRS. Wound complications were observed in 24% of patients, the majority of whom experienced superficial surgical site infections. The complication rate is consistent with the reported 17–46% wound complication rate in the CRS literature, suggesting our technique does not carry an increased risk of wound complications [ 12 – 14 ]. No patient demographic variables were significantly associated with increased risk of wound complication. Our data demonstrate satisfactory aesthetic results and high patient satisfaction scores while maintaining an acceptable level of wound complications. Understandably, there may be hesitancy in performing an immediate reconstructive procedure in settings with wounds are at high risk for infection, such as those with faeculant or biliary contamination [ 15 ]. However, with early recognition and appropriate antimicrobial treatment of infections, we have demonstrated no significant change in the final cosmetic result. Clinicians should also demonstrate heightened vigilance and awareness when evaluating surgical wounds, especially in cases where reconstruction has taken place. In contrast to cosmetic surgery, open abdominal surgery for peritoneal malignancy places less (or no) emphasis on body image and cosmesis. Optimal oncological resection is the most important for outcome for surgeons however, from a patient perspective, improved cosmesis and body image have been shown to be advantageous in improving quality of life, self-esteem, and functional outcomes [ 16 ]. This is well established in breast cancer surgery with breast reconstruction and onco-plastics becoming a subspecialty field of its own [ 17 ]. Similarly, one of the many benefits of laparoscopic surgery is fewer scars leading to better cosmesis and improved body image [ 16 , 18 ]. Unfortunately, considerations of body image are often overlooked in the context of radical cancer surgery for peritoneal malignancy: CRS significantly distorts normal surface anatomy with a midline scar, multiple drain sites and potentially a stoma. However, stomas are often reversed, and scars fade to become less prominent, leaving the lack of the umbilicus a distinct remaining anomaly. The umbilicus serves as a significant landmark and contributes to the natural appearance of the abdomen; therefore, its preservation is important to one’s body image [ 8 ]. Complete reconstruction of the umbilicus or “neo-umbilicoplasty” by general surgeons differs from the usual technique of transposing the umbilicus performed after detachment during umbilical hernia operations [ 7 ]. With neo-umbilicoplasty, the precise position, symmetry and recreation of a natural-looking umbilicus are essential. This requires careful attention to detail regarding the shape, depth and proportion of the umbilicus. Joseph et al described the “perfect umbilicus” as a vertically oriented, oval-shaped umbilicus with slight superior hooding [ 8 ]. Our described technique incorporates various elements from different techniques reported in the literature. We utilise the vertical ellipse incision and attachment of the umbilicus to the rectus as described by Bruekers et al. and Mazzocchi et al [ 19 , 20 ]. Periumbilical defatting was described by several authors and is also a fundamental component in our approach [ 7 , 10 ]. Admittedly, there are a vast number of reconstructive techniques developed by plastic surgeons who perform abdominoplasties: several involves complex flaps, staged reconstruction, and the use of autologous grafts to recreate the natural umbilicus shape and appearance [ 7 ]. Our technique is specifically tailored for patients undergoing maximally invasive surgery, acknowledging that achieving a perfect abdominal appearance may not be possible due to the radical nature of surgery. Thus, our aim is to offer a semblance of normalcy in an otherwise battle-scarred abdomen. One advantage of our technique is its ability to be performed concurrently with the index operation and requiring minimal additional time to perform in comparison to the entire operation. Its simplicity also allows for an easy learning curve, and the necessary concepts are readily applicable to general surgeons without requiring plastic surgical input. This study strength includes being performed in the two highest-volume peritoneal malignancy units in Australia. We of course acknowledge several limitations including its retrospective design. The sample size is small; however, it is important to consider this in the context of the relatively rare incidence of peritoneal malignancy. This study could be strengthened by the inclusion of a direct comparison group of patients who underwent umbilical excision without subsequent reconstruction. Future prospective and randomised studies will be useful to confirm the demonstrated safety and benefits of this initial pilot study. This technique has the potential to extend further than just CRS and is transferable to other midline abdominal incisions requiring umbilical excision such as revisional ventral hernia surgery, endometriosis involving the radical excision of the umbilicus and primary tumours originating near the umbilicus. 5. Conclusion Umbilical reconstruction in patients undergoing CRS is safe and technically feasible, without significant compromise to wound healing outcomes. A meticulously crafted umbilicus not only reinstates the semblance of a visually normal abdomen, but also enhances patients to experience improved self-esteem and body confidence. Our novel technique can be employed by all surgeons to improve cosmesis, patient satisfaction, and long-term body image for patients undergoing major abdominal surgery where umbilical excision is required. Declarations Ethics statement This study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all patients to participate in this study and have their data published. The authors affirm that human research participants provided informed consent for publication of the images in Figs. 2a, 2b, 2c, 3a and 3b. Ethics approval was granted by both hospital’s Local Health District’s ethics committee. Competing Interests David L Morris is the owner and director of the company Mucpharm Pty Ltd, Sydney, Australia.All other authors disclose no conflicts of interest. Funding information: This research received no external funding or support. Author Contribution E.C. Study conception and design; Acquisition of data; Analysis and interpretation of data; Drafting of manuscript; Critical revision of manuscript. M.S. Critical revision of manuscript. P.Y. Study conception and design; Acquisition of data; Drafting of manuscript. S.K. Acquisition of data; Drafting of manuscript. J.M. Drafting of manuscript; Critical revision of manuscript. R.W. Study conception and design; Acquisition of data; Critical revision of manuscript. N.A. Study conception and design; Acquisition of data; C.K. Study conception and design; Acquisition of data. D.M. Study conception and design; Acquisition of data. N.A. Study conception and design; Acquisition of data; Analysis and interpretation of data; Drafting of manuscript; Critical revision of manuscript. Data Availability: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. References Sakata S, Tan TG, Kostadinov D, Ahmadi N, Dayal SP, Tzivanakis A, et al. Patients undergoing cytoreductive surgery for peritoneal malignancy of appendiceal origin should be consented for umbilical excision as 30% have umbilical infiltration. 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Cite Share Download PDF Status: Published Journal Publication published 21 Jan, 2025 Read the published version in Techniques in Coloproctology → Version 1 posted Editorial decision: Revision requested 18 Nov, 2024 Reviews received at journal 15 Nov, 2024 Reviews received at journal 15 Nov, 2024 Reviewers agreed at journal 15 Nov, 2024 Reviewers agreed at journal 26 Oct, 2024 Reviewers invited by journal 17 Oct, 2024 Editor assigned by journal 13 Oct, 2024 Submission checks completed at journal 23 Sep, 2024 First submitted to journal 23 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5135276","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":379560741,"identity":"61a3d849-ffe9-4764-a753-8cd56942f980","order_by":0,"name":"Ernest 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mina","middleName":"","lastName":"Sarofim","suffix":""},{"id":379560755,"identity":"30aba99f-a1ba-4c39-b56c-fab360b7eca8","order_by":5,"name":"Ruwanthi Wijayawardana","email":"","orcid":"","institution":"St George Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruwanthi","middleName":"","lastName":"Wijayawardana","suffix":""},{"id":379560756,"identity":"a7ce52e4-d4fe-4aac-9976-3ff7349d1826","order_by":6,"name":"Nabila Ansari","email":"","orcid":"","institution":"Royal Prince Alfred Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nabila","middleName":"","lastName":"Ansari","suffix":""},{"id":379560757,"identity":"2b883234-be91-4ff6-89fa-ec617de117ed","order_by":7,"name":"Cherry Koh","email":"","orcid":"","institution":"Royal Prince Alfred Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cherry","middleName":"","lastName":"Koh","suffix":""},{"id":379560758,"identity":"66189a26-c7b3-4b84-9352-f505c50c693a","order_by":8,"name":"David Morris","email":"","orcid":"","institution":"St George Hospital","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Morris","suffix":""},{"id":379560759,"identity":"72719d00-ba6f-44bb-a22c-5448feb85915","order_by":9,"name":"Nima Ahmadi","email":"","orcid":"","institution":"St George Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nima","middleName":"","lastName":"Ahmadi","suffix":""}],"badges":[],"createdAt":"2024-09-23 05:36:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5135276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5135276/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10151-024-03095-y","type":"published","date":"2025-01-21T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69962293,"identity":"0aed2740-9391-48a6-9125-b2d4a836ff8c","added_by":"auto","created_at":"2024-11-27 04:49:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2923858,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrative representation of umbilical reconstruction after umbilical excision as part of cytoreductive surgery\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5135276/v1/6abc96bc3571892e97ad0869.jpg"},{"id":69963632,"identity":"d0d3e689-9d21-4348-bb02-6520d5f9bdfb","added_by":"auto","created_at":"2024-11-27 04:57:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":363640,"visible":true,"origin":"","legend":"\u003cp\u003eExample of one patient’s abdomen who underwent the described umbilical reconstruction technique. A: Image taken preoperatively with incision markings. B: Image taken two weeks post-operatively. C: Image taken six weeks post-operatively.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5135276/v1/d641221a3792f78c65ff1b9b.jpg"},{"id":69962294,"identity":"554d072c-866e-4878-aca8-944dd68564a8","added_by":"auto","created_at":"2024-11-27 04:49:01","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":754301,"visible":true,"origin":"","legend":"\u003cp\u003eFurther examples of umbilical reconstruction outcomes A: Image taken six weeks\u003c/p\u003e\n\u003cp\u003epost-operatively B: Different patient with image taken eight-weeks post operatively.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5135276/v1/fbcc8d0885036b00aed8e15c.jpg"},{"id":74858253,"identity":"bdc143fb-ef9e-4570-9857-dbe2eb88451b","added_by":"auto","created_at":"2025-01-27 16:02:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4689363,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5135276/v1/6630a1db-15c8-4082-93f5-5eac803f7d7c.pdf"}],"financialInterests":"Competing interest reported. David L Morris is the owner and director of the company Mucpharm Pty Ltd, Sydney, Australia.\nAll other authors disclose no conflicts of interest.","formattedTitle":"Novel technique and outcomes of umbilical reconstruction during cytoreductive surgery; a multi-centre study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCytoreductive surgery (CRS) is the mainstay treatment for removal of macroscopic disease in peritoneal malignancies. Complete cytoreduction, achieved through a combination of extensive disease excision and delivery of heated intraperitoneal chemotherapy (HIPEC), has been shown to improve survival in peritoneal surface malignancies [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To facilitate the removal of all disease, cytoreductive surgery traditionally entails a midline laparotomy and careful resection of involved organs and involved peritoneal surfaces [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The umbilicus is hypothesized as a frequent haven for tumour deposits. Sakata et al found 30% of patients undergoing CRS had disease involving the umbilicus and thus advocated for routine umbilical excision [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The infiltration of tumour at the umbilicus can originate from previous diagnostic or staging laparoscopies with port sites acting as a conduit of disease spread, or alternatively, the result of direct spread of disease [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, the risk of incomplete cytoreduction remains a concern if umbilical excision is not performed. Routine excision of the umbilicus is performed in some centres as standard practice for patients with peritoneal surface malignancies.\u003c/p\u003e \u003cp\u003eCrucially, there are body image and cosmetic implications for patients requiring umbilical excision. Patients often perceive the absence of the umbilicus as aesthetically displeasing and may experience significant psychological distress as a result. The umbilicus serves as a noticeable and essential landmark on the abdomen and therefore affects one\u0026rsquo;s overall appearance and body confidence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Plastic surgeons have recognised both the importance of umbilical appearance and necessity of reconstruction when excised, and therefore have published numerous reconstructive techniques [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, a suitable method specifically applicable in the context of CRS and peritoneal malignancy has not yet been described. The aim of this study is to describe a novel technique of umbilical reconstruction during CRS and evaluate postoperative would complications and patient satisfaction.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003eA review of prospectively collected data was conducted on consecutive patients undergoing CRS and HIPEC requiring concurrent umbilical excision between January 2021 and December 2023, at the two largest peritoneal malignancy units in Australia. Written consent was obtained from all patients, and ethics approval was granted by the Human Research Ethics Committee of both Local Health Districts. Patient data collected included age, body mass index (BMI), preoperative skin height (measured on preoperative CT scans from skin to fascia at the iliac crest), smoking status, diabetes, and intraoperative PCI score.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurgical technique\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe same reconstruction technique was performed for all patients. We utilise a standardised laparotomy approach marking the xiphisternum, pubic bone, and midline. An elliptical incision is made at the midline to incorporate the umbilicus with the creation of semioval skin flaps at the level of the umbilicus for later reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Entry into the abdomen is made with a combination of diathermy and sharp dissection, and an elongated elliptical wedge of fascia is taken to include the umbilicus. This allows for spread of tension at the time of closure of both fascia and skin. CRS is then performed. Prior to HIPEC, a 2 cm wide subcutaneous dissection is performed at the fascia to expose the anterior sheath and allow for the fascia to be submerged into the HIPEC fluid.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eClosure of the fascia is performed using a continuous 1 PDS\u0026reg; (polydioxanone) suture in a standardised manner ensuring that the surgical knots are not placed at the level of the umbilical reconstruction. In patients with a large amount of subcutaneous fat, the fat is removed at the semioval flaps. Two 1 Vicryl\u0026reg; (polyglactin 910) mattress sutures are placed at the cranial and caudal aspect of the vertices of the semioval flaps as well as the fascia and tied down to anchor what will be the base of the umbilical reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Further 1 Vicryl sutures are placed at the cranial and caudal base of the semioval flap on either side and the skin is reapproximated, thus creating a conical shaped umbilical reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). A 1 Vicryl suture on a 48mm needle is then passed parallel to the skin plane in the subcutaneous fat from the cranial apposition suture and removed at the caudal end, ensuring a semicircular path. This is repeated on the other side and tied slowly to narrow the aperture of the neo-umbilicus for cosmesis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003eThe remainder of the wound is closed in two layers; continuous Vicryl subdermal stitches then staples or Monocryl\u0026reg; (poliglecaprone 25) sutures in continuous fashion. No further sutures are placed at the neo-umbilicus to allow for drainage. An alginate dressing is fashioned into a ball and placed in the neo-umbilicus to facilitate drainage and bolster the reconstruction.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOutcomes\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe primary outcome measured was the rate and type of wound complication associated with this umbilical reconstruction technique. This included common wound-related complications such as inflammation, dehiscence and both superficial and deep wound infections. We additionally assessed for wound stenosis and widening at the umbilicus. Secondary outcomes were post operative complications and patient satisfaction using a modified version of the Patient and Observer Scar Assessment Scale (POSAS) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS software version 24 (IBM corporation, New York, USA). Descriptive statistics included mean, percentage, standard deviation (SD) and range. Multivariant analysis was performed to compare between patients with and without complications.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 50 patients with peritoneal surface malignancy underwent umbilical reconstruction during CRS using our novel technique. The mean age was 56.4 years (SD 11.2, range 30 to 85) with a mean BMI of 27.3 kg/m\u003csup\u003e2\u003c/sup\u003e (SD 8.24). A summary of patient baseline and operative characteristics is provided in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Wound classification was considered \u0026ldquo;clean\u0026rdquo; or \u0026ldquo;clean-contaminated\u0026rdquo; in 48 (96%) patients, and mesh was used for abdominal wall reconstruction in four (8%) patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients who had umbilical reconstruction with cytoreductive surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients (%)\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD), years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.4 (11.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrigin of primary cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendiceal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorectal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (e.g. ovarian, mesothelioma)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, mean (SD), kg/m\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.3 (8.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-operative skin height, mean (SD), mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.0 (10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEx-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eData are presented as no. of patients (%) unless otherwise stated. Percentages may not total 100 because of rounding.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eSD, standard deviation; ASA, American Society of Anesthesiology; BMI, body-mass index.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative characteristics of patients who underwent umbilical reconstruction with their cytoreductive surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients (%)\u003csup\u003ea, b\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI score, median (interquartile range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (6\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClean-contaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIPEC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxaliplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitomycin\u0026thinsp;+\u0026thinsp;cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of mesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time in minutes, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e626 (188)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eData are presented as no. of patients (%) unless otherwise stated. Percentages may not total 100 because of rounding.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003ePCI, peritoneal cancer index; CC, completeness of cytoreduction\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 12 (24%) of patients experienced wound-related complications (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Four patients showed signs of wound inflammation, two of whom subsequently developed superficial surgical site infections requiring antibiotic treatment. The other two patients did not require any treatment. Eight patients in total experienced superficial surgical site infections requiring antibiotic treatment. Two of these patients required bedside drainage of the wounds resulting in minor wound dehiscence. One patient experienced a deep surgical site infection requiring antibiotics and washout of their wound performed at the bedside. All complications observed were classified as either Grade I or Grade II according to the Clavien-Dindo classification scale. None of the patients experience wound seroma, skin necrosis, widening of the wound or umbilical stenosis. Additionally, no patients required radiological interventions for their wound, nor did any require a return to the operating theatres for wound revision procedures. The median hospital length of stay for all patients was 19 days (range 5\u0026ndash;47).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative Characteristics and Complications in Patients with Wound Complications.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSkin height (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSmoking status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDeep SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial SSI\u0026thinsp;+\u0026thinsp;wound dehiscence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial SSI\u0026thinsp;+\u0026thinsp;wound dehiscence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEx-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInflammation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEx-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInflammation\u0026thinsp;+\u0026thinsp;superficial SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInflammation\u0026thinsp;+\u0026thinsp;superficial SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInflammation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial dehiscence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSuperficial SSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eBMI, body-mass index; PCI, peritoneal cancer index; SSI, surgical site infection\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAt routine follow up at six weeks postoperatively, all patients expressed satisfaction with their umbilical reconstruction and did not wish to pursue any further revisional surgery for their umbilical appearance.\u003c/p\u003e \u003cp\u003e72% of patients who completed the POSAS satisfaction survey reported being very satisfied with their umbilical reconstruction, while the remaining 28% were moderately satisfied. Notably, none of the patients expressed dissatisfaction with their scar. The cohort of patients who developed wound-related complications had similarly high patient satisfaction scores as those without complications. Figures\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provide a chronological demonstration of patients undergoing the umbilical reconstruction over a six-week period.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWhen comparing individuals who experienced wound complications with those who did not, preoperative factors such as age, preoperative skin height, BMI, and PCI score demonstrated no significant impact on the occurrence of wound complications (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). None of the patients who underwent mesh repairs experienced any wound complications. Additionally, the presence of diabetes did not increase their risk of wound-related complications in our study population.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of pre-operative factors for patients with and without wound complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound complication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo wound complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.45\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, mean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.61\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin height, mean in cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.46\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI score, median\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.19\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound clean-contaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.33\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAlthough numerous techniques for umbilical reconstruction have been described in the literature, this series of 50 patients is the first to present a simple and reproducible method of umbilical reconstruction during CRS where excision of the umbilicus is of oncological importance [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our technique is novel due to its ease, applicability, and ability to be performed concurrently with CRS. Wound complications were observed in 24% of patients, the majority of whom experienced superficial surgical site infections. The complication rate is consistent with the reported 17\u0026ndash;46% wound complication rate in the CRS literature, suggesting our technique does not carry an increased risk of wound complications [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. No patient demographic variables were significantly associated with increased risk of wound complication.\u003c/p\u003e \u003cp\u003eOur data demonstrate satisfactory aesthetic results and high patient satisfaction scores while maintaining an acceptable level of wound complications. Understandably, there may be hesitancy in performing an immediate reconstructive procedure in settings with wounds are at high risk for infection, such as those with faeculant or biliary contamination [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, with early recognition and appropriate antimicrobial treatment of infections, we have demonstrated no significant change in the final cosmetic result. Clinicians should also demonstrate heightened vigilance and awareness when evaluating surgical wounds, especially in cases where reconstruction has taken place.\u003c/p\u003e \u003cp\u003eIn contrast to cosmetic surgery, open abdominal surgery for peritoneal malignancy places less (or no) emphasis on body image and cosmesis. Optimal oncological resection is the most important for outcome for surgeons however, from a patient perspective, improved cosmesis and body image have been shown to be advantageous in improving quality of life, self-esteem, and functional outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This is well established in breast cancer surgery with breast reconstruction and onco-plastics becoming a subspecialty field of its own [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, one of the many benefits of laparoscopic surgery is fewer scars leading to better cosmesis and improved body image [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Unfortunately, considerations of body image are often overlooked in the context of radical cancer surgery for peritoneal malignancy: CRS significantly distorts normal surface anatomy with a midline scar, multiple drain sites and potentially a stoma. However, stomas are often reversed, and scars fade to become less prominent, leaving the lack of the umbilicus a distinct remaining anomaly. The umbilicus serves as a significant landmark and contributes to the natural appearance of the abdomen; therefore, its preservation is important to one\u0026rsquo;s body image [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComplete reconstruction of the umbilicus or \u0026ldquo;neo-umbilicoplasty\u0026rdquo; by general surgeons differs from the usual technique of transposing the umbilicus performed after detachment during umbilical hernia operations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. With neo-umbilicoplasty, the precise position, symmetry and recreation of a natural-looking umbilicus are essential. This requires careful attention to detail regarding the shape, depth and proportion of the umbilicus. Joseph et al described the \u0026ldquo;perfect umbilicus\u0026rdquo; as a vertically oriented, oval-shaped umbilicus with slight superior hooding [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our described technique incorporates various elements from different techniques reported in the literature. We utilise the vertical ellipse incision and attachment of the umbilicus to the rectus as described by Bruekers et al. and Mazzocchi et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Periumbilical defatting was described by several authors and is also a fundamental component in our approach [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Admittedly, there are a vast number of reconstructive techniques developed by plastic surgeons who perform abdominoplasties: several involves complex flaps, staged reconstruction, and the use of autologous grafts to recreate the natural umbilicus shape and appearance [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our technique is specifically tailored for patients undergoing maximally invasive surgery, acknowledging that achieving a perfect abdominal appearance may not be possible due to the radical nature of surgery. Thus, our aim is to offer a semblance of normalcy in an otherwise battle-scarred abdomen. One advantage of our technique is its ability to be performed concurrently with the index operation and requiring minimal additional time to perform in comparison to the entire operation. Its simplicity also allows for an easy learning curve, and the necessary concepts are readily applicable to general surgeons without requiring plastic surgical input.\u003c/p\u003e \u003cp\u003eThis study strength includes being performed in the two highest-volume peritoneal malignancy units in Australia. We of course acknowledge several limitations including its retrospective design. The sample size is small; however, it is important to consider this in the context of the relatively rare incidence of peritoneal malignancy. This study could be strengthened by the inclusion of a direct comparison group of patients who underwent umbilical excision without subsequent reconstruction. Future prospective and randomised studies will be useful to confirm the demonstrated safety and benefits of this initial pilot study. This technique has the potential to extend further than just CRS and is transferable to other midline abdominal incisions requiring umbilical excision such as revisional ventral hernia surgery, endometriosis involving the radical excision of the umbilicus and primary tumours originating near the umbilicus.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eUmbilical reconstruction in patients undergoing CRS is safe and technically feasible, without significant compromise to wound healing outcomes. A meticulously crafted umbilicus not only reinstates the semblance of a visually normal abdomen, but also enhances patients to experience improved self-esteem and body confidence. Our novel technique can be employed by all surgeons to improve cosmesis, patient satisfaction, and long-term body image for patients undergoing major abdominal surgery where umbilical excision is required.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics statement\u003c/h2\u003e\n\u003cp\u003eThis study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all patients to participate in this study and have their data published. The authors affirm that human research participants provided informed consent for publication of the images in Figs. 2a, 2b, 2c, 3a and 3b. Ethics approval was granted by both hospital\u0026rsquo;s Local Health District\u0026rsquo;s ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDavid L Morris is the owner and director of the company Mucpharm Pty Ltd, Sydney, Australia.All other authors disclose no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding information:\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding or support.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eE.C. Study conception and design; Acquisition of data; Analysis and interpretation of data; Drafting of manuscript; Critical revision of manuscript. M.S. Critical revision of manuscript. P.Y. Study conception and design; Acquisition of data; Drafting of manuscript. S.K. Acquisition of data; Drafting of manuscript. J.M. Drafting of manuscript; Critical revision of manuscript. R.W. Study conception and design; Acquisition of data; Critical revision of manuscript. N.A. Study conception and design; Acquisition of data; C.K. Study conception and design; Acquisition of data. D.M. Study conception and design; Acquisition of data. N.A. Study conception and design; Acquisition of data; Analysis and interpretation of data; Drafting of manuscript; Critical revision of manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability:\u003c/h2\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSakata S, Tan TG, Kostadinov D, Ahmadi N, Dayal SP, Tzivanakis A, et al. Patients undergoing cytoreductive surgery for peritoneal malignancy of appendiceal origin should be consented for umbilical excision as 30% have umbilical infiltration. Colorectal Dis. 2021;23(5):1153\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/codi.15571\u003c/span\u003e\u003cspan address=\"10.1111/codi.15571\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChua TC, Yan TD, Smigielski ME, Zhu KJ, Ng KM, Zhao J, et al. Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution. 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J Surg Oncol. 2019;120(4):794\u0026ndash;802. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jso.25642\u003c/span\u003e\u003cspan address=\"10.1002/jso.25642\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoran B, Cecil T, Chandrakumaran K, Arnold S, Mohamed F, Venkatasubramaniam A. The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy. Colorectal Dis. 2015;17(9):772\u0026ndash;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/codi.12975\u003c/span\u003e\u003cspan address=\"10.1111/codi.12975\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugarbaker PH. Peritonectomy procedures. Ann Surg. 1995;221(1):29\u0026ndash;42. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000658-199501000-00004\u003c/span\u003e\u003cspan address=\"10.1097/00000658-199501000-00004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao Q, Guo L, Wang B. The Pathogenesis and Prevention of Port-Site Metastasis in Gynecologic Oncology. Cancer Manag Res. 2020;12:9655\u0026ndash;63. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/CMAR.S270881\u003c/span\u003e\u003cspan address=\"10.2147/CMAR.S270881\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSisti A, Huayllani MT, Boczar D, Restrepo DJ, Cinotto G, Lu X, et al. Umbilical Reconstruction Techniques: A Literature Review. 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The 'Celtic cross' technique for immediate umbilical reconstruction post-laparotomy and surgical ablation of the umbilicus. J Plast Reconstr Aesthet Surg. 2009;62(2):258\u0026ndash;61. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bjps.2007.10.016\u003c/span\u003e\u003cspan address=\"10.1016/j.bjps.2007.10.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranco D, Medeiros J, Farias C, Franco T. Umbilical reconstruction for patients with a midline scar. 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Ann Plast Surg. 2009;63(1):15\u0026ndash;20. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SAP.0b013e3181877b60\u003c/span\u003e\u003cspan address=\"10.1097/SAP.0b013e3181877b60\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Umbilicus, Umbilical reconstruction, abdominal aesthetics, cytoreductive surgery","lastPublishedDoi":"10.21203/rs.3.rs-5135276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5135276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe goal of cytoreductive surgery for peritoneal malignancy is to remove all macroscopic disease, which occasionally requires the excision of the umbilicus. While the absence of the umbilicus can be aesthetically undesirable for patients, umbilical reconstruction is rarely performed due to the perceived complexity and increased risk of wound infections [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This study aims to evaluate the outcomes, cosmetic results, and patient satisfaction of umbilical reconstruction during cytoreductive surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eConsecutive patients from a prospectively maintained database who underwent cytoreductive surgery with umbilical excision and reconstruction were evaluated. Our technique for umbilical reconstruction involved recreating the subcutaneous fat space and fashioning umbilical skin flaps that anchor to the anterior fascia. Outcomes assessed included postoperative infection rate, wound dehiscence, seroma formation, wound appearance, and patient satisfaction.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eUmbilical reconstruction was performed on 50 patients, with 12 (24%) experiencing wound-related complications. Of these, 8 patients (16%) had superficial wound infections, while 1 patient (2%) developed a deep wound infection. Three patients (6%) required local wound drainage, though none needed surgical revision. There were no reports of wound seromas, skin necrosis, wound widening, or umbilical stenosis. All patients reported satisfaction with the outcome of their reconstruction.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur novel technique for umbilical reconstruction during cytoreductive surgery did not negatively impact wound healing outcomes. Recreating the umbilicus improved cosmetic results and patient satisfaction, enhancing body image for those undergoing major abdominal surgery. This approach should be considered for patients undergoing major laparotomies that necessitates umbilical excision.\u003c/p\u003e","manuscriptTitle":"Novel technique and outcomes of umbilical reconstruction during cytoreductive surgery; a multi-centre study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-27 04:48:56","doi":"10.21203/rs.3.rs-5135276/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-18T15:19:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-15T22:35:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-15T13:37:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14097263999895069973012534849623305461","date":"2024-11-15T13:35:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38323591517597887532521939362705873340","date":"2024-10-26T13:20:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-17T12:17:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-13T20:59:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-23T11:29:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2024-09-23T05:34:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0d1b88fd-7981-43a3-9e67-3d31e9dd1aac","owner":[],"postedDate":"November 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T15:58:38+00:00","versionOfRecord":{"articleIdentity":"rs-5135276","link":"https://doi.org/10.1007/s10151-024-03095-y","journal":{"identity":"techniques-in-coloproctology","isVorOnly":false,"title":"Techniques in Coloproctology"},"publishedOn":"2025-01-21 15:56:51","publishedOnDateReadable":"January 21st, 2025"},"versionCreatedAt":"2024-11-27 04:48:56","video":"","vorDoi":"10.1007/s10151-024-03095-y","vorDoiUrl":"https://doi.org/10.1007/s10151-024-03095-y","workflowStages":[]},"version":"v1","identity":"rs-5135276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5135276","identity":"rs-5135276","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}