title: Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness.
abstract: BACKGROUND
  Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present.
  
  
  OBJECTIVE
  The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure).
  
  
  METHODS
  Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region.
  
  
  RESULTS
  All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques.
  
  
  CONCLUSIONS
  The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA. Electronic address: easmithmd@gmail.com.
authors.forename: Edwin A
authors.initials: EA
authors.lastname: Smith
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Arun
authors.initials: A
authors.lastname: Srinivasan
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Hal C
authors.initials: HC
authors.lastname: Scherz
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Tracey
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Bruce
authors.initials: B
authors.lastname: Broecker
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Kirsch
mesh_terms: D034861:Abdominal Wall / Q000601:surgery; D061645:Abdominoplasty / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D053580:Muscle Strength / Q000502:physiology*; D011535:Prune Belly Syndrome / Q000175:diagnosis / Q000601:surgery*; D017568:Rectus Abdominis / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000637:transplantation*; D013718:Tensile Strength; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
keywords: Abdomen; Laparoscopy; Prune belly syndrome; Surgery; Umbilicus