congenital anomalies of the urachal remnant range from a diverticulum to a sinus or a patent urachal remnant extended from the bladder up to the umbilical fossa .
the latter anomaly often induces inflammation along the tract and/or urine leakage from the umbilicus .
the principal treatment of an urachal remnant is the complete resection of the whole tract .
this requires a long midline skin incision in the lower abdomen , which inevitably causes a major cosmetic disadvantage of a conspicuous scar formation . to alleviate this drawback , laparoscopic excision of the urachal remnant
was first demonstrated in 1992 by neufung et al . , and since then several trials of laparoscopic surgery to correct the urachal anomaly have been reported , , , , , , , , . however , the techniques , including port placement arrangements and division and suture of the bladder , have not yet been standardized .
furthermore , the method of closing the bladder opening after resection of the remnant tract is still controversial .
some authors maintain the usefulness of a stapler under laparoscopic view to close the bladder apex , a technique which contradicts the opinion of urologists who argue that absorbable sutures should be used to minimize the risk of urolithiasis . here , we review our experience of excising the urachal remnant using the abdominal wall - lift laparoscopy .
this method provides for the relatively free use of conventional instruments and techniques and eliminates pneumoperitoneum- or co2-related complications . for optimal incision and closure of the bladder apex
a 21-year - old previously healthy woman was referred to our hospital with complaints of periumbilical discharge and pain on urination .
she had a lean physique with body mass index of 17 [ 42.6  kg/(1.58  m ) ] .
a physical examination found purulent discharge from the bottom of the umbilicus and a reddish tinge to the surrounding skin .
abdominal computed tomography(ct ) and magnetic resonance imaging(mri ) revealed an abscess in the umbilical region that was connected to the bladder via a long band , in part via a long tube - like structure(fig .
after treatment with antibiotics and anti - inflammatory drugs , an elective laparoscopic surgery was performed . under general anesthesia ,
the patient was placed in a leg - open position and a transurethral foley catheter was inserted .
the surgeon and camera surgeon stood on the left side of the patient with the monitor in a caudal position relative to the patient . through a 15  mm infra - umbilical incision ,
the subcutaneous tissue and the anterior layer of the rectus fascia were dissected in a t - shape .
the urachal remnant was then continuously dissected distally as far as possible in the preperitoneal space .
a small - sized lapprotector ( hakko , nagano , tokyo ) was inserted through the umbilical incision into the preperitoneal space .
for the abdominal wall - lift , two wires were placed subcutaneously and pulled upward , 2  cm below the umbilicus and halfway between the umbilicus and the pubis , respectively ( fig .
2 ) . a rigid , straight - viewing laparoscope was inserted via the lapprotector. the urachal remnant was dissected toward the bladder mainly with a bipolar sealing device ( ligasure)(covidien , mn ) .
the dissection was mostly performed in the preperitoneal space and sometimes in the abdominal cavity .
a 6  cm pfannenstiel incision was added 2  cm above the pubis to get access to the conjunction of the urachal remnant to the bladder .
after the bladder was filled with 300  ml of saline through the foley catheter , a bladder cuff including the urachal insertion was excised along with the whole urachal sinus .
the opening at the bladder apex was closed with absorbable sutures ( 4 - 0 vicryl)(johnson & johnson , nj ) under direct vision .
the peritoneal defects were closed with several running sutures under a laparoscopic view from the umbilical incision ( fig .
3 ) . seprafilm ( kaken pharmaceutical , tokyo , japan ) was placed under the sutured peritoneum to prevent adhesion .
the patient had no complaints of symptoms 18 months postoperatively and was satisfied with the cosmetic results .
the umbilical - incision scar was hardly visible and the pfannenstiel incision was concealed by regrowth of pubic hair .
under general anesthesia , the patient was placed in a leg - open position and a transurethral foley catheter was inserted .
the surgeon and camera surgeon stood on the left side of the patient with the monitor in a caudal position relative to the patient . through a 15  mm infra - umbilical incision ,
the subcutaneous tissue and the anterior layer of the rectus fascia were dissected in a t - shape .
the urachal remnant was then continuously dissected distally as far as possible in the preperitoneal space .
a small - sized lapprotector ( hakko , nagano , tokyo ) was inserted through the umbilical incision into the preperitoneal space .
for the abdominal wall - lift , two wires were placed subcutaneously and pulled upward , 2  cm below the umbilicus and halfway between the umbilicus and the pubis , respectively ( fig .
2 ) . a rigid , straight - viewing laparoscope was inserted via the lapprotector. the urachal remnant was dissected toward the bladder mainly with a bipolar sealing device ( ligasure)(covidien , mn ) .
the dissection was mostly performed in the preperitoneal space and sometimes in the abdominal cavity .
a 6  cm pfannenstiel incision was added 2  cm above the pubis to get access to the conjunction of the urachal remnant to the bladder .
after the bladder was filled with 300  ml of saline through the foley catheter , a bladder cuff including the urachal insertion was excised along with the whole urachal sinus .
the opening at the bladder apex was closed with absorbable sutures ( 4 - 0 vicryl)(johnson & johnson , nj ) under direct vision .
the peritoneal defects were closed with several running sutures under a laparoscopic view from the umbilical incision ( fig .
3 ) . seprafilm ( kaken pharmaceutical , tokyo , japan ) was placed under the sutured peritoneum to prevent adhesion .
the patient had no complaints of symptoms 18 months postoperatively and was satisfied with the cosmetic results .
the umbilical - incision scar was hardly visible and the pfannenstiel incision was concealed by regrowth of pubic hair .
the lumen near the umbilicus was covered with stratified squamous cells . inflammatory cell infiltration was mild and no abscess formation was found .
the patient had no complaints of symptoms 18 months postoperatively and was satisfied with the cosmetic results .
the umbilical - incision scar was hardly visible and the pfannenstiel incision was concealed by regrowth of pubic hair .
the urachal remnant is a rare congenital anomaly with an incidence of 1:300,000 in infants and 1:5000 in adults .
infection can occur as a common complication of the urachal remnant , and urachal carcinomas have also been reported , .
until recently , excision of the urachal remnant was performed by a laparotomy with a long skin incision from the umbilicus to the suprapubic area , . after the description of a laparoscopic resection of the urachal remnant by neufang et al .   in 1992 ,
several more reports on laparoscopic techniques have been published , , , , , , , , . a laparoscopic resection of the urachal remnant has been suggested to be technically feasible and minimally invasive .
it has also been suggested that a laparoscopic procedure provides better cosmesis , thus contributing to the quality of life of young female patients in particular . according to earlier reports
, laparoscopic management of the urachal remnant seems to be safe and relatively easy , but attention should be made to the following points .
first , various port placement arrangements have been proposed . before the advent of single - port laparoscopic surgery ,
a camera port and other trocars were placed away from the umbilicus , and a 30 oblique laparoscope was used to observe the lesion in the anterior abdominal wall . in the current case
, we used the abdominal wall - lift laparoscopy to get a good view of the preperitoneal space with a camera port at the umbilicus . in this way we could insert a straight - viewing laparoscope and some additional manipulating instruments without the need for additional trocars .
second , an incomplete resection of the remnant may lead to recurrent infections . in this sense ,
complete excision is essential although the edge of the bladder has an ill - defined border .
furthermore , the technique chosen to close the bladder opening after resection of the remnant tract ( stapler or absorbable sutures ) is also important and has consequences for possible urolithiasis . for precise detection and division of the bladder junction followed by meticulous suturing of the bladder opening
, we suggest that surgeons make an additional incision above the pubis , as described in the present case . the pfannenstiel incision that we used provides a good view of the operative field as well as an excellent cosmetic outcome .
third , peritoneal defects can occur during excision of the urachal remnant even with a preperitoneal approach .
but the direct sutures from the umbilical incision are easily done under a laparoscopic view with an abdominal wall - lift .
the combined use of a bio - absorptive adhesion - preventive film may be of some help to prevent intestinal obstruction after surgery .
in conclusion , we propose that the abdominal wall - lift technique is a promising surgical option for patients with a symptomatic urachal remnant , in terms of optimal procedures and satisfactory cosmetic results .
written informed consent was obtained from the patient for publication of this case and any accompanying images .
 highlightsabdominal wall - lift technique is a promising surgical option for patients with a symptomatic urachal remnant.the pfannenstiel incision provides a good view of the operative field as well as an excellent cosmetic outcome.urachal sinus excision using the abdominal wall - lift laparoscopy seems to surpass the previously reported methods in term of safety , cosmetics , and adequacy of surgical procedures . 
Introduction
Case report
Materials and surgical technique
Pathological findings
Postoperative treatment
Discussion
Conclusion
Conflict of interest
Source of funding
Ethical approval
Consent
Author contribution
Supplementary data