Intestinal Injury Secondary to an Umbilical Piercing
Mi Hee Park, BS, Amir Mehran, MD
Background: Body piercing has become increasingly
popular throughout the world and may cause unantici-
pated complications during surgery.
Methods: We describe the case of a 35-y-old woman with
hepatocellular carcinoma who underwent a diagnostic
laparoscopy for metastatic disease evaluation.
Results: An early intestinal injury occurred upon abdom-
inal entry and introduction of pneumoperitoneum. The
injury was secondary to a single adhesion between the
abdominal wall and small bowel caused by a previous
Conclusions: Umbilical piercing can lead to unantici-
pated intraoperative complications even if it is removed
prior to surgery. Surgeons performing laparoscopy should
be aware of potential pitfalls associated with these art
Key Words: Body jewelry, Umbilical piercing, Laparo-
scopic surgery, Complications of pneumoperitoneum, In-
testinal adhesions, Intestinal injury, Laparoscopy compli-
Body piercing is a popular form of art in the United States
(US). Reasons cited for having body piercings include
peer pressure, a physical manifestation of one’s individu-
ality, or a commemoration of pivotal life events.1Umbil-
ical piercings in particular are the third most common type
after ear and nose piercings, with a gender ratio of nearly
10 to 1 in favor of women.2The presence of this type of
jewelry, however, can lead to various complications in
both the surgical and nonsurgical population.1,3,4,5,6
We describe a case of intestinal injury that occurred dur-
ing laparoscopic surgery in a patient with a history of
umbilical piercing. Intestinal adhesions due to body jew-
elry have previously been described, but to our knowl-
edge no reports on actual intestinal injury have ever been
A 35-y-old woman with chronic hepatitis-B presented
with worsening liver function tests. Other than her Asian
ethnicity, her past medical and surgical history did not
point to a cause for contracting hepatitis-B, such as blood
transfusion, sexual contact, or previous body art. She had
been asymptomatic without abdominal pain, weight loss,
jaundice, pruritus, or any other systemic signs. Further
workup included a computed tomography (CT) scan of
the abdomen and pelvis that demonstrated an extensive
infiltrating 14.2cm x 6.3cm mass involving nearly the en-
tire left lobe of the liver and extending into the right lobe
without evidence of metastatic disease. A CT-guided bi-
opsy confirmed the tumor to be hepatocellular carcinoma.
She was subsequently referred to our institution for sur-
gical evaluation. She was scheduled for a diagnostic lap-
aroscopy followed by an open resection of her liver mass,
in case of the absence of metastatic disease. On the day of
surgery, her abdominal examination revealed a very ath-
letic build and a small umbilical scar from recently re-
moved navel jewelry. The umbilical piercing had been
placed in the previous 4 mo and was not removed in the
interim despite the patient having been asked to do so.
The patient was very scar conscious and had requested
minimal cosmetic side effects should the surgery be lim-
Section for Minimally Invasive and Bariatric Surgery, Department of Surgery,
University of California, Los Angeles, USA (all authors).
The authors wish to acknowledge Mr. Ben Poling from Piercology in Columbus,
OH for technical information related to body art.
Address correspondence to: Amir Mehran, MD, Section for Minimally Invasive &
Bariatric Surgery, UCLA Department of Surgery, 10833 Le Conte Avenue, BOX
956904, Los Angeles, CA 90095-6904, USA. Telephone: (310) 206-7235, Fax: (310)
267-4632. E-mail: email@example.com
© 2012 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
ited to the first portion. We therefore chose to enter the
abdominal cavity through the small umbilical scar using
an open “Hasson” technique and utilizing a 5-mm trocar
to insufflate the abdomen. Upon insertion of the laparo-
scope, the intestinal lumen was viewed instead of the
peritoneal cavity. Insufflation was immediately stopped
but the trocar was left in place. The incision was extended
around the umbilicus. Upon inspection, the patient had a
loop of small bowel attached to her anterior abdominal
wall at the site of her previous umbilical ring placement.
The firm attachment remained intact even when the trocar
was removed, confirming the pre-existing adhesion. This
was taken down sharply and the enterotomy was closed
in 2 layers. The small bowel was examined proximal and
distal to this site and no other adhesions were noted. The
fascial defect was closed around the 5-mm trocar that was
left in place to regain pneumoperitoneum. Laparoscopy
revealed a large tumor in the left lobe of the liver without
evidence of intraabdominal carcinomatosis. A decision
was made by the primary liver surgery team to proceed
with the liver resection. The patient’s postoperative course
remained unremarkable, and there were no sequelae from
the intestinal injury.
Body piercings remain a popular form of art and may pose
risks during laparoscopic surgery, including electrical
burns and local or systemic infections. Generally, all navel
piercings are performed with the patient in the supine
position, due to aesthetic rather than safety concerns.
Body piercers in the US are not able to use anesthetic
injections due to government regulations that limit their
use to licensed health professionals. They also typically
avoid using topical anesthetics due to safety concerns,
e.g., allergic reactions, and the like. Nevertheless, other
countries, such as the United Kingdom, allow body pierc-
ers to apply topical anesthetics, such as Xylocaine spray
and other creams prescribed by a physician. Certain reg-
ulations still apply though. Topical anesthetics are gener-
ally discouraged for tongue piercings, and if applied,
information on potential risks must be provided to the
patient prior to the piercing.8
The presence of intestinal adhesions due to previously
removed umbilical piercings has been reported in the
past.7However, the actual incidence of this complication
or the presence of any associated symptoms remains un-
known. This is of particular importance, because the um-
bilicus remains a favorite site for both body piercings and
laparoscopic point of entry. Previous studies indicate that
laparoscopic bowel injury would most likely occur during
the access phase, typically in patients who have had a
history of adhesions or previous laparotomies, and carries
a significant morbidity rate.9,10There are several methods
to gain access to the peritoneal cavity, each offering dis-
tinct advantages and drawbacks in terms of ease of entry
or safety.11,12,13,14A thorough discussion of this topic,
however, is beyond the scope of our case report. The
optimal entry technique also remains unclear. In this par-
ticular patient, our decision to utilize the small-sized open
technique though her previous scar was directed by the
patient’s wishes and her favorable abdominal wall anat-
omy. At the time, our team was unaware of the potential
for an intestinal adhesion following the removal of body
jewelry. In retrospect, choosing a separate entry site in
one of the upper quadrants, utilizing our customary opti-
cal trocar entry technique, and downplaying the patient’s
cosmetic concerns would have been more prudent and
may have avoided this complication.
Surgeons performing laparoscopy should be cognizant of
complications associated with navel piercings even long
after their removal. The umbilicus and the scar left from
jewelry remain attractive sites for the initial entry; never-
theless, careful consideration should be given to the
potential presence of lingering intestinal adhesions that, in
turn, may lead to major injury and additional morbidity.
Therefore, we do not recommend utilizing past surgical or
body-art scars as the initial port of entry into the abdom-
logical motivations. Lancet. 2003;361(9364):1205–1215.
Stirn A. Body piercing: medical consequences and psycho-
United States: a national data set. J Am Acad Dermatol. 2006;
Laumann AE, Derick AJ. Tattoos and body piercings in the
Meltzer DI. Complications of body piercing. Am Fam Phy-
Beeri R. Navel piercing as a cause for Streptococcus viridans
endocarditis: case report, review of the literature and implica-
tions for antibiotic prophylaxis. Cardiology. 2007;108:159–160.
Barkan D, Abu Fanne R, Elazari-Scheiman A, Maayan S,
Marenzi B. Body piercing: a patient safety issue. J Perianesth
piercing affecting laparoscopy: perioperative precautions. J Am
Assoc Gynecol Laparosc. 2004;11(4):537–541.
Jacobs VR, Morrison JE Jr., Paepke S, Kiechle M. Body
Intestinal Injury Secondary to an Umbilical Piercing: Caution During Laparoscopy, Park MH et al.
piercing. J Am Assoc Gynecol Laparosc. 2003;10(2):281.
Ventolini G, Kleeman S. Adhesions caused by umbilical
control of infection. North Yorkshire Health Protection Unit.
January 2007. (http://www.nyypct.nhs.uk/AdviceInformation/
Tattooing and Body Piercing: Guidelines for prevention and
a complication of laparoscopy. Br J Surg. 2004;91(10):1253–
Van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as
10. Bishoff JT, Allaf ME, Kirkels W, Moore RG, Kavoussi LR,
Schroder F. Laparoscopic bowel injury: incidence and clinical
presentation. J Urol. 1999;161(3):887–890.
11. Mayol J, Garcia-Aguilar J, Ortiz-Oshiro E, De-Diego Car-
mona JA, Fernandez-Represa JA. Risks of the minimal access
approach for laparoscopic surgery: multivariate analysis of mor-
bidity related to umbilical trocar insertion. World J Surg. 1997;
12. Larobina M, Nottle P. Complete evidence regarding major
vascular injuries during laparoscopic access. Surg Laparosc En-
dosc Percutan Tech. 2005;15(3):119–123.
13. Vilos GA, Ternamian A, Dempster J, Laberge PY. The Society
of Obstetricians and Gynaecologists of Canada. Laparoscopic
entry: a review of techniques, technologies, and complications.
J Obstet Gynaecol Can. 2007;29(5):433–465.
14. Scha ¨fer M, Lauper M, Kra ¨henbu ¨hl L. Trocar and Veress
needle injuries during laparoscopy. Surg Endosc. 2001;15(3):