- UMBILICAL HERNIA
Anatomy of umbilical region
- Umbilical ring is located at L4 and L5 (lower in infants)
- The umbilical skin supplied by T10 spinal cord
- Components of the umbilical ring – linea alba, falciform ligament, median umbilical ligament, umbilical fascia
- Meeting pointing of 4 folds of embryonic plate and three systems
- Gastrointetinal (vitellointestinal), urinary (urachus), vascular (umbilical vessels)
Epidemiology/etiology
- Umbilical hernia can develop due to either
- Absence of umbilical fascia
- Incomplete closure of umbilical defect (omphalocele)
- Can be congenital – more common in males
- Or acquired – more common in females
- Raised intra-abdominal pressure – pregnancy, obesity
- Incisional hernia through umbilical scar following surgery
- More common in Down’s syndrome and Beckwith-Weidman syndrome
Clinical features
- Swelling in the umbilical region within first few months after birth
- Size increases during crying
- Can be felt with finger during crying
- If the hernia is irreducible and obstructive it can present with pain, distension and vomiting
Treatment
- Initially conservative – can disappear spontaneously in few months after birth
- Can be assisted by adhesive strapping across abdomen
- Indications for surgery
- Persists for >2 years
- Defect is >2cm
- Acquired/adult hernia
Types of surgeries
- Primary closure of defect
- Infraumbilical incision made encircling its lower half
- Sac is dissected and released from the umbilicus and subcutaneous tissue
- Sac is opened and its contents are reduced, excess part is excised. Defect is closed
- Sublay mesh repair
- For hernias >3cm with degenerated skin on surface
- Polypropylene mesh used as sublay and then rectus sheath is closed
- Umbilectomy
- When there is unhealthy thin skin over the large hernia
- Only done in adults with large umbilical hernias and thinning of umbilical skin
- Laparoscopic repair
- PARAUMBILICA HERNIA
- Can be supra or infra umbilical hernias
- More common in adults, especially females
- Protrusion or herniation through linea alba, just above or below the umbilicus
- Enlarges ovally; neck of sac is usually narrow
- Contents – omentum, small intestine and sometimes large intestine
- There is a tendency for adhesions, irreducibility and obstruction
- Predisposing factors – obesity, multiple pregnancies, flabby abdominal wall
Clinical features
- Swelling with smooth surface, distinct edges, resonant with dragging pain and impulse on coughing
- Large hernias can cause intestinal colic due to subactue intestinal obstruction
- Eventually strangulation can occur
Treatment
- Always surgery
- Dissection of hernial sac and placement of mesh in retrorectus plane
- Umbilectomy may be required – if paraumbilical hernia is >4cm
- UMBILICAL CYST (Urachal cyst)
- The urachus is a primitive structure that connects the umbilical cord to the bladder in the developing baby
- It normally disappears before birth but may remain patent in some people
- Urachal cysts form when both the umbilical and vesical ends of the urachal lumen close while a portion in the middle remains patent and fluid-filled
- They usually remain asymptomatic until complicated by an infection – usually in adolescents or adults
Clinical features
- Lower abdominal pain
- Fever
- Abdominal lump/mass
- Urinary symptoms – pain, UTI, hematuria
Investigations
- Ultrasound
- MRI
- CT
Treatment
- If asymptomatic then only monitoring is required
- Antibiotics
- Surgical excision
- UMBILICAL FISTULA
Etiology
- Patent vitellointestinal duct
- Patent urachus
- Post surgical
- Tuberculosis
Clinical features
- Faecal/urinary/mucoid discharge
- Recurrent infection
- Pain, tenderness, excoriation in and around umbilicus
Investigations
- Fistulogram
- CT
- US abdomen
- Discharge study, cytology
Treatment
- Fistulectomy and resection of bowel segment, patent vitellointestinal tract and anastomosis of the bowel