SURGICAL UMBILICUS

Expected learning outcomes:

[Presumed prior knowledge: physiological triggers of vomiting e.g. via central nervous system,
neurohormonal etc.; embryological, histological and anatomical features of normal gastrointestinal
tract]

Describe the above congenital causes of gastrointestinal obstruction with respect to: basic
pathophysiology, presenting features, key diagnostic radiological features, principles of pre-surgical
stabilization, description of corrective surgical procedure in layman’s terms and long-term outcome.

UMBILICAL HERNIA
A) DEFINITION:

Hernia:
Protrusion of an organ from the cavity where it normally resides, through a defect in the wall
of that cavity
Umbilical hernia:
Abdominal contents herniate through a defect in the umbilicus as a result of the incomplete
closure of the umbilical ring following the return of the bowel into the abdominal cavity
during development

B) PATHOPHYSIOLOGY:

Incidence:
 Common: at least 3% of newborn;
 5-10% higher incidence in black patients

C) CLINICAL PRESENTATION:

 Skin defect does not necessarily reflect size of

sheath defect.
 Considerable variation in diameter (0,5-4cm)
 Visible mass protruding from the umbilicus
 Palpable round opening in the umbilicus
 Eurgling sound on reduction
 Usually easily reducible

Associated syndromes: (rare)

 Trisomy 13 or 18
 Hurlers syndrome
 Beckwith Wiedemann syndrome

D) MANAGEMENT

Indications for surgery

 In most cases the hernia will close spontaneously without problems(> 50% by 3
years)
  Surgery is not recommended before three years of age
 1 cm @1 year-may well close
 2 cm @ 2 years - the chances are that it will not close

Procedure:
 Peri-umbilical incision
 Mobilisation of hernia sac
 Herniotomy and closure of defect

E) DIFFERENTIAL DIAGNOSIS:

Para-umbilical hernia:
 The para-umbilical hernia arises from a defect in the linear alba, above the umbilicus
 The defect is elliptical in shape
 This hernia seldom closes spontaneously
 There is a higher risk of intestinal obstruction
 It is surgically repaired

RECTUS-SHEATH DIASTATIS:
 Normal variant of abdominal wall

F) POTENTIAL COMPLICATIONS:

 Cosmetic concerns
 Almost no recurrence
 Incarceration of omentum or bowel is rare. There is an increased risk of bowel
incarceration in the following patients:
 Patients with pica who eat sand
 During pregnancy (girls)

UMBILICAL DISCHARGES

An umbilical discharge can be one of the following:

1. Pus as a result of infection
2. Mucus
3. Faeces
4. Urine (clear fluid)
 OMPHALITIS

A) DEFINITION:

 Infection of the umbilical cord

 Can be prevented by daily cleansing of the umbilical cord with an antiseptic e.g.
spirits until it has dried out. Attention to avoid contact of the spirits with the
abdominal wall is important

B) PATHOPHYSIOLOGY:

Common in South Africa

Causative organisms:
 Usually Staphylococcus or a haemolytic Streptococcus.
 Fungal infections may also occur.
 Tetanus due to use of traditional dressings to newborn umbilical cord e.g. cow
dung have declined

C) CLINICAL PRESENTATION:

 Foul-smelling umbilicus
 Purulent discharge
 Erythema, oedema and cellulitis of the abdominal wall surrounding the
umbilicus

D) COMPLICATIONS:
Infection of the umbilicus is always regarded as a severe infection. The congenital
connections to the umbilicus may result in dissemination of the infection.
The impaired immunity of the baby may result in septicaemia and other serious infection
related complications

 Septicaemia
babies have a higher chance of developing septicaemia and must be admitted
for intravenous antibiotics administration
 Cellulitis spreads to the abdominal wall
 Umbilical gangrene
 Necrotising fasciitis can spread out of the umbilicus, a very severe infection
which requires aggressive management:
 Abscesses from infections spreading along congenital tract
 Omphalomesenteric duct remnants
 Urachal remnants – urachal abscesses
 Umbilical vein thrombosis: From infection; results in long-term extra-hepatic
portal vein obstruction and portal hypertension

E) MANAGEMENT:
 IV fluid
 Correction of electrolytes
 Broad-spectrum antibiotics
  Surgical debridement of necrotizing fasciitis
 Immunoglobulin (passive immunity)

UMBILICAL GRANULOMA

A) DEFENITION:

Red granuloma of the umbilicus develops as a result of a low-grade infection. May drain a
little pus

B) MANAGEMENT:

 Dehydrating with topical table salt may be tried

 Usually responds to HgNO3 (Silver nitrate) application
 May be tied off - if narrow base
 Surgery may be required if not responding to conservative management

UMBILICAL MUCOSAL POLYP

A) DEFINITION:

 Mucous discharge results from mucosal remnants or a "cherry tumour"

B) CLINICAL PRESENTATION:

 It is generally to redder than the umbilical granuloma

C) MANAGEMENT:

 Treatment is surgical excision

 VITELLO-INTESTINAL DUCT REMNANTS

A) EMBRIOLOGY:

 Towards the end of the seventh week

of embryonic development, the
vitello-intestinal duct (connection
between the yolk sac and the bowel -
old name of omphalomesenteric duct
is less accurate) is normally totally
obliterated

 Incomplete obliteration may lead to the following:

 a patent vitello-intestinal fistula. A communication exists between the small bowel
and the umbilicus which drains faeces
 a fibrous band ("Meckel's band") can remain
between the small bowel and the umbilicus
which may result in a volvulus of the bowel
 cysts may
develop due
to
incomplete
obliteration of the central part of the duct and
may result in abscesses formation

MECKEL’S DIVERTICULUM

A) DEFINITION:

Intestinal remnant of vitello-intestinal duct

B) CLINICAL PRESENTATION:

 Often asymptomatic- incidental at surgery

 “The rule of 2’s”
  2% population
 only ~2% symptomatic
 2-3x more common in males
 usually present with painless massive rectal bleeding around 2 years of age
 2 feet (~60cm) from ileocaecal valve
 2 inches (~5cm in adults) long
 can contain 2 different types of mucosa

C) SPECIAL INVESTIGATIONS:

Scintigraphy (Tc 99) taken up by ectopic gastric mucosa (Meckel’s Scan)

D) MANAGEMENT:

Surgical excision and repair

E) COMPLICATIONS:

 Rectal bleeding (40%)- due to peptic ulceration resulting from ectopic gastric mucosa
 Lead point in intussusception 20%
 Diverticulitis or free perforation 15%
 Intestinal obstruction – volvulus around Meckel’s band 7%

PATENT URACHUS

A) DEFENITION:

Urinary discharge from umbilicus

B) CLINICAL PRESENTATION:

 A discharge of clear fluid may be urine, indicating a patent urachus

 In this situation, a bladder neck obstruction (posterior urethral valves) must be
eliminated

C) MANAGEMENT:

Surgical excision and repair