31. Umbilical hernia, umbilical cysts and fistulas

Question 1

Umbilical hernia - Definition

Answer 1

Umbilical hernia is the failure of the umbilical ring to close which results in central defect in linea alba

The Resulting umbilical hernia is covered by normal umbilical skin, subcutaneous tissue.

The fascial defect allows protrusion of abdominal contents

Question 2

Umbilical hernia - main point

Answer 2

• Hernia <1cm at birth usually will close spontaneously by 4-5yrs of life

Question 3

Umbilical hernia - Type 1

• Type 1 Treatment

Answer 3

Exomphalos: developmental anomaly due to failure of whole or part of midgut to return to abdominal cavity during early fetal life

There are 2 types of Exomphalos:

i. Minor sac = small sac

tx twist to cord may reduce the contents of the sac into peritoneal cavity

ii. Major = umbilical cord attachment to inf aspect of a large swelling containing large + small intestine + a portion of liver
tx: operation should be urgent otherwise sac may burst

Question 4

Umbilical hernia - Type 2

& Type 2 Treatment

Answer 4

Umbilical hernia in infants + children

Hernia through a weak umbilical scar, may follow neonatal sepsis. Usually symptomless + increase in size during crying

a. Tx: 90% spontaneously within 12-18 mnths. Op if does not restore

Question 5

Umbilical hernia - Type 3

& Type 3Treatment

Answer 5

Paraumbilical hernia of adults: hernia does not protrude through umbilical cicatrix (scar resulting from formation + contraction of fibrous tissue in wound). Protrusion through linea alba just above/below umbilicus = paraumbilical
Contents of hernia = greater omentum, small intestine, transverse colon

Women 5x > men

Predisposing factors: obesity, flabbiness of abdominal muscle, repeated preg, Ab pain, bilious emesis, tender hard mass protruding from umbilicus

Tx: Mayo’s op = there are adhesions b/w sac + the content mostly at fundus, neck of sac remains free of adhesions therefore hernia sac is reached at neck first

Question 6

Umbilical Cyst - Characterised by

Answer 6

Ab pain + fever if infx – rupture – peritonitis or drain through umbilicus

Question 7

Umbilical Cyst - Occurs

Answer 7

Occurs in remnants (urachus. Fibrous remnant of allantois (canal that drains urinary bladder of fetus that joins + runs within umbilical cord)) b/w the umbilicus + bladder

• Occurs in persistent portion of the urachus presenting as an extraperitoneal mass in umbilical region

Question 8

Umbilical Cyst - Clinical Presentation

Answer 8

Clinically silent until infx, calculi or adenocarcinoma develop

Question 9

Umbilical fistula - what passes through the urachus

Answer 9

Vitello-intestinal duct + urachus pass through umbilicus during fetal development. Both of these normally obliterate + disappear

Umbilical vein + arteries pass through urachus

Question 10

Umbilical fistula - Types

Answer 10

1. Patent vitello-intestinal duct: v. rare – discharges mainly mucus + rarely faeces through umbilicus
2. Patent urachus: allows leak of urine through umbilicus. Does not relieve itself until adult life. This is due to contractions of bladder start at apex of organ + pass towards the base as urachus opens at apex of bladder it is closed during contractions – so no urine through umbilicus. Urinary leakage through umbilicus becomes only symptomatic. When there is some urinary obstruction at the lower urinary tract

Question 11

Treatment

Answer 11

Of Patent vitello-intestinal duct:

Should be excised together with Meckel’s diverticulum. During such an excision, you need to excise base of Meckel’s diverticulum with end-to-end anastomosis of the small intestine.

Of Patent urachus:
Excision of umbilicus with excision of urachus down to apex of bladder