A Clinical Study and Management of Umbilical Disorders

Introduction

Umbilicus, commonly known as navel, is a localized depressed area that marks the connection of an individual with his or her mother during the foetal life. In abdomen, it represents the opening, which contains the umbilical vessels and structures related to the digestive and urinary systems. Umbilical disorders form an important part of general surgical practice. These disorders may be either congenital or acquired, and may manifest in any age group and both genders.

Umbilicus also represents a weak point—the anterior abdominal wall—prone to herniation. It has virtually become the gateway to abdominal surgeries with the advent and wide spread use of laparoscopic surgeries. Umbilical disorders can range from granuloma to adenocarcinoma of urachal elements. Investigating the abnormal conditions at the umbilicus is crucial,¹ because corrective surgical interventions may be required as soon as possible. Various surgical and conservative modalities² can be used for investigation and management of these umbilical disorders. According to The European Hernia Society, any hernia arising in midline 3 cm above to 3 cm below umbilicus is known as umbilical hernia.³ Other umbilical disorders include umbilical granuloma, urachal sinus, urachal cyst, patent urachus, and umbilical abscess.

The aim of this study was to evaluate various umbilical disorders and their modalities of their treatment.

Materials and Methods

This study was conducted on 30 patients admitted in surgical ward after a detailed clinical examination. This is a prospective interventional study conducted in Mahadevappa Rampure Medical College in the Department of General Surgery, Kalaburagi. This study was conducted from October 2018 to April 2020.

Results

Thirty (30) patients including 18 (60%) male patients and 12 (40%) female patients were studied over a period from October 2018 to April 2020. Age group of presentation had 3 (10%) patients below the age of 5 years, while 18 (60%) patients were between the age of 5-40 years and 9 (30%) patients were above the age of 40 years. Various umbilical disorders were identified and umbilical hernia formed the most common umbilical disorder among all the patients. Twenty-five (25; 83.33%) patients had umbilical hernia, while two (6.66%) patients each had umbilical granuloma and umbilical sinus and one (3.33%) patient had omphalitis (Graphs 1 and 2).

Ultrasonogram abdomen and pelvis was the most commonly performed investigation in 29 patients to know the size of the defect and content followed by culture and sensitivity of the umbilical discharge in two patients, while magnetic resonance imaging (MRI), sonogram, and erect X-ray abdomen were performed in one patient each. Of the various modalities of treatment available, umbilical hernia was repaired with either suture herniorrhaphy in 10 (33.33%) patients, while extraperitoneal polypropylene mesh repair was performed in 15 (50%) patients, and excision of umbilical granuloma and umbilical sinus was done in three (10%) patients. However, two (6.66%) patients were managed conservatively.

Among umbilical hernia patients, one patient presented with features of sub-acute intestinal obstruction with irreducibility and was taken up for emergency exploratory laparotomy and treated with closure of the defect after confirming the bowel viability (Figure 1). One patient who underwent suture herniorrhaphy had a recurrence and was treated with mesh placement, while one case had an umbilical hernia along with peri vesical mass, both of which were treated and a mesh repair was performed. Umbilical granuloma was excised uneventfully in one case, while one other case was managed conservatively. Both the cases of umbilical sinus were treated with complete excision of the sinus tract with neo- umbilicoplasty (Figures 2 and 3). On the contrary, one case of omphalitis presented in sepsis was managed conservatively (Graph 3). There was recurrence in one case, while rest of the cases were uneventful postoperatively according to the follow-up.

Discussion

Umbilical disorders have rarely been studied. They form an important group of entity that require surgical intervention worldwide. Umbilicus functions as a blood channel during intra uterine life, besides a major role in the development of the intestine and urinary symptoms. If any of these or communications persists after birth, it will lead to the development of umbilical disorders.

Umbilical disorders may be either congenital or acquired. Congenital disorders include absence or abnormal position of umbilicus, patent urachus, vitelline duct, umbilical polyp, or hernia. Acquired conditions include omphalitis, umbilical granuloma, umbilical abscess, or pilonidal sinus.⁴ Neoplasms of umbilicus are rare.⁵ If there is a failure of the vitelline duct to disappear at birth, it can cause vitelline fistula, Meckel’s diverticulum, vitelline sinus, vitelline cyst, and vitelline band causing the obstruction of the bowel.^{6, 7} Umbilical disorders form the most common form of surgical disorder in umbilicus. With advent of minimal access surgery, the laparoscopic repair of the umbilical hernia is proved to be safe and comfortable, though Mayo’s repair or suture herniorrhaphy is still widely used due to cost effectiveness and simplicity.⁸ Berger et al concluded that the chances of recurrence were less with mesh repair as it increased the risk of surgical site infection and seromas formation.9 Although in our study there was one recurrence following suture repair, but none after the mesh repair and no cases of surgical site infection were noted. In a study by Salati et al, a total of 75 cases were studied and was concluded that umbilical hernia can be repaired under local anesthesia or general anesthesia depending on the technique being used, while ventral patch repair was found to be more effective by being less extensive and lesser recurrence rates.¹⁰

In our study, there were a total of 25 cases of umbilical hernias, while two patients were each of umbilical granuloma and umbilical sinus respectively, while one case was of omphalitis. Of the 25 cases of umbilical hernia, 10 cases underwent anatomical repair, while 15 cases were repaired using polypropylene mesh. Among these, there was recurrence in one case of anatomical repair, which was later repaired using mesh. Three (3) cases consisting of umbilical sinus and umbilical granuloma were treated with excision, while one case of omphalitis and one granuloma were treated conservatively.

Conclusion

Umbilicus is the gateway to abdomen for minimal access surgery. It can be affected by a wide range of disorders, which may be congenital or acquired. Hence, it is important to identify the disorder and treat them promptly, while mesh repair is better for umbilical hernias repair as compared to the anatomical repair. However, umbilical sinus can be managed with complete excision.

Conflict of Interest

None.