Hernia Of The Umbilical Cord

(1)

Kingdom of Saudi Arabia, King Abdulaziz university, Jeddah

Hernia Of The Umbilical Cord

Dr. Mazen O. Kurdi (FRCSI) Ass. Prof. pediatric surgery

Prof. Dr. Yasir S. Jamal (FRCSI, FICS)

f f d l

Prof. of pediatric & plastic surgery

President, Saudi association of ped. Surgery

d d f f l

Vice-president, Saudi scientific ass. of plastic surgery Head, division of pediatric surgery

(2)

Umbilical cord hernia

Introduction: Introduction:

It is a simple failure of complete It is a simple failure of complete

return of the midgut to the peritoneal return of the midgut to the peritoneal return of the midgut to the peritoneal return of the midgut to the peritoneal cavity which usually occurs around cavity which usually occurs around th

th 10 10 kk the

the 10 10 week. week.

(3)

Umbilical cord hernia…cont

It is uncommon . It is uncommon .

Small defect (less than Small defect (less than 2 2 cm) . cm) .

Located at the umbilicus with the Located at the umbilicus with the umbilical cord extending from it

umbilical cord extending from it umbilical cord extending from it.

umbilical cord extending from it.

Covered with a sac. Covered with a sac.

Contains only the midgut . Contains only the midgut .

(4)

These patients might have ese pat e ts g t a e malrotation , although it is not

ll f i i l

usually a cause of intestinal obstruction

obstruction.

( Michael D.Klein / Grosfeld etal. pediatric surgery sixith edition 1157-1171,2006)

(5)

W t bili l l & D

Wet umbilical cord

clamp. & sep.

cord

Dryness

(6)

Normal Umbilical Cord

(7)

Normal Umbilical Cord

(8)

How to differentiate?

(9)

Cogenital Abdominal wall defects

Defect site sac contents frequency Associated

anomalies

outcome

Omphlocele (lat. Fold)

umbilicus yes Liver ,

intestine ,spleen,

gonad

common Chromo. &

cardiac

Good (dep.

on the associated

anomaly)

gonad anomaly)

Omphlocele (cephalic

Fold)

Sup.

umbilicus

yes Liver,

intestine

rare Cardiac,stern al cleft ,central t d di h

poor

tendon diph.

Omphlocele (caudal Fold)

Inf. umbilicus yes intestine rare Bladder

extophy,impe rforated

fair rforated

anus&episp Umbilical

cord hernia

umbilicus yes intestine unusual uncommon good

Gastoschisis Rt. umbilicus No intestine common Intestinal atresia

good

Ectopia cordis thoracis

Midline sternum

No heart rare cardiac poor

(10)

Umbilical cord hernia…cont

Management:

¾ Counseling and reassuring the parents

¾ Careful examination to determine the following:

9 Diameter(<2cm)Diameter( 2cm)

9 Status of the content

• Reducible

• Irreducible which might be due to adhesions or membrane.

(11)

h f d d

The type of management depends upon:

¾ If the base is narrow & there is short protrusion

f h d i f h

of the contents Reduction of the contents

& Simple ligation of the sac .

(12)

Umbilical cord hernia…cont

¾ If the base is Broad & there is long

epithelialized protrusion around the umbilicus epithelialized protrusion around the umbilicus Initial reduction , clamping & immediate or later repair with cosmetic umbilicoplastyp p y

(13)

¾ If the contents are not reducible or if there

i bl di M d i l

is bleeding Mandatory surgical intervention .

(14)

Umbilical cord hernia…cont

The contents are easily reduced by holding the sac upwards & gently

milking the bowel into the peritoneal g p cavity.

The fascia can always be closed

primarily & a cosmetic umbilicoplasty

is nea l al a s feasible hich might

is nearly always feasible which might

be immediate or late (OR).

(15)

(16)

Different presentations:

(17)

(18)

(19)

(20)

Care should be taken as the content of the sac is the midgut with or without

9

Appendix

9

Appendix.

9

Patent omphalomesenteric duct.

9

Adhesions between the bowel and

the sac as it will be seen in one of our the sac as it will be seen in one of our cases.

(Catrena Borgna - pignatti etal. Journal of pediatric surgery,30:1717-1718,Des.1995) (David M. sherer .Gynecol obstet Invest 51:66-68,2001)

(21)

(22)

(23)

(24)

(25)

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(27)

(28)

(29)

The umbilical abnormality can be

di d i h i f d li

diagnosed with certainty after delivery , but ,antenatal ultasonography , can be

h l f l d h

helpful in determining these abnormalities such as

¾

Hernia of the umbilical cord

¾

Omphalocele

¾

Omphalocele

¾

Teratoma of the cord.

(30)

Umbilical cord hernia…cont

This gives a indication for

distal clamping of the cord to avoid injury of the bowel

til th b b i tt d d b

until the baby is attended by the pediatric surgeon

the pediatric surgeon.

(31)

(32)

(33)

(34)

(35)

In KAUH 14 cases of umbilical cord

hernia seen & treated over the last 10 years (1997-2007).

y ( )

Retrospective review of antenatal

ultrasonography did not indicate the ultrasonography did not indicate the presence of the abnormality.

All of the cases were near term ranging

between 34-38 weeks.

(36)

12 of which had reducible content while the other 2 cases presented by irreducibility due to adhesions in one irreducibility due to adhesions in one of them and septum that prevent

the reduction in the other one which

led to hemorrhagic fluid upon trial of

the reduction.

(37)

8 of the cases were managed by a simple

d ti f th t t d li ti f

reduction of the contents and ligation of

the sac. (short neck ,narrow base)

(38)

4 f h h d id b &

4 of the cases had wide base &

long epithelialzed protrusion , were managed by repair of the umbilical managed by repair of the umbilical hernia ( mayo s repair & cosmetic umbilicoplasty )

2 i di

¾ 2 immediate .

¾ 2 late closure.

(39)

Umbilical cord hernia…cont

2 cases needed immediate surgical intervention in the form of Repair & umbilicoplasty due to irreducibility which was due to:

Adhesions

¾ Adhesions.

¾ The presence of septum.

(40)

Despite of that most of the patients p p with hernia of the umbilical cord

were having malrotation but this were having malrotation, but , this was not an indication to explore

any of our patients.

( Grosfeld etal. pediatric surgery sixith edition 1157-1171,2006)

(41)

Conclusion:

¾

Hernia of the umbilical cord is a rare entity of the abdominal wall defects , y , but , careful attention should be paid in order not to miss it.

¾

If there is any suspicion of an umbilical

cord hernia , the umbilical clamp should , p

be applied distally to avoid injury of the

contents.

(42)

¾

Force should not be applied in pp

order not to cause any damage

to the bowel while reducing the

contents, keeping in mind the

possible causes of irreducibility.

(43)

(44)

(45)

suggest the presense of an umbilical mass , but other diffrentials can not be excluded

but, other diffrentials can not be excluded which might be an omphalocele , umbilical hernia with associated omphalomesenteric hernia with associated omphalomesenteric duct (David M. sherer .Gynecol obstet Invest 51:66-68,2001) or an isolated patent

51:66 68,2001) or an isolated patent

omphalomesenteric duct (Jona JZ:congenital hernia of the cord and associated patent

omphalomesenteric duct :a frequent neonatal problem ? Am J perinatol 1996;13:223-226.)

(46)

Umbilical cord hernia…cont

Differentiation from other abdominal wall f

defect should be kept in mind

umbilical hernia--- the defect is covered by a normal skin and is rarely present at birth ,

instead usually becoming apparent in the first weeks or months of life after the cord

separation & epithelialization of the umbilical stump.

(47)

(48)

(49)

(50)

(51)

(52)

(53)

(54)

(55)

(56)

Umbilical cord hernia…cont

4 of the cases had wide base &

long epithelialzed protrusion , were managed by repair of the

managed by repair of the

umbilical hernia ( mayo s repair &

cosmetic umbilicoplasty )

¾

2 immediate

¾

2 immediate .

¾

2 late closure.

(57)

If the base is narrow

& there is short protrusion ---

d f h

Reduction of the

contents & Simple

l f h

ligation of the sac .

(58)

Umbilical cord hernia…cont

If the base is Broad

& there is long epithelialized protrusion --- Initial reduction ,

l

clamping &

immediate or later h

repair with cosmetic umbilicoplasty