Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Disorders of the Umbilicus Workup

  • Author: Robert K Minkes, MD, PhD; Chief Editor: Eugene S Kim, MD, FACS, FAAP  more...
 
Updated: Nov 02, 2015
 

Laboratory Studies

For healthy children undergoing umbilical hernia repair or excision of omphalomesenteric or urachal remnants, routine laboratory tests are not needed. However, for infants with necrotizing fasciitis, who may be extremely ill, umbilical cultures and blood cultures are needed. Frequent hematologic, electrolyte, and blood gas analyses may be necessary.

Next

Imaging Studies

Radiography is not indicated in most children with umbilical disorders. Umbilical hernias are diagnosed by means of physical examination.

Fistulography or sinography may be performed if a definitive opening is observed within the umbilicus. Fistulography can be performed by injecting water-soluble contrast medium into the opening at the base of the umbilicus. If the track is blind-ended, the child has a sinus; if it enters the intestine or bladder, a fistula is present.

Ultrasonography is helpful when a mass is present. It may be useful in identifying cysts of the umbilicus. Evaluating for a urachal cyst is useful; this cyst most commonly appears as a mass between the umbilicus and suprapubic area. Ultrasonography can also be used to identify a patent urachal fistula between the umbilicus and bladder.

Plain radiography may be useful in children with omphalitis. Air in the subcutaneous tissue or muscle planes is an ominous sign. An umbilical hernia may be incidentally observed on an upper gastrointestinal tract contrast study with small-bowel follow-through (see the image below).

Upper gastrointestinal contrast study showing inci Upper gastrointestinal contrast study showing incidental umbilical hernia in an infant. Red line outlines the umbilical hernia. The arrow shows contrast flowing into the intestine within the umbilical hernia. The umbilical hernia was easily reducible and no intervention based on this study was performed.

Cystography or cystoscopy may be indicated to identify bladder outlet obstruction in children draining frank urine from a urachal fistula. However, studies suggest that, in most cases, history and ultrasonography are sufficient for the diagnosis.[5]

Previous
Next

Histologic Findings

The histology of umbilical remnants depends on the tissue of origin and may reveal intestinal or gastric mucosa. Examination of urachal remnants shows transitional or columnar epithelium.

Previous
 
 
Contributor Information and Disclosures
Author

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Mark V Mazziotti, MD Associate Professor of Surgery and Pediatrics, Baylor College of Medicine, Texas Children's Hospital

Mark V Mazziotti, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Medical Association, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Li Ern Chen, MD Medical Director of Surgical Services, Baylor Health Care System; Director of Surgical Outcomes Research, Department of Surgery, Baylor University Medical Center

Li Ern Chen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Eugene S Kim, MD, FACS, FAAP Associate Professor of Surgery, Division of Pediatric Surgery, Keck School of Medicine of the University of Southern California; Attending Pediatric Surgeon, Children's Hospital Los Angeles

Eugene S Kim, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, Society of University Surgeons, Texas Medical Association, Children's Oncology Group

Disclosure: Nothing to disclose.

Stephen M Megison, MD Professor of Surgery, University of Texas Southwestern Medical Center; Medical Director, Trauma Service, Children's Medical Center, Dallas

Stephen M Megison, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Pediatric Surgical Association, American Trauma Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Deborah F Billmire, MD Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Eugene S Kim, MD, FACS, FAAP Associate Professor of Surgery, Division of Pediatric Surgery, Keck School of Medicine of the University of Southern California; Attending Pediatric Surgeon, Children's Hospital Los Angeles

Eugene S Kim, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, Society of University Surgeons, Texas Medical Association, Children's Oncology Group

Disclosure: Nothing to disclose.

Additional Contributors

Robert Kelly, MD 

Robert Kelly, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Abdominal Surgeons, Medical Society of Virginia, Norfolk Academy of Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Robert S Bloss, MD Clinical Associate Professor of Surgery and Pediatrics, University of Texas Medical School; Clinical Assistant Professor, Department of Surgery, Baylor College of Medicine; Consulting Staff, Houston Pediatric Surgeons

Robert S Bloss, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Southwestern Surgical Congress, and Texas Pediatric Society

Disclosure: Nothing to disclose.

References
  1. Pacilli M, Sebire NJ, Maritsi D, et al. Umbilical polyp in infants and children. Eur J Pediatr Surg. 2007 Dec. 17(6):397-9. [Medline].

  2. Blumberg NA. Infantile umbilical hernia. Surg Gynecol Obstet. 1980 Feb. 150(2):187-92. [Medline].

  3. Cappele O, Sibert L, Descargues J, Delmas V, Grise P. A study of the anatomic features of the duct of the urachus. Surg Radiol Anat. 2001. 23(4):229-35. [Medline].

  4. Rosen JM, Adams PN, Saps M. Umbilical hernia repair increases the rate of functional gastrointestinal disorders in children. J Pediatr. 2013 Oct. 163(4):1065-8. [Medline].

  5. Little DC, Shah SR, St Peter SD, et al. Urachal anomalies in children: the vanishing relevance of the preoperative voiding cystourethrogram. J Pediatr Surg. 2005 Dec. 40(12):1874-6. [Medline].

  6. Bertozzi M, Riccioni S, Appignani A. Laparoscopic treatment of symptomatic urachal remnants in children. J Endourol. 2014 Sep. 28(9):1091-6. [Medline].

  7. Kosloske AM, Bartow SA. Debridement of periumbilical necrotizing fasciitis: importance of excision of the umbilical vessels and urachal remnant. J Pediatr Surg. 1991 Jul. 26(7):808-10. [Medline].

  8. Ciley RE, Krummel TM. Disorders of the umbilicus. Pediatric Surgery. 5th ed. Philadelphia, PA: WB Saunders Co; 1998. 1029-43.

  9. Friedman JM. Umbilical dysmorphology. The importance of contemplating the belly button. Clin Genet. 1985 Oct. 28(4):343-7. [Medline].

  10. Hall DE, Roberts KB, Charney E. Umbilical hernia: what happens after age 5 years?. J Pediatr. 1981 Mar. 98(3):415-7. [Medline].

  11. Haller JA Jr, Morgan WW Jr, White JJ, Stumbaugh S. Repair of umbilical hernias in childhood to prevent adult incarceration. Am Surg. 1971 Apr. 37(4):245-6. [Medline].

  12. Hayward AR, Harvey BA, Leonard J, Greenwood MC, Wood CB, Soothill JF. Delayed separation of the umbilical cord, widespread infections, and defective neutrophil mobility. Lancet. 1979 May 26. 1(8126):1099-101. [Medline].

  13. Kutin ND, Allen JE, Jewett TC. The umbilical polyp. J Pediatr Surg. 1979 Dec. 14(6):741-4. [Medline].

  14. Lally KP, Atkinson JB, Woolley MM, Mahour GH. Necrotizing fasciitis. A serious sequela of omphalitis in the newborn. Ann Surg. 1984 Jan. 199(1):101-3. [Medline].

  15. Larralde de Luna M, Cicioni V, Herrera A. Umbilical polyps. Pediatr Dermatol. 1987 Dec. 4(4):341-3. [Medline].

  16. Lassaletta L, Fonkalsrud EW, Tovar JA, Dudgeon D, Asch MJ. The management of umbilicial hernias in infancy and childhood. J Pediatr Surg. 1975 Jun. 10(3):405-9. [Medline].

  17. Lee SL, DuBois JJ, Greenholz SK, Huffman SG. Advancement flap umbilicoplasty after abdominal wall closure: postoperative results compared with normal umbilical anatomy. J Pediatr Surg. 2001 Aug. 36(8):1168-70. [Medline].

  18. Moore TC. Omphalomesenteric duct malformations. Semin Pediatr Surg. 1996 May. 5(2):116-23. [Medline].

  19. Nagar H. Umbilical granuloma: a new approach to an old problem. Pediatr Surg Int. 2001 Sep. 17(7):513-4. [Medline].

  20. Novack AH, Mueller B, Ochs H. Umbilical cord separation in the normal newborn. Am J Dis Child. 1988 Feb. 142(2):220-3. [Medline].

  21. Pomeranz A. Anomalies, abnormalities, and care of the umbilicus. Pediatr Clin North Am. 2004 Jun. 51(3):819-27, xii. [Medline].

  22. Reyna TM, Hollis HW Jr, Smith SB. Surgical management of proboscoid herniae. J Pediatr Surg. 1987 Oct. 22(10):911-2. [Medline].

  23. Robinson JN, Abuhamad AZ. Abdominal wall and umbilical cord anomalies. Clin Perinatol. 2000 Dec. 27(4):947-78, ix. [Medline].

  24. Rowe PC, Gearhart JP. Retraction of the umbilicus during voiding as an initial sign of a urachal anomaly. Pediatrics. 1993 Jan. 91(1):153-4. [Medline].

  25. Samuel M, Freeman NV, Vaishnav A, Sajwany MJ, Nayar MP. Necrotizing fasciitis: a serious complication of omphalitis in neonates. J Pediatr Surg. 1994 Nov. 29(11):1414-6. [Medline].

  26. Sheth NP. Transumbilical resection and umbilical plasty for patent omphalomesenteric duct. Pediatr Surg Int. 2000. 16(1-2):152. [Medline].

  27. Skandalakis JE, Gray SW, Ricketts R. The anterior body wall. Embryology for Surgeons. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1994. 563-8.

  28. Skinner MA, Grosfeld JL. Inguinal and umbilical hernia repair in infants and children. Surg Clin North Am. 1993 Jun. 73(3):439-49. [Medline].

  29. Steck WD, Helwig EB. Umbilical granulomas, pilonidal disease and the urachus. Surg Gynecol Obstet. 1965. 120:1043.

  30. Weik J, Moores D. An unusual case of umbilical hernia rupture with evisceration. J Pediatr Surg. 2005 Apr. 40(4):E33-5. [Medline].

  31. Wilson CB, Ochs HD, Almquist J, et al. When is umbilical cord separation delayed?. J Pediatr. 1985 Aug. 107(2):292-4. [Medline].

 
Previous
Next
 
Cartoon illustrating the developing umbilical cord. (A) Embryonic disk: At this stage, the ventral surface of the fetus is in contact with the yolk sac. (B) The yolk sac narrows as the fetus grows and folds. The intracoelomic yolk sac forms the intestine and communicates with the extracoelomic yolk sac through the vitelline duct. The vitelline duct is also referred to as the omphalomesenteric duct and the yolk stalk. The allantois has begun to grow into the body stalk. (C) The yolk and body stalks fuse to become the umbilical cord.
Umbilical region viewed from the posterior surface of the abdominal wall of an infant with the umbilical cord attached. UA: Umbilical artery; UV: Umbilical vein; RL: Round ligament (obliterated umbilical vein); UR: Umbilical ring; UL: Umbilical ligament; medial (obliterated umbilical arteries); median (obliterated urachus). Note fascial covering of surface and umbilical ring.
Variations in the umbilical ring structure. (A) Usual configuration of the round ligament and urachus. (B) Less common configuration that can result in weakness at the umbilical ring.
Animation demonstrating variability in the covering of the umbilical ring by the umbilical fascia. (A) Complete cover of the umbilical ring (36%). (B) Umbilical fascia is present but does not cover the umbilical ring (4%), or fascia is absent (16%). (C) Umbilical fascia covers the superior portion of the umbilical ring only (38%). (D) Umbilical fascia covers the inferior portion only (6%). Incomplete coverage of the umbilical ring may predispose individuals to formation of umbilical hernias.
Preoperative photograph demonstrating umbilical hernia with redundant skin.
Omphalomesenteric duct remnants. (A) Meckel diverticulum. Note feeding vessel. (B) Meckel diverticulum attached to posterior surface of anterior abdominal wall by a fibrous cord. (C) Fibrous cord attaching ileum to abdominal wall. (D) Intestinal-umbilical fistula. Intestinal mucosa extends to skin surface. (E) Omphalomesenteric cyst arising in a fibrous cord. The cyst may contain intestinal or gastric mucosa. (F) Umbilical sinus ending in a fibrous cord attaching to the ileum. (G, H) Omphalomesenteric cyst and sinus without intestinal attachments.
Photograph of newborn with intestinal prolapse through a patent omphalomesenteric duct. Both the proximal and distal limbs of the intestine have prolapsed. The umbilicus was explored, the bowel was easily reduced, and the patent duct was excised. The child was discharged from the hospital 2 days later.
Anatomic relationship between the umbilicus and its embryologic attachments.
Laparoscopic removal of urachal cyst (U). L indicates the left medial umbilical ligament. R indicates the right medial umbilical remnant. B indicates the bladder. The distal attachment to the bladder is being grasped.
Laparoscopic removal of urachal cyst. View is from left lower abdomen port. The umbilicus is on the right and the bladder on the left. The attachments or the urachal cyst to the bladder and the umbilicus have been clipped (not shown) and divided. Note the convergence of the right and left medial umbilical ligaments as they approach the umbilical ring on the right.
Photograph of laparoscopically removed urachal cyst and its attachments.
Urachal sinus with purulent drainage in midline below the umbilicus (black arrow). A laparoscope was placed in the supraumbilical crease (red arrow) for mobilization of the internal portion of the urachal remnant as depicted in the next image.
Urachal cyst mobilized by the laparoscopic approach. Arrow demonstrates sinus communication through abdominal wall and skin 3 cm inferior to the umbilicus. See next image.
External mobilization of urachal sinus through abdominal wall incision 3 cm inferior to umbilicus. Patient presented with recurrent drainage and infection from sinus. The internal portion was mobilized laparoscopically. See previous image.
Neoumbilicus following umbilicoplasty.
Upper gastrointestinal contrast study showing incidental umbilical hernia in an infant. Red line outlines the umbilical hernia. The arrow shows contrast flowing into the intestine within the umbilical hernia. The umbilical hernia was easily reducible and no intervention based on this study was performed.
Laparoscopic view of urachal fistula, which extends from umbilicus above to bladder below. Image courtesy of Eugene S Kim, MD.
Laparoscopic view of remnant fibrous band of omphalomesenteric duct, which extends from umbilicus to terminal ileum below. Image courtesy of Eugene S Kim, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.