History and Physical Examination
Umbilical infections can occur because of an embryologic remnant or poor hygiene. Traditionally, gram-positive organisms, such as Staphylococcus aureus and Streptococcus pyogenes, were most commonly identified. Gram-negative and polymicrobial infections are seen today, especially in rapidly progressing cellulitis and necrotizing fasciitis.
Umbilical granulomas appear as 1-mm to 1-cm, pink, friable lesions at the base of the umbilicus. They produce variable amounts of drainage that can irritate the surrounding skin. An umbilical polyp is brighter red than a granuloma and represents retained intestinal or gastric mucosa from the vitelline duct.
The presentation of omphalomesenteric remnants depends on the specific type of defect (see the first image below). If a communication persists from the terminal ileum to the umbilicus, intestinal contents or stool can be observed leaking from the umbilicus. Prolapse of intestine through an omphalomesenteric fistula can also be observed (see the second image below). The drainage from a fistula that does not communicate with the ileum varies; it may be clear, bloody, or purulent. Cystic remnants may become infected and manifest with pain and swelling.
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.
The presentation of urachal remnants also varies. Clear drainage from the umbilicus is characteristic of a urachal fistula. Drainage of urine from the umbilicus may suggest bladder outlet obstruction and warrants further investigation.
A urachal cyst is usually discovered as a painful mass between the umbilicus and suprapubic area when it becomes infected. Pain and retraction of the umbilicus during urination may suggest a urachal anomaly. A urachal sinus manifests with drainage that can be clear or purulent and occurs through the umbilicus or midline skin below the umbilicus (see the image below).
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.
Patients with umbilical hernias present early in life with bulging at the umbilicus. The swelling is most prominent when the infant or child is crying or straining. Umbilical hernias are usually asymptomatic and rarely cause pain. The skin can become severely stretched, which may be alarming to parents and physicians (see the image below). Parents often mention that the child plays with the redundant skin.
Incarceration, strangulation, bowel obstruction, erosion of the overlying skin, and bowel perforation are rare events in infants and small children. The risk of incarceration increases significantly in adults with umbilical hernias.
Patients with umbilical infections can present with drainage from the umbilicus, swelling, and redness. Cellulitis may rapidly progress and lead to necrotizing fasciitis. Necrotizing fasciitis is characterized by abdominal distention, tachycardia, purpura, leukocytosis, and other signs of sepsis despite antibiotic therapy.
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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.
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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.
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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.
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Preoperative photograph demonstrating umbilical hernia with redundant skin.
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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.
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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.
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Anatomic relationship between the umbilicus and its embryologic attachments.
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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.
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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.
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Photograph of laparoscopically removed urachal cyst and its attachments.
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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.
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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.
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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.
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Neoumbilicus following umbilicoplasty.
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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.
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Laparoscopic view of urachal fistula, which extends from umbilicus above to bladder below. Image courtesy of Eugene S Kim, MD.
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Laparoscopic view of remnant fibrous band of omphalomesenteric duct, which extends from umbilicus to terminal ileum below. Image courtesy of Eugene S Kim, MD.
