Umbilicus

Umbilicus, UMBILICAL REGION. The umbilicus (umbilicus, omphalos), a scar remaining on the body after the detachment of the umbilical cord, appears as a depression at the bottom of which is a small papilla (papilla umbilicalis)-the remnant of the umbilical cord attachment. The umbilicus is located in the center of the umbilical region (regio umbilicalis), i.e., in that part of the mesogaster which is bounded above by a line connecting the lower points of the tenth ribs, below by a line connecting both cristae iliacae, and on the sides_:-by two vertical lines passing through the middle of the Poupart ligaments. In adults, the umbilicus is usually located above the midpoint of the body, on the midline connecting the xiphoid process with the pubis. In newborns, it is located below the midpoint of the body and gradually ascends as the lower limbs develop. Projected onto the spine, the umbilicus corresponds to the intervertebral cartilage between LIII and LV.-The umbilical depression is formed because in the area of the papilla umbilicalis there is no fatty padding, so that the papilla lies below the level of the skin. The subcutaneous fatty layer stops around the umbilical ring and together with the skin forms a circular ridge around the depression. The skin here is drawn inward, thin, and sometimes becomes irritated due to the accumulation of products of the sebaceous glands and epidermal cells. Beneath the skin is the umbilical ring (annulus umbilicalis), the site of entry of the umbilical vessels, appearing as a slit with sharp edges and formed by the aponeurosis of the linea alba. The posterior wall of the umbilical scar is lined by peritoneum. The skin in front and the peritoneum behind are closely adherent to the umbilical ring. The umbilicus is a locus minoris resistentiae, where through the stretched umbilical ring, internal organs can protrude, causing the abdominal wall to bulge and leading to the formation of hernias. On the peritoneal surface from the umbilicus, 4 cords extend; one of them goes upward, backward, and to the right, this is the ligamentum teres hepatis, the remnant of the umbilical vein entering through the umbilical gates; the other 3 cords go downward to the upper and lateral parts of the bladder; the middle one is the remnant of the urachus, and the 2 lateral ones are obliterated umbilical arteries (see Abdominal Wall). Pathology of the umbilicus includes: 1) developmental defects, 2) inflammatory processes, 3) tumors, and 4) bleeding. 1. As developmental defects, complete or incomplete closure of the abdominal wall is observed. In the first case, the abdominal cavity is widely open; usually there is eventeration; the umbilicus is completely absent. The consequence of incomplete closure are congenital hernias of the umbilical region (see Hernias). Another form of developmental defect of the umbilicus-fistulas-is associated with the presence in the umbilicus of embryonic formations (see below).-2. Inflammatory processes are observed mainly in newborns. The umbilical wound after the detachment of the umbilical cord usually quickly granulates and dries. If, as happens with thick and succulent umbilical cords or with excessive granulations, the wound remains moist for a long time, it is called a "weeping umbilicus." If there is much discharge and it is of a sero-purulent nature, this is umbilical blennorrhea, or more correctly pyorrhea, as the gonococcus is not the causative agent here. Such discharge can cause reddening of the surrounding skin and umbilical excoriations (excoriatio umb.). Sometimes it leads to tissue breakdown and the formation of an ulcer (ulcus umb.) with a dirty base, swollen and reddened edges, and abundant sero-purulent discharge. Inflammation of the umbilicus is called omphalitis (see).-Severe inflammatory processes include phlegmon and the now rare gangrene of the umbilicus, which was frequent in the pre-aseptic era. It sometimes develops from an ulcer, from omphalitis in emaciated, weak, septic children. If the process extends deeply, purulent peritonitis may develop. The prognosis is extremely grave. Therapy: if the umbilical cord is still attached, it should be removed, the wound is cleansed and washed with H₂O₂, coated with 2-5% silver nitrate, dusted with xeroform, and covered with dermatol. With extensive discharge-wet suction dressings, with gangrene-thermocautery and general treatment.-Umbilical diphtheria is usually the result of infection of the umbilical wound by the hands of the attending personnel. Clinically, the formation of a characteristic membrane with moderate reactive redness around and slight elevations of temperature is observed. The course is usually favorable if serum is administered promptly. 3. Tumors of the umbilicus are divided into benign and malignant. Benign ones include granulomas-small tumors located at the bottom of the umbilical wound (fungus umb., umbilical mushroom) after the umbilical cord has not completely detached properly. They are cauterized with a silver nitrate stick or tied with a silk thread if the tumor is on a stalk. Rarely, lipomas, fibromas, angiomas, endometriomas (Talalaev) are encountered. Most authors consider adenomas to be remnants of Meckel's diverticulum. Malignant tumors of the umbilicus are represented by sarcomas and carcinomas. The latter can develop as a primary node [in this case, excision of the umbilicus (umbilectomy) is possible] or as secondary cancerous tumors. Here they are either the result of direct infiltration of cancer from neighboring organs (liver, gallbladder, small intestine) or the result of metastasis. The prognosis is unfavorable and surgery is pointless.-4. Bleeding from the umbilicus (omphalorrhagia) is divided into early and late. Early bleeding occurs in the first hours of the child's life and is usually associated with insufficient ligation of the umbilical cord or (extremely rarely) with congenital hemophilia of the child. Late bleeding is usually parenchymatous, occurs during the detachment of the umbilical cord, and is usually an expression of general infection of the body (sepsis, syphilis). Therapy: pulling the umbilical ligature, applying a tampon with adrenaline and a tight bandage, cauterization with thermocautery, finally surgical infiltration of the umbilical cord. In septic cases-treatment of the underlying disease.

T. Chebotarevskaya. Fistulas of the umbilicus can be complete and incomplete, being the result of incomplete regression of the omphalo-mesenteric duct (see also Meckel's diverticulum). A complete fistula, usually detected immediately after the detachment of the umbilical cord, connects the abdominal wall with the lumen of the intestine. Its external opening in the umbilicus is lined with velvety dark red mucous membrane; the fistula secretes mucus, sometimes the liquid contents of the small intestine. A complete fistula soon after the birth of the child can be complicated by the prolapse of the mucous membrane of the fistula itself and even the prolapse of the mucous membrane of the small intestine into which it opens. The consequence of such "prolapse" can be necrosis of the prolapsed section with all its consequences. A complete umbilical fistula usually leads to the death of newborns from rapidly developing infection of the abdominal wall under the influence of irritation by the fistula secretion. Surgical treatment-resection of the fistula with a segment of the small intestine-often also ends in death, especially in cases complicated by prolapse and necrosis (according to Morian up to 47%).-- In cases of non-closure of only the external opening of the omphalo-mesenteric duct, an incomplete, external umbilical fistula arises, which has no communication with the lumen of the intestine. Its lumen is also lined with mucous membrane having the structure of the small intestine mucous membrane. The opening of the fistula can be very small and secrete so little discharge (mucus) that the fistula can remain unnoticed for a long time and cause only very slight subjective and objective phenomena. Often patients for many years do not pay attention to their disease, not attaching importance to the slight discharge from the umbilicus. Only the subsequent inflammation of the umbilical skin, and sometimes of the fistula itself, clarifies the true picture. Treatment consists in total extirpation of the fistula.-Blockage of the fistula opening by discharge can lead to expansion of the fistula, which sometimes reaches considerable size and can be palpated in the thickness of the abdominal wall as a large tumor. These cases are particularly prone to secondary inflammation, causing very severe local and general phenomena.