Umbilical Endometriosis Mimicking Malignancy on 18 F-FDG PET/CT.

ABSTRACT: Umbilical endometriosis is a rare event. A 44-year-old woman complained of a palpable abdominal mass with bloody secretion and chronic abdominal pain for 2 months. 18 F-FDG PET/CT images demonstrated multiple foci of increased tracer uptake indicating malignant tumor with metastases in the region of umbilicus and lower segment of the esophagus. Unexpectedly, the subsequent histology and immunohistochemistry of the umbilical lesion demonstrated endometriosis.

Hypermetabolic Sister Mary Joseph's nodule in pancreatic carcinoma.

Metastasis to umbilicus is often defined as Sister Mary Joseph's (SMJ) nodule. These nodules may be a manifestation of various underlying malignancies, about 50% arising from abdominopelvic cavity most frequently from the gastrointestinal tract. Pancreatic cancer is the predisposing cause in only about 6% of cases and the most common histopathology is adenocarcinomas. We present the case of a 64-year-old male who was found to have a SMJ nodule on staging F18 FDG PETCT scan.

Gossypiboma with perforation of the umbilicus mimicking a complicated urachal cyst: a case report.

BACKGROUND: A retained surgical sponge, also known as a gossypiboma, is a rare cause of serious postoperative complications. Diverse retained surgical materials including instruments such as clamps and sutures have been reported, but surgical sponges are the most common material. We report an unusual case of a gossypiboma mimicking a complicated urachal cyst that led to perforation of the umbilicus. CASE PRESENTATION: A 38-year-old female patient presented in our facility with a palpable periumbilical mass and discharge of pus from the umbilicus for 7 months after an open appendectomy. Since the onset of symptoms, the patient had been treated conservatively in a peripheral hospital where she had been operated on. As no improvement was seen, an ultrasound scan was performed that suggested an intraperitoneal abscess adjacent to the umbilicus. Consequently, the patient was referred to our specialist outpatient department for surgical intervention. Suspecting a complicated urachal cyst, an exploratory laparotomy was performed but revealed a retained surgical sponge as the underlying cause. The gossypiboma was resected, and the postoperative period was unremarkable. CONCLUSION: This case demonstrates that gossypibomas, even though rare, continue to occur. They may clinically and radiologically mimic other pathologies, especially abscesses and tumors. Preventive measures as well as the inclusion of gossypibomas in the differential diagnosis of intraabdominal masses or fistulation detected in patients with a history of surgery are of utmost importance to minimize morbidity, mortality, and potential medicolegal implications.

Complexities of an uncomplicated symptom: two cases of umbilical discharge.

A 10-year-old boy presented with a low volume feculent umbilical discharge associated with fever and anorexia. Exploratory laparotomy revealed a complex fistula communicating with multiple small bowel loops and extensive peritoneal nodules with caseous mesenteric lymph nodes; suggestive of abdominal tuberculosis. Fistulectomy, adhesiolysis and a diversion jejunostomy were done and antituberculosis therapy was started. A 20-year-old man presented with serous umbilical discharge, having a history of similar complaints in his infancy. While he was being investigated, he developed peritonitis and had to be operated on emergency basis. An umbilical sinus connected with a fibrous band to Meckel diverticulum and a proximal closed loop small bowel obstruction perforation were found. Resection and anastomosis of the affected segment were done, and the patient recovered well.

Evaluation of umbilical anatomy via computed tomography prior to single-incision laparoscopy.

Laparoscopic surgery performed through a single incision is relatively new. Here, we investigated the importance of radiological anatomical evaluation of the umbilicus prior to such surgery.Umbilical images of 500 patients who underwent computed tomography (CT) in 2019 were evaluated retrospectively, using both transverse and sagittal sections.Spearman rank correlation analysis indicated a significant positive relationship between age and the sagittal and transverse umbilical measurements (all patients: P < .01; men: P = .001; women: P < .01). Mean transverse and sagittal measurements were 5.63 ±â€Š1.9 and 6.2 ±â€Š2.0 mm in women and 5.49 ±â€Š1.9 and 6.2 ±â€Š1.8 mm in men.Umbilical anatomy can be evaluated radiologically as a component of preoperative evaluation.

Potential False-Positive Meckel's Scan Caused by Umbilical Ornamentation.

An 18-year-old woman presented to the emergency department for bloody stools. A CT scan of the abdomen ruled out intussusception. Meckel's scan was ordered to rule for Meckel's diverticulum before upper endoscopy and colonoscopy. After proper pretreatment with H2 blocker, Tc-pertechnetate Meckel's scan was performed. Dynamic planar imaging revealed a focus of gradual increase in uptake in midabdomen suggestive of Meckel's diverticulum. A SPECT/CT was done to localize the focus of uptake. Surprisingly, the focus of uptake localized to the periumbilical region on SPECT/CT images. The cause of uptake could be due to local inflammation from umbilical ornamentation.

The urachus revisited: multimodal imaging of benign & malignant urachal pathology.

The urachus is a fibrous tube extending from the umbilicus to the anterosuperior bladder dome that usually obliterates at week 12 of gestation, becoming the median umbilical ligament. Urachal pathology occurs when there is incomplete obliteration of this channel during foetal development, resulting in the formation of a urachal cyst, patent urachus, urachal sinus or urachal diverticulum. Patients with persistent urachal remnants may be asymptomatic or present with lower abdominal or urinary tract symptoms and can develop complications. The purpose of this review is to describe imaging features of urachal remnant pathology and potential benign and malignant complications on ultrasound, CT, positron emission tomography CT and MRI.

Pseudolesion in the right parafissural liver parenchyma on CT: The base is found in embryology and collagen content.

BACKGROUND: Computed tomography (CT) images of livers may show a hypo-attenuated structure alongside the falciform ligament, which can be a focal fatty pseudolesion and can mimic a malignancy. The preferred location is on the right parafissural site, ventral in segment IVa/b. The etiology is not clear, nor is it known how the histology of this location develops. These are evaluated in this study. METHODS: 40 adult cadavers with autopsy and / or postmortem CT in a university hospital and a forensic center were included. Liver biopsies were taken at the left side of the falciform ligament as control, and at the right side as the possible precursor of a pseudolesion; these were examined for collagen and fat content. Cadavers with steatotic (>5% fat) or fibrotic (>2% collagen) control samples were excluded. RESULTS: Significantly more collagen was present in the right parafissural liver parenchyma: median 0.68% (IQR: 0.32-1.17%), compared to the left side 0.48% (IQR: 0.21-0.75%) (p 0.008), with equal fat content and CT attenuation values. The etiophysiology goes back to the demise of the umbilical venes in the early embryonic and neonatal period. CONCLUSIONS: The right parafissural area contains more collagen and an equal amount of fat compared to the control left side. This supports the hypothesis of delayed, 'third' inflow: the postnatal change in blood supply from umbilical to portal leaves the downstream parafissural area hypoperfused leading to hypoxia which in turn results in collagen accumulation and the persistence of paraumbilical veins of Sappey.

Umbilical metastasis of a pancreatic origin: Sister Mary Joseph's nodule.

An 84-year-old male patient presented with an umbilical mass. Upon examination, he had an umbilical lesion of approx. 2 cm that was nodular and painful on palpation. The abdominal CT showed a soft tissue mass of 20 x 22 mm in the umbilical subcutaneous tissue, associated with inflammatory changes. In addition, a hypodense tumor of 3.6 x 3.6 x 3.8 cm was seen located in the pancreatic tail, infiltrating the splenic hylum. Bloodwork revealed the following: haemoglobin 7.9 mg/dl, platelets: 175 x 100 /µl, prothrombin activity: 81%, INR: 1.13, Ca 19.9: 4289 U / ml, CEA: 4.38 ng / ml. The histopathological study of the umbilical lesion showed an adenocarcinoma with a moderately differentiated primary pancreatic origin, compatible with an umbilical metastasis of pancreatic cancer.

Aiming for complete safety of first trocar insertion of laparoscopic surgery: usefulness of preoperative ultrasonography of umbilical region.

AIM: Vascular or intestinal injuries at the time of the first trocar insertion can cause serious complications during laparoscopic surgeries. In this study, we evaluate the usefulness of ultrasound scans of the umbilical region as well as intraumbilical conditions to help prevent serious complications. METHODS: The subjects included 430 cases who underwent laparoscopic gynecologic surgeries. The umbilical ultrasound scan was performed after tracheal intubation to observe the intestinal movements associated with respiration. Structures of the umbilical region as well as peristalsis and the movement of the intestinal tract were observed. Then, the thickness of the subcutaneous fat (between the umbilical skin surface and the rectus fascia) and the preperitoneal fat (between the rectus fascia and the peritoneum) were measured. The relationship between body mass index (BMI), insertion time of the first trocar and ultrasound measurements were analyzed. RESULTS: The anatomical structures of the umbilical region (the subcutaneous tissue and the preperitoneal fat) were clearly observed in all cases. The BMI score had a significant relationship with subcutaneous fat thickness (r = 0.547), but remarkably not with preperitoneal fat thickness (r = 0.174). There was no significant relationship between BMI and insertion time. However, insertion time of the first trocar had a significant relationship with preperitoneal fat thickness (r = 0.534). CONCLUSIONS: Preoperative ultrasonography of the umbilical region is asimple process, and it is helpful inpreventing serious complications caused by the first trocar insertion. We have found that preperitoneal fat thickness seems to be an important factor in predicting the potential difficulty of the first trocar insertion.

Ultrasonographic findings in primary umbilical endometriosis

Abstract: Primary cutaneous endometriosis is a rare condition. It appears without a prior history of surgical procedure and the umbilicus is the most frequently involved area. Primary umbilical endometriosis, or Villar's nodule, usually presents as a painful nodule. Its differential diagnosis may be challenging. Although histopathological assessment represents the gold standard for diagnosis, cutaneous ultrasonography may be useful in guiding the surgical treatment. Ultrasonographic features of cutaneous endometriosis have not yet been fully explored in the literature. Hence, we report peculiar ultrasonographic findings of primary umbilical endometriosis

The relationship between the umbilicus and the aortic bifurcation in Turkish women: implications for laparoscopic entry.

PURPOSE: We aimed to determine the location and vertical distance of the umbilicus relative to the aortic bifurcation using computed tomography (CT), and assess their relationship with BMI among Turkish women and their implications for laparoscopic entry. METHODS: This cross-sectional study included a total of 209 women undergoing abdominopelvic CT; the vertical distance between the aortic bifurcation and the umbilicus was evaluated on coronal sections. The distance between the skin and the parietal peritoneum was measured from the umbilical pit to the peritoneum, and the distance between the skin and the aorta was measured from the umbilical pit to the surface of the aortic bifurcation. The measurements were performed along the sagittal plane. The age, height, and weight of the patients were recorded. For comparison, women were divided into three groups according to BMI. RESULTS: The aortic bifurcation was located above (cephalic to) the umbilicus in 30 patients in the non-obese group (48.4%), 54 patients in the overweight group (55.7%), and 34 patients (68%) in the obese group. The mean distances between the umbilicus and the parietal peritoneum were 15.1 ± 6.4, 19 ± 5.5, 27.2 ± 10.8 mm, respectively, in the non-obese group, overweight group, and obese group. The mean distances between the umbilicus and the aorta were 85.8 ± 26.3, 110 ± 2.9, 132.1 ± 26.7 mm, respectively, in the non-obese group, overweight group, and obese group. CONCLUSIONS: The location of the umbilicus relative to the aortic bifurcation can vary according to age, BMI and ethnicity or nationality of patients; therefore, a surgeon should not stick to a particular angle of insertion during laparoscopic entry. It is better for surgeons to know their unique patient population.

Ultrasonographic diagnosis and minimally invasive treatment of a patent urachus associated with a patent omphalomesenteric duct in a newborn: A case report.

RATIONAL: Patent urachus (PU) is due to an incomplete obliteration of the urachus, whereas patent omphalomesenteric duct (POMD) is due to an incomplete obliteration of the vitelline duct. These anomalies are very rarely associated with one another. We describe a case of a newborn with a PU associated with a POMD, who was diagnosed by an abdominal ultrasound (US) and laparoscopy, and managed with a minimally invasive excision. PATIENT CONCERN: A 28-day-old male neonate was referred to our hospital to investigate a delay in umbilical healing, with blood-mucinous material spillage for 3 weeks prior to the referral. The baby had no symptoms and was in good general health. DIAGNOSIS: After a thorough cleaning of the umbilical stump, a clear granuloma with a suspected fistula was evident under the seat of the ligature of the stump. An abdominal US examination revealed the formation of a full communication, starting below the umbilical stump and developing along the anterior abdominal wall that connected with the bladder dome. The US also revealed a tubular formation containing air, which was compatible with POMD, in the deepest portion of the same umbilical stump. Considering these findings, the rare diagnosis of a PU associated with a POMD duct was suspected. INTERVENTIONS: The child was then hospitalized for an elective laparoscopy that confirmed the US picture, and a minimally invasive excision was performed. OUTCOME: The postoperative course was favorable and uneventful. LESSONS: Our case underlines the importance of evaluating all persisting umbilical lesions without delay when conventional pharmacological therapies fail. Using a US as the first approach is valuable and should be supported by laparoscopy to confirm the diagnosis; a minimally invasive excision of the remnants appears to be an effective therapeutic approach.

Port site endometrioma: a rare cause of abdominal wall pain following laparoscopic surgery.

Endometriomas are a rare cause of abdominal wall pain. We report a case of a port site endometrioma presenting with an umbilical swelling. The patient underwent a laparoscopy for pelvic endometriosis 6 months previously and presented with a swelling around her umbilical port site scar associated with cyclical pain during menses. Ultrasound scan reported a well-defined lesion in the umbilicus and MRI scanning excluded other pathology. As she was symptomatic, she underwent an exploration of the scar and excision of the endometrioma with resolution of her symptoms. Precautions should be taken to reduce the risk of endometrial seeding during laparoscopic surgery. All tissues should be removed in an appropriate retrieval bag and the pneumoperitoneum should be deflated completely before removing ports to reduce the chimney effect of tissue being forced through the port site. The diagnosis should be considered in all women of reproductive age presenting with a painful port site scar.

A review of the open laparoscopic Hasson technique and retrieval of adnexal specimen via umbilicus.

Laparoscopic entry techniques vary amongst surgeons and gynaecologists, with gynaecologists favouring Veress needle entry. Recent RCOG/BSGE recommendations have recommended retrieval of ovarian masses via the umbilical port with resultant less postoperative pain and a faster retrieval time than with retrieval through lateral ports of the same size. This is a prospective observational study reviewing the Hasson entry technique and the introduction of retrieval of specimens via the umbilicus in patients scheduled for a laparoscopy procedure at our day surgery unit. We found no immediate or major surgical complications and all specimens were successfully retrieved through the umbilicus. Pain scores were low. We recommend the technique for extirpative gynaecological surgery. Impact Statement This study confirms that conversion from the closed Veress to the open Hasson technique is achievable in a university hospital setting. Operator confidence during the learning phase is enhanced by the use of ultrasound to locate and measure the depth of the umbilical ligament. Retrieval of benign adnexal specimens through the umbilicus was very satisfactory.

Poorly understood and often miscategorized congenital umbilical cord hernia: an alternative repair method.

PURPOSE: Umbilical cord hernia is poorly understood and often miscategorized as "omphalocele minor". Careless clamping of the cord leads to iatrogenic gut injury in the situation of umbilical cord hernia. This study aimed to determine the characteristics and outcomes of umbilical cord hernias. We also highlight an alternative repair method for umbilical cord hernias. METHODS: We recorded 15 cases of umbilical cord hernias over 10 years. The patients' data were retrospectively reviewed, and preoperative preparation of the newborn, gestational age, birth weight, other associated malformations, surgical technique used, enteral nutrition, and length of hospitalization were recorded. RESULTS: This study included 15 neonates with umbilical cord hernias. The mean gestational age at the time of referral was 38.2 ± 2.1