Determination of the umbilicus position in Japanese children.

BACKGROUND: Although there have been many reports concerning the normal position of the umbilicus, the measurements were performed from the surface of the body in all cases. We examined computed tomography (CT) images to determine the accurate position of the umbilicus in children. METHODS: We retrospectively examined the CT data of 120 Japanese children (60 boys, 60 girls). The angle between both iliac crests to the umbilicus (IU angle), the angle between both anterior superior iliac spines and the umbilicus (AU angle), and the ratio of the length from the xiphoid process to the umbilicus and length from the umbilicus to the pubic symphysis were measured. RESULTS: The mean AU angle was 33.7° ± 5.1°, showing the least data variations. A significant difference was noted in the AU angle between boys and girls (32.7° ± 4.6° and 34.6° ± 5.4° respectively; p = 0.04). When we defined the position of the umbilicus as an AU angle of 33° in boys and 35° in girls, 115 children (95.8%) fell within ±10°. CONCLUSIONS: The AU angle is the preferable predictor of the umbilicus position in children.

Ultrasonographic evaluation of umbilical structures in Holstein calves: A comparison between healthy calves and calves affected by umbilical disorders.

The aim of this study was to evaluate, during the first 4 wk of life, the involution of umbilical structures in clinically healthy calves and in calves affected by umbilical disorders, in both B-mode and color Doppler ultrasonography. The present study was carried out on 63 Holstein Friesian calves, divided into 3 different groups: group H (clinically healthy, n = 17), group A, (affected by omphaloarteritis, n = 24), and group V (affected by omphalophlebitis, n = 22). B-mode ultrasonography was performed at weekly intervals, using a portable device (LOGIQ Book XP, GE Healthcare, Little Chalfont, UK) and a linear multifrequency 7 to 10 MHz probe. In addition to the ultrasound examinations, the umbilicus of the calves was also evaluated using a color Doppler. The extra-abdominal as well as the intra-abdominal hemodynamics within the umbilical structures were evaluated using 3 different ranges of speed-flow detections (23, 14, and 7 cm/s). In healthy calves, as the age increased, the umbilical structures decreased in size and their ultrasonographic identification became more difficult. Conversely, in affected calves the umbilical structures did not show the same progressive reduction of external diameters and areas, but had an irregular trend of regression. Also the color Doppler ultrasonography showed a significant difference in frequency and percentage of speed-flow in the early days of examination between the 3 groups, with the most reliable results detected from the umbilical arteries. In our experimental study, omphaloarteritis could be detected at the d 1 color Doppler exam, with a 100% specificity and a 100% positive predictive value.

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.

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.

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.

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.

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.

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.

Abdominal tuberculosis manifested as tuberculosis of the urachal sinus in an adolescent and the role of laparoscopy in the management: a rare case report.

BACKGROUND: Abdominal tuberculosis (TB) is an uncommon affliction in adolescence. It is usually associated with pulmonary tuberculosis. The disease is caused by lymphohaematogenous spread after primary infection in the lung or ingestion of infected sputum and has a typically protean and nonspecific presentation. The occurrence of TB in an urachal remnant is probably from the contiguous spread of an abdominal focus or mesenteric lymph node. Urachal TB is a rare entity, with only two reported cases in the literature. We report here a case of clinically silent pulmonary and abdominal TB that manifested in the infection of an urachal sinus and highlight the role of laparoscopy in its diagnosis and treatment. CASE PRESENTATION: A 14-year-old boy presented to our institution with peri-umbilical swelling and purulent discharge from his umbilicus for 2 weeks duration. There were no radiological, microbiological or clinical evidences of TB in the initial presentation, though he had close social contact with someone who had TB. A computed tomography scan of the abdomen confirmed the diagnosis of an urachal abscess. An incision and drainage procedure was performed followed by a course of antibiotics. A scheduled laparoscopic approach later showed that the peritoneum and serosal surface of the small and large intestines were studded with nodules of variable sizes, in addition to the urachal sinus. The histology of the resected tissues (urachal sinus and nodules) was consistent of TB infection. He recovered fully after completing 6 months of anti-tuberculous therapy. CONCLUSION: This report highlights a rare case of TB urachal abscess in an adolescent boy, the difficulties in the diagnosis of abdominal tuberculosis, the need to consider TB as a cause of urachal infection in endemic areas and the use of laparoscopy in both diagnosis and treatment.

Maternal and fetal Doppler velocimetry in women diagnosed with fear of childbirth.

AIM: This study aimed to investigate maternal and fetal Doppler flow parameters in term pregnant women diagnosed with fear of childbirth (FOC). MATERIALS AND METHODS: Women between 20 and 40 years with full-term singleton pregnancies (≥37 gestational weeks) were included in the study. All patients were questioned with Turkish form of Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A. Women with W-DEQ scores ≥85 were defined as FOC. Forty women diagnosed with FOC (FOC group) and 45 women with W-DEQ scores <85 (control group) underwent Doppler waveform analysis and the pulsatility index (PI) and resistance index (RI) values for uterine, umbilical, and mid cerebral arteries were recorded. RESULTS: Both groups had similar PI and RI values for umbilical and mid cerebral arteries (P > 0.05). However, PI and RI values for both right and left uterine arteries were higher in FOC group than control group (P < 0.05, for right uterine artery PI; P< 0.001, for left uterine artery RI; and P< 0.01, for others). CONCLUSION: It may be suggested that the presence of FOC in term pregnant women seems to have a negative effect on uterine blood flow parameters. When diagnosed with FOC, the women should be referred to a specialist for psychoeducation and psychosomatic support to decrease her fear and to minimize the negative impact of fear on the fetus.

Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging.

OBJECTIVES: Advances in laparoscopy have demonstrated that supraumbilical primary ports can be desirable in complex cases with large masses. This study evaluated distances to vital retroperitoneal vasculature that were encountered with 45- and 90-degree angle entry from the umbilicus and 2 commonly described supraumbilical entry points at 3 and 5 cm cephalad from the umbilicus. STUDY DESIGN: Retrospective analysis of computed tomography scans of the abdomen and pelvis from 100 randomly selected women who were 18-50 years old with normal anatomy was performed. Three-dimensional models of sagittal sections were generated using IMPAX software. Measurements from the abdominal wall at the umbilicus and 3 and 5 cm cephalad with 45- and 90-degree angles to retroperitoneal structures were performed. RESULTS: With 90-degree angle entry, the abdominal wall thickness (AWT) was thinnest at the umbilicus; however, the thickness at 3 and 5 cm was similar. AWT increased at all sites with 45-degree angle entry, and the same pattern was observed. AWT and intraperitoneal distance positively correlated with body mass index and supraumbilical entry points. With 90-degree angle entry, the aorta was 1.9 cm (95% confidence interval [CI], 1.4-2.4) and 2.5 cm (95% CI, 2.0-2.9) farther away at 3 and 5 cm cephalad compared with umbilical entry. In one-third of the cases, regardless of port placement, a vascular structure other than the aorta was the most anterior vessel. With 45-degree angle entry at the umbilicus, no vessels were encountered. With 45-degree angle entry at 3 and 5 cm cephalad, the aorta was the most anterior vessel in 1% and 2% of cases, respectively, and was noted to be 1.0 cm (95% CI, 1.0-1.0) and 2.3 cm (95% CI, 1.2-3.3) farther away than with 90-degree angle entry. A vessel other than the aorta was encountered in 4% and 7% of cases at 3 and 5 cm, respectively. CONCLUSION: According to theoretic modeling, supraumbilical primary port placement can be implemented safely in laparoscopy. With supraumbilical entry, the distance to retroperitoneal vessels was greater than at the umbilicus. Compared with a 90-degree angle, with a 45-degree angle entry, it was uncommon to encounter vasculature, and all measured distances were greater.

Umbilical metastasis derived from breast cancer: report of a case.

Umbilical metastases mainly arise from malignancies of the digestive and gynecological systems, but rarely from breast cancer. A 64-year-old woman with a history of breast cancer was referred to us for investigation of a painful lesion in the umbilicus. Immunohistochemical staining of a specimen obtained by biopsy from the nodule showed umbilical metastasis of breast cancer. After a work up, she was successfully treated with a combination of surgery and endocrine therapy. We report this case to reinforce that not all periumbilical tumoral deposits are consistent.

The umbilicus: a reliable surface landmark for the aortic bifurcation?

PURPOSE: Anatomical surface landmarks are frequently used by clinicians to guide both diagnosis and treatment. Few studies have examined the reliability of vascular anatomical landmarks in living subjects. The umbilicus has traditionally been described as a surface landmark for the bifurcation of the abdominal aorta. This study examined the factors affecting the position of the umbilicus relative to that of the aortic bifurcation in 95 patients. METHODS: 106 consecutive abdominal CT scans were analysed by a surgeon and radiologist. Following exclusion of CT scans with relevant significant intra-abdominal pathology, 95 patients were included in the study. Measurements were taken of the craniocaudal distance between the aortic bifurcation and umbilicus, as well as maximum subcutaneous fat thickness at the level of the umbilicus. Patient age and gender were also documented. RESULTS: The umbilicus was found to lie -6.3 ± 26.5 mm from the aortic bifurcation. Increasing subcutaneous fat thickness was associated with a more caudal position of the umbilicus relative to the aortic bifurcation. This result was highly statistically significant in males over 65 years old. CONCLUSIONS: This study suggests that the umbilicus is a reliable clinical surface landmark for the bifurcation of the abdominal aorta. Whilst some variation in craniocaudal distance exists between patients, in the majority of cases, the bifurcation of the abdominal aorta lies within a clinically narrow range of distances from the umbilicus.

Primary umbilical endometriosis presenting as umbilical drainage in a nulliparous and surgically naive young woman.

Endometriosis is well known as a chronic condition associated with significant morbidity. Umbilical endometriosis, however, may go unrecognized because of its rarity, leading to multiple medical visits and a delayed diagnosis. Chronic umbilical drainage is an unusual presentation for umbilical endometriosis. Even more unusual is the development at this location in a patient without previous abdominal surgery. There are very few published case reports about primary umbilical endometriosis. A 24-year-old nulliparous African American woman presents to the emergency department with a complaint of chronic umbilical drainage of 3-year duration and undergoes a computed tomographic scan and subspecialty referral, which lead to the diagnosis of primary abdominal wall endometriosis and a new left ovary endometrioma. Although this is an unusual occurrence, it may be considered in patients with chronic umbilical drainage without other cause.

Sister Mary Joseph nodule: a tip of an iceberg.

A Sister Mary Joseph nodule represents a cutaneous metastasis into the umbilicus. This clinical sign of intra-abdominal malignancy is frequently overlooked or misinterpreted by both patients and their physicians. We report 4 patients with a Sister Mary Joseph nodule. The umbilical metastases appeared sonographically as hypoechoic masses with irregular margins and small internal hyperechoic foci. Further evaluation revealed disseminated malignancy, and the umbilical nodule was just "a tip of an iceberg."

Primary umbilical endometriosis (Villar's nodule) - case study, literature revision.

Spontaneous umbilical endometriosis, also known as Villar's nodule, is an unusual location of the endometrial tissue.Whilst in the case of umbilical locations secondary to surgical procedures endometriosis occurs quite frequently,the frequency of the primary umbilical location is lower than 1% of all endometriosis locations. The authors present such a case diagnosed in a young, nulliparous patient with no history of surgical procedures, the diagnosis being suggested by the presence of an umbilical tumor mass whose symptomatology concurs with menstrual periods. The aspects regarding differential diagnosis and the therapeuticoptions for the surgical cure of this type of lesion are discussed.