The umbilical region is a part of the abdominal wall, bounded by horizontal lines, above connecting the ends of X ribs, below the anterior-superior spine of the iliac bones, with vertical lines running laterally through the middle of the pupartic ligaments . In this area, the navel is located - a retracted scar that forms at the point where the umbilical cord falls off. The navel covers the umbilical ring - a hole in the aponeurosis of the white line of the abdomen, through which blood vessels , the yolk and urinary ducts penetrate into the abdominal cavity of the fetus (Fig. 1). After the umbilical cord falls off, the hole closes; ducts running in it, run empty. The skin of the navel is thin, devoid of the subcutaneous fat layer, soldered to the slightly elastic and easily stretchable scar tissue of the umbilical ring, which has its own fascia often absent, which makes it a weak part of the abdominal wall and the place of hernia (Fig. 2).
Fig. 1. The umbilical ring with the germinal vessels and ducts, from the remains of which fistula and navel cysts develop in children and adults: 1 - the umbilical vein; 2 - umbilical-intestinal (yolk) duct; 3 - urinary duct; 4 - umbilical artery.
Fig. 2. Congenital umbilical hernia.
In the area of the navel may be congenital and acquired fistula. The latter are due to a breakthrough through the navel of the abscesses of the abdominal cavity. Surgical treatment - excision of the navel along with a fistula. Of benign tumors in the navel are possible lipomas, fibromas , adenomas and cysts from the remnants of the yolk and urinary ducts. Malignant tumors often secondary - metastasis of cancer of the stomach, intestines, uterus and its appendages.Go
The navel (umbilicus, omphalos) is a scar that forms at the point where the umbilical cord falls off after birth. Located in the center of the umbilical region (regio umbilicalis), which is part of the anterior abdominal wall (see). The skin of the navel serves as an outer cover for the umbilical ring — the defect of the white line of the abdomen, through which the embryonic vessels (the umbilical vein and arteries) and ducts: urinary, yolk (Fig. 1) passed in the antenatal period of development. In the navel area there is no subcutaneous and preperitoneal fat - the skin is directly adjacent to the scar tissue that has completed the umbilical ring. Then follow the umbilical fascia (part of the transverse fascia of the anterior abdominal wall) and the peritoneum welded to the circumference of the umbilical ring. In a third of cases, the umbilical fascia is absent (A. A. Deshin). The location of the navel depends on age, gender, condition of the abdominal wall, etc., and on average corresponds to the level of the III — IV lumbar vertebrae. Newborn premature babies have a low standing navel.
Fig. 1. The umbilical ring with the germinal vessels and ducts passing from the remains of which fistula and navel cysts develop in children and adults: 1 — umbilical vein; 2 - umbilical arteries; 3 - the urinary duct; 4 - umbilical-intestinal (yolk) duct.
The umbilical ring is one of the weakest areas of the anterior abdominal wall and the site of the hernia (see).
A variety of pathological processes in the abdominal cavity affect the location, shape and even the color of the navel, which should be considered in the diagnosis and therapeutic measures. With ascites, the navel is bulging, with peritonitis, on the contrary, somewhat retracted. In acute and chronic inflammatory processes in the abdominal cavity, the navel shifts and is located asymmetrically with respect to the white line. The coloring of the skin of the navel is of diagnostic importance: it is yellow with biliary peritonitis, blue with liver cirrhosis and congestion in the abdominal cavity with insufficient compensation of collateral circulation, with intraperitoneal bleeding in patients with an umbilical hernia. Preservation of the natural color of the navel with peritonitis indicates sufficient vascularization of the peritoneum and is a prognostic sign.
In emergency surgery, the symptom of “navel crepitus” is of great diagnostic value. It is determined in the presence of air in the abdominal cavity (violation of the integrity of organs) and at the same time an umbilical hernia. The air, coming out through the umbilical ring, gives a feeling of crunch on palpation of the navel (as with subcutaneous emphysema).
Umbilical symptoms occupy a large place in the diagnosis of inflammation of Meckel's diverticulum - pain in this disease constantly radiates to the navel, aggravated by pulling up the abdominal wall anteriorly, in some cases edema and hyperemia of the navel are noted.Go
In the umbilical region - rich arterial and venous communications. Arteries are located in two "floors" - in the subcutaneous tissue and the preperitoneal layer, between the two layers there are anastomoses. Arteries are branches of the superficial, superior and inferior epigastric, as well as superior cystic and umbilical arteries, which retain patency in a certain part and in the postnatal period of development (G. S. Kiryakulov). Through them, you can enter the contrast and medicinal substances in the abdominal aorta. The surface, upper and lower epigastric arteries are involved in the formation of the surface circle at the base of the umbilical funnel.
The preperitoneal arterial circle is formed mainly by the lower epigastric arteries, the branches of the cystic and umbilical arteries. Between the two “circles” there are many anastomoses that play a large role in the collateral circulation of the anterior abdominal wall.
Of the veins of the umbilical region, the umbilical and paraumbilical veins (v. Umbilicalis et v. Paraumbilical) belong to the portal vein system (v. Portae), and the superficial vena cava inferior vena cava (vv. epigastriacae superficiales sup., inf.). Thus, extensive porto-caval anastomoses are formed around the navel, which expand significantly with intrahepatic portal blocks, especially with liver cirrhosis (Fig. 2), and have the appearance of a “jellyfish head” (caput medusae). This symptom also has a certain diagnostic value in recognizing a violation of the portal blood circulation.Fig. 2. Significant dilation of the collateral saphenous veins of the umbilical region in case of cirrhosis of the liver and non-expanded umbilical vein.
The common idea of the obliteration of the umbilical vein in the extrauterine period of life is incorrect. This vessel is only in the state of functional closure and its passability is maintained for a considerable length of time. The full patency of the umbilical vein is observed with a special form of cirrhosis of the liver - the syndrome Cruvelier - Baumgarten. This syndrome is characterized by a strong expansion of the superficial veins of the umbilical region, splenomegaly, loud blowing noise in the navel.
The absence of morphological obliteration of the umbilical vein allows for the insertion of contrast and medicinal substances through the liver [direct transupuncture portography (Fig. 3), regional perfusion], and blood transfusion. G. E. Ostroverkhov and A. D. Nikolsky developed simple extraperitoneal access to the umbilical vein (Fig. 4). In cirrhosis, primary and metastatic liver cancer, angiography through the umbilical vein is widely used. In newborns possible angiocardiography through the umbilical vein. The umbilical vein is also used to discharge part of the blood from the portal system to the caval during portal hypertension. To do this, impose a vascular anastomosis between the umbilical and inferior vena cava or from one of the branches of the renal veins. G. E. Ostroverkhov, S. A. Gasparyan, and E. G. Shifrin for the same purpose developed an extracavitary port-caval shunt between the umbilical vein and the great saphenous vein of the thigh. The umbilical vein, located in the round ligament of the liver, extends for a considerable length in the umbilical canal, the walls of which are the white line (front), the umbilical fascia (behind). The umbilical canal is a good guide when looking for the umbilical vein.Fig. 3. Intravital transupupinal portal venogram in an adult; visible portal veins. A catheter is projected on the spine (below) in the umbilical vein.
Fig. 4. Diagram of on-line access to the umbilical vein for carrying out portography; after retraction to the right, the umbilical vein (4) becomes clearly visible by hooking the rectus abdominis muscle: 1 - incision line; 2 - retracted rectus muscle; 3 - the peritoneum.
Purulent process from the umbilical wound can cause inflammation of the skin and subcutaneous tissue in the navel (see Omphalitis), and can also go to the corresponding vascular vagina, and then to the vessel itself. In the umbilical artery, a thrombus can occur, in the umbilical vein - phlebitis, which spread to the liver, where abscesses occur. Damage of vessels, more often arteries, in a newborn is already the beginning of sepsis (see).
Treatment of inflammation of the umbilical vessels includes drip administration of antibiotics, blood transfusion.
The beginning of the lymphatic vessels of the navel and the umbilical region is a dense network of lymphatic capillaries lying under the skin of the umbilical sulcus and along the posterior surface of the ring, under the peritoneum. Further lymph flow continues in three directions (flows): in the axillary, inguinal and iliac lymph nodes, which are regional for the umbilical region (Fig. 5). All the way from the navel to these regional areas of the lymph nodes are no longer present. Hence the rapid spread of infections from the navel to distant areas. According to N. N. Lavrov, the movement of lymph is possible along the described paths in both directions, which explains the infection of the umbilical region and the navel from the primary foci in the axillary and inguinal regions.
Fig. 5. Lymph drainage from the navel and the umbilical region: 1 - axillary lymph nodes; 2 - inguinal lymph nodes; 3 - ileal lymph nodes.
The innervation of the umbilical region is carried out by intercostal nerves (nn. Intercostales) (upper sections), ileal nerves (nn. Iliohypogastrici) and ileal-inguinal (nn. Ilioinguinales) from the lumbar plexus (lower sections).
Fistulas and cysts of the umbilical-intestinal (yolk) duct. After the birth of the child, the umbilical duct (ductus omphaloentericus) can maintain permeability throughout, then a complete intestinal umbilical fistula occurs with the secretion of intestinal contents. Permeability of the duct can be maintained only near the navel - an incomplete umbilical fistula. If the middle part of the duct fails to open, its significant expansion is formed - enterokistoma, which can be mistaken for a tumor of the abdominal cavity. Sometimes there is a lumen in the part of the duct associated with the ileum - the so-called Meckel's diverticulum. The preservation of residues of the yolk duct, in addition to the marked pathology, can cause obvorotov and internal hernias.
Fistulas and cysts of the urinary duct. Persistent throughout the urinary duct (urachus) causes a complete congenital urinary fistula. When maintaining the patency only in areas in contact with the navel or bladder, there are respectively incomplete fistula and diverticulum. To recognize the pathological consequences associated with incomplete reduction of the embryonic ducts, one should resort to the study of secretions, probing, fistulography.
There are also cysts and tumors emanating from the yolk and urinary ducts.
Treatment of fistula and cysts of the urinary duct operative.
Fistula umbilical vessels. Failure to delay or late functional closure of the umbilical vein or arteries leads to the formation of vascular fistula, which is one of the causes of umbilical sepsis and late umbilical bleeding. At the same time there are bloody discharge. In the differential diagnosis should be borne in mind that bleeding navel can be with endometriosis (see). The endometriomas of the umbilical region increase sharply during menstruation and pregnancy. Torlakson (K. Thorlakson) proposed to use the umbilical region for permanent colostomy.
Specific processes are observed in the umbilical region. These include tuberculosis, including primary navel tuberculosis, actinomycosis, usually secondary (passage from the intestines), and syphilis; most often it is gumma, the possibility of primary damage to the navel is not excluded.
Tumors of the umbilical region are benign and malignant. Among the first, lipomas are most frequent, developing due to preperitoneal fat.
Frequent granulomas (fungus), representing the excessive growth of granulations with prolonged healing of the umbilical wound. Fibromas are observed, including neurofibromas, rhabdomyomas, dermoid tumors, tumors arising from the remnants of the embryonic ducts - adenomas (from the umbilical-intestinal duct), fibrolipomyyomas (from the urinary duct). Malignant tumors of the umbilical region - cancer, sarcoma, as a rule, are secondary.
Injuries to the umbilical region can lead to rupture of the rectus abdominis muscles and damage to internal organs.