PUPOK, PUPOCHNAYA OBLAST

From Big Medical Encyclopedia

NAVEL, UMBILICAL AREA [umbilicus (PNA, JNA, BNA); regio umbilicalis (PNA, BNA); pars (regio) umbilicalis (JNA)].

Umbilical area (regio umbilicalis) — the part of a front abdominal wall located in mezogastralny area (mesogastrium) between two horizontal lines (from them upper connects the ends of bone parts of the tenth edges, and lower — upper front ileal bones) and limited from sides to the semi-oval lines corresponding to the outer edges of direct muscles of a stomach. In umbilical area big curvature of a stomach (is projected at its filling), a cross colon, loops of a small bowel, the horizontal (lower) and ascending parts of a duodenum, a big epiploon, nizhnevnutrenny departments of kidneys with initial departments of ureters, partially belly part of an aorta, the lower vena cava and lumbar nodes of sympathetic trunks.

Navel represents the skin cicatricial pole located in umbilical area and which is formed after the birth of the child as a result of falling away umbilical cords (see).

Formation of a navel

Formation of a navel is preceded by complex processes of development in the pre-natal period when the fruit is connected to a placenta an umbilical cord. The elements which are its part undergo essential changes in process. So, the vitellicle at mammals represents rudimentary, remained out of a body of an early embryo, education, a cut it is possible to consider a part of primary gut. The vitellicle connects to primary gut by means of an umbilical and intestinal (vitelline) channel. Involution of a vitellicle begins at a 6 weeks embryo. Soon it is reduced. Pupochno-kishechny Canal also atrophies and completely disappears. In an umbilical cord the allantois which opens in a back gut (more precisely a foul place) an embryo is located. A proximal part of an allantois in development extends and participates in formation of a bladder. The pedicle of an allantois which is also located in an umbilical cord is gradually reduced and forms uric channel (see) which serves at an embryo for removal of primary urine in amniotic waters. By the end of the pre-natal period the gleam of an uric channel is usually closed, it is obliterated, turning into a median umbilical sheaf (lig. umbilicale medium). In an umbilical cord there pass umbilical vessels which are formed by the end of the 2nd month of the pre-natal period in connection with development of placental blood circulation. Formation of a navel happens after the birth at the expense of the skin of a stomach passing to an umbilical cord. The navel covers an umbilical ring (anulus umbilicalis) — an opening in the white line of a stomach. Through an umbilical ring the umbilical vein, umbilical arteries, uric and vitelline channels get into an abdominal cavity of a fruit in the pre-natal period.

Anatomy

Distinguish three forms of an umbilical pole: cylindrical, cone-shaped and pear-shaped. The navel is most often on the middle of the line connecting a xiphoidal shoot of a breast to a pubic symphysis and is projected on the upper edge of the fourth lumbar vertebra. The navel can be involved, flat and evaginated. In it allocate: the peripheral skin roller, the umbilical furrow corresponding to the line of a spayaniye of skin with an umbilical ring and a skin stump — the nipple formed as a result of falling away of an umbilical cord and the subsequent scarring. The umbilical fascia is a part of an intraperitoneal fascia (fascia endoabdominalis). It can be dense and well-marked, its cross fibers, being interwoven into back walls of vaginas of direct muscles, close and strengthen an umbilical ring; sometimes the umbilical fascia happens weak, friable that promotes formation of umbilical hernias. At a well-marked umbilical fascia existence of the umbilical channel formed in front by the white line of a stomach, behind — an umbilical fascia, from sides — vaginas of direct muscles of a stomach is noted. In the channel there pass the umbilical vein and arteries. The lower opening of the channel is at the upper edge of an umbilical ring, and upper — is 3 — 6 cm higher than it. The umbilical channel is the place of an exit slanting umbilical hernias (see). When it is not expressed, there are hernias called by straight lines.

From an abdominal cavity there are four peritoneal folds going to an umbilical ring: the round ligament of a liver (lig.teres hepatis) — partially obliterated umbilical vein approaches its upper edge; to bottom edge — a median umbilical fold (plica umbilicalis mediana) covering the obliterated uric channel, and medial umbilical folds (plicae umbilicales mediales) covering the obliterated umbilical arteries.

The umbilical area is characterized by the peculiar vascularization connected with reorganization of blood circulation at the birth. Arteries of umbilical area are branches of superficial, top and bottom epigastriß, upper vesical, and also umbilical arteries which keep passability in a certain part and in the post-natal period. Through them it is possible to enter contrast agents into a belly part of an aorta for contrasting of an aorta and its branches — a transumbilikalny aortografiya (see. Catheterization of umbilical vessels ), and also pharmaceuticals newborn. Branches top and bottom epigastriß arteries create the anastomosing rings around a navel: superficial (skin and hypodermic) and deep (muscular and subperitoneal).

From veins of umbilical area to system portal vein (see) the umbilical vein (v. umbilicalis) and paraumbilical veins belong (vv. paraumbilicales), to system of the lower vena cava (see. Venas cava ) — superficial and lower epigastriß (vv. epigastricae superficiales et inf.) and to system of an upper vena cava — upper epigastriß veins (vv. epigastricae sup.). All these veins form among themselves an anastomosis (see. Porto-caval anastomosis ). The umbilical vein is located between a cross fascia of a stomach and a peritoneum. By the time of the birth of the child length of an umbilical vein reaches 70 mm, diameter of a gleam in the place of falling into a portal vein of 6,5 mm. After bandaging of an umbilical cord the umbilical vein zapustevat. By 10th day after the birth the atrophy of muscle fibers and growth of connecting fabric in a wall of an umbilical vein are noted. By the end of the 3rd week of life the atrophy of a wall of a vein, especially about a navel, is expressed clearly. However at newborns and even at children of more advanced age the umbilical vein can be allocated from surrounding fabric, a razbuzhirovan and is used as access to vessels of system of a portal vein. Considering this communication, the umbilical vein already right after the birth can be used for to lay down. actions (zamenny hemotransfusion at a hemolitic disease of newborns, partial perfusion of pharmaceuticals at resuscitation of newborns, etc.).

The umbilical vein is used during the carrying out a portomanometriya and portogepatografiya (see. Portografiya ). On a portogramma at normal portal blood circulation the place of a confluence of an umbilical vein in portal clearly is visible, and also it is possible to receive a sharp image of intra hepatic branchings of a portal vein. Contrasting of vessels of a liver on the portogepatogramma received at administration of contrast medium through an umbilical vein, clearer than on splenoportogramma. G. E. Peaked and A. D. Nikolsky developed simple extra peritoneal access to an umbilical vein that allows to use at adults it for an angiography at cirrhosis, and also at primary and metastatic cancer of a liver.

In umbilical area there is a network limf, capillaries which lie under skin of an umbilical furrow and on a back surface of an umbilical ring under a peritoneum. From them current of a lymph goes in three directions: in axillary, inguinal and ileal limf. nodes. According to H.H. Lavrova, the movement of a lymph is possible on these ways in both directions, than and infection of umbilical area and a navel from primary centers in axillary and inguinal areas speaks.

The innervation of an upper part of umbilical area is carried out by intercostal nerves (nn. intercostales), lower — iliohypogastric nerves (nn. iliohypogastrici) and ilioinguinal (nn. ilioinguinales) nerves from a lumbar texture (see. Lumbosacral texture ).

Pathology

In umbilical area can note sya various malformations, diseases, tumors. Reaction of a navel to change of pressure in a stomach (protrusion is noted at ascites, peritonitis). At acute and chronic inflammatory processes in an abdominal cavity the shift of a navel is possible aside. At a row patol, states decolourization of skin of a navel is observed: she is yellow at bilious peritonitis, cyanotic at cirrhosis and developments of stagnation in an abdominal cavity. At some morbid conditions at adults, napr, Kryuvelye's syndrome — Baumgarten (see. Kryuvelye-Baumgarten syndrome ), full passability of an umbilical vein with considerable expansion of superficial veins of umbilical area, a splenomegaly, the loud blowing noise in a navel is observed.

Malformations are a consequence of disturbance of normal development or a delay of a reduction of the educations passing through umbilical area at early stages of an embryogenesis (hernias, fistulas, cysts, etc.).

Hernias. Delay of growth and smykaniye of side shoots of primary vertebrae or disturbance of rotation of intestines in the first period of turn lead to development of an omphalocele (hernia of an umbilical cord, funic hernia), edges comes to light at the birth of the child; at this hernia funic covers perform functions of a hernial bag (see. Hernias , at children). Weakness of muscles of a front abdominal wall, umbilical fascia in an upper semi-circle of an umbilical ring can be led to formation of umbilical hernia. They come to light later when the navel was already created. Hernial protrusion at children (is more often at girls) arises at a strong tension of a prelum abdominale at cough, shout, locks, and also as a result of the general weakness of muscles; at adults umbilical hernias are more often observed at women. Treatment operational.

Fistulas and cysts. At a delay of an obliteration of an uric channel it can remain open throughout (it leads to formation of vesicoumbilical fistula) or on certain sites that promotes emergence of an urachal cyst, umbilical fistula, a diverticulum of a bladder (see. Mochevoy Canal ).

At a delay of involution of an umbilical and intestinal (vitelline) channel there are such defects as Mekkel's diverticulum (see. Mekkelya diverticulum ), full umbilical and intestinal fistula (full fistula of a navel), incomplete fistula of a navel and enterokist.

Fig. 1. Diagrammatic representation of some malformations of a navel (sagittal section): and — full fistula of a navel and — incomplete fistula of a navel (1 — a fistular opening, 2 — fistula of a navel, 3 — a small bowel); in — an enterokist of a navel (1 — an abdominal wall, 2 — an enterokist, 3 — a small bowel).

Full fistula of a navel develops if the umbilical and intestinal channel after the birth of the child remains open throughout (fig. 1, a). Klien, a picture of this pathology is typical. At the newborn right after falling away of an umbilical cord from an umbilical ring gases and liquid intestinal contents begin to depart this results from the fact that the channel connects an umbilical pole to terminal department of an ileal gut. On edge of an umbilical ring the nimbus of a mucous membrane of bright red color clearly is visible. At wide fistula constant allocation of contents of intestines exhausts the child, skin around an umbilical ring is quickly macerated, the inflammatory phenomena join. Evagination (loss) of a gut with disturbance of passability of intestines is possible. Diagnosis does not represent considerable difficulties, in not clear cases resort to sounding of fistula (the probe passes in a small bowel) or carry out contrast fistulografiya (see) with Iodolipolum.

Treatment of full fistula of a navel operational. Operation is performed under anesthetic, fistula is previously tamponed a thin turunda and taken in that prevents possible infection of a wound. Fistula is excised throughout the outlining section. Quite often at the wide basis of fistula carry out wedge-shaped bowel resection. Defect of an intestinal wall take in one - or a two-row intestinal seam at an angle 45 ° to an axis of an intestinal wall. Forecast, as a rule, favorable.

Incomplete fistula of a navel (fig. 1, b) it is formed at partial disturbance of involution of an umbilical and intestinal channel from an abdominal wall (if the channel is open only in a navel, this pathology carries the name Roser's hernia). Diagnosis of this malformation is possible only after falling away of an umbilical cord. In the field of an umbilical pole there is a deepening, from to-rogo mucous or mucopurulent liquid is constantly emitted. The end of a channel in these cases is covered by the epithelium identical intestinal which cosecretes slime. Quickly the secondary inflammatory phenomena join. The diagnosis specify by means of sounding of fistula and definition of pH it separated.

Differential diagnosis is carried out with incomplete urachus fistulas (see. Mochevoy Canal ), growth of granulations at the bottom of an umbilical pole — fungusy (see below), omphalitis (see) and calcification of fabrics of paraumbilical area (see below).

Treatment of incomplete fistula of a navel is begun with conservative actions. The wound is regularly cleared solution of hydrogen peroxide with the subsequent cauterization of walls of the fistular course by 5% spirit solution of iodine or 10% solution of silver nitrate. Cauterization by a lyapisny pencil is possible. At inefficiency of conservative treatment at the age of 5 — 6 months make an operational syringectomy. In order to avoid infection of surrounding fabrics and the subsequent suppuration of a wound fistula is previously carefully processed by 10% spirit solution of iodine and 70% alcohol.

Fig. 2. A stomach of the child at calcification of a navel: are visible white color of adjournment of salts of calcium in a navel.

Complication of full or incomplete fistula is calcification of a navel, for to-rogo adjournment of salts of calcium (fig. 2) in fabrics of an umbilical ring and paraumbilical area is characteristic. In hypodermic cellulose of paraumbilical area there are centers of consolidation, secondary inflammatory changes of the struck fabrics which complicate join or make impossible epithelizations:) umbilical wound. The wedge develops, a picture it is long the becoming wet navel — the umbilical wound badly begins to live, becomes wet, from it the serous or serous and purulent discharge is allocated. The fistular course or growth of granulations at calcification are absent. Edges and a bottom of an umbilical wound are covered with necrotic fabrics. The diagnosis of calcification of a navel is made on existence of consolidations in fabrics of an umbilical ring and paraumbilical area. In doubtful cases the survey X-ray analysis of soft tissues of area of a navel in two projections is shown. On roentgenograms calcificats have an appearance of dense foreign particulates. Treatment of calcification of a navel consists calcificats by a scraping an acute spoon or operational excision of the struck fabrics at a distance.

Enterokista — the inborn, filled with liquid cyst seldom meeting, a structure of a wall a cut reminds a structure of a wall of intestines. It proceeds from a wall of average department of an umbilical and intestinal channel. Enterokista in one cases lose communication with a gut and are located in an abdominal wall under a peritoneum — are in others about a small bowel and contact it a thin leg (fig. 1. в). Enterokista can suppurate and become the reason local or diffuse peritonitis (see).

Enterokista, located in an abdominal cavity, it is necessary to differentiate with the lymphatic cysts arising from embryonal limf, educations (see. Absorbent vessels ), and also with dermoid cysts (see. Dermoid ), the being derivatives of an ectoderm, otshnurovavshimisya in the embryonal period and shipped in the subject connecting fabric. Treatment enterokist operational.

Malformations of a vein and arteries of an umbilical cord. Lack of an umbilical vein or defects of its development lead, as a rule, to pre-natal death of a fruit. Umbilical arteries can be asymmetric or one of arteries can be absent. This pathology is quite often combined with malformations of abdominal organs, napr, with a disease of Girshsprunga (see. Megacolon ), or retroperitoneal space, e.g. with malformations kidneys (see), ureters (see).

Skin navel — one of frequent malformations of a navel. At the same time surplus of skin which remains further is noted. It is considered only as cosmetic defect. Treatment operational.

Amniotic navel — rather rare anomaly, at a cut amniotic covers from an umbilical cord pass to a front abdominal wall. After falling away of the rest of an umbilical cord on a front abdominal wall there is a site with a diameter of 1,5 — 2,0 cm deprived of a normal integument and gradually epidermiziruyushchiysya. This site needs to be preserved against accidental traumatizing and infection carefully.

Diseases. The mummified umbilical cord usually disappears on 4 — the 6th day of life, and the remained umbilical wound at a normal granulation is epithelized and begins to live by the end of the 2nd — the beginning of the 3rd week. At infection of the rest of an umbilical cord he is not mummified and timely does not disappear, and remains wet, gains dirty-brown color and exudes an unpleasant fetid smell. This pathology carries the name of gangrene of the rest of an umbilical cord (sphacelus umbilici). Further the umbilical cord disappears then usually there is an infected, strongly diapyetic and badly beginning to live umbilical wound, in a cut the gaping umbilical vessels are visible. Quite often gangrene of the rest of an umbilical cord can become the reason of development sepsis (see). Treatment is complex, includes prescription of antibiotics of a broad spectrum of activity.

At to pyorrhea or blennory navel, caused by streptococci and stafilokokka or gonokokka and other activators, the discharge from an umbilical wound gains purulent character and accumulates in a significant amount pleated and deepenings of the forming navel. Topical treatment (processing of a wound solution of potassium permanganate, physiotherapeutic procedures) and general (prescription of antibiotics).

Fig. 1 — 3. Diseases of a navel. Fig. 1. Inflammation of a navel with an ulceration (ulcus umbilici). Fig. 2. Fungoid growth of granulyatsionny fabric in a navel (fungus umbilici). Fig. 3. Distribution of inflammatory process from a navel on surrounding skin and hypodermic cellulose (omphalitis).

Prolonged healing of a diapyetic umbilical wound can lead to an ulceration of its basis, a cut in these cases becomes covered serous and purulent separated grayish-greenish color — an ulcer of a navel (ulcus umbilici) — tsvetn. fig. 1. At prolonged healing of an umbilical wound granulyatsionny fabric can expand and the small tumor — a mushroom of a navel (fungus umbilici) — tsvetn is formed. fig. 2. Topical treatment — cauterization of a wound of 2% solution of silver nitrate, processing by its strong solution of potassium permanganate or solution of tetraethyl-diamino-triphenyl-carbohydride sulfate.

The plentiful inflammatory discharge from an umbilical wound sometimes is the reason of irritation and secondary infection of skin around a navel. There are small, and sometimes also larger pustules — pemphigus periumbilical is. Treatment consists in opening of pustules and processing by their disinfecting solutions; at widespread process appoint antibacterial therapy.

If inflammatory process from an umbilical wound passes to skin and hypodermic cellulose, the omphalitis develops in circles of a navel (tsvetn. fig. 3), a current to-rogo can be various. Allocate several forms: a simple omphalitis (the becoming wet navel), phlegmonous and necrotic omphalitis (see).

In some cases the infection extends on umbilical vessels, most often on a vagina of an artery, and passes to a vascular wall that leads to development of an umbilical periarteritis. The inflammation of an umbilical vein is observed much less often, but proceeds more hard since the infection extends on system of a portal vein in a liver, causing diffusion hepatitis, multiple abscesses and sepsis. If inflammatory process from vessels or the fabrics surrounding them passes to connecting fabric and cellulose of a front abdominal wall, then preperitonealny phlegmon develops. Treatment is complex, includes antibacterial therapy and is directed to the prevention of development of sepsis.

Infection of an umbilical wound with the causative agent of diphtheria (diphtheria of a navel), mycobacteria (tuberculosis of a navel) is possible. Treatment specific (see. Diphtheria , Tuberculosis ).

Umbilical bleedings. Distinguish bleedings from umbilical vessels and parenchymatous bleedings from the granulating umbilical wound. Umbilical bleedings arise owing to insufficiently careful bandaging of an umbilical cord or as a result of increase in blood pressure in an artery at circulatory disturbances in a small circle that is most often observed at the children who were born in asphyxia and also at lungs, premature with an atelectasis, and at inborn heart diseases. Disturbance of process of a normal obliteration of umbilical vessels, a delay of a thrombogenesis in them in connection with disturbance of coagulating properties of blood of the child or the subsequent fusion of blood clot under the influence of secondary infection can also be the cause of vascular umbilical bleedings.

Treatment operational also consists in repeated bandaging of an umbilical cord, and also appointment according to indications of the means increasing coagulability of blood.

Tumors. In umbilical area benign and malignant tumors are observed, metastasises of various malignant tumors, napr, ovarian cancer are sometimes noted. Seldom tumors, coming from an uric channel (urakhus) meet. Occur among benign tumors of a navel and umbilical area fibroma (see. Fibroma, fibromatosis ), leiomyoma (see), lipoma (see), neurinoma (see), neurofibroma (see), hemangioma (see).

Tumors of an uric channel occur preferential at men 50 years are more senior. There are complaints to pain, the hamaturia is sometimes noted, at a palpation tumorous education in the field of an abdominal wall can be defined. On localization allocate the tumors located in a wall of a bladder (the colloid adenocarcinoma is more often), the tumors located between a bladder and a navel (usually fibroma, myoma, sarcoma) and tumors in a navel (adenoma, a fibroadenoma is more often). Metastasises of tumors of an uric channel are noted seldom. Quite often tumors arise in the field of umbilical fistula and, as a rule, do not reach the big sizes. At a colloid adenocarcinoma from umbilical fistula or an ulcer gelatinous weight can be allocated. Malignant tumors can burgeon in an abdominal cavity and its bodies.

Differential diagnosis of tumors of an uric channel should be carried out with tumors bladder (see), with cysts uric channel (see), tumors ovary (see), tumors and parasitic cysts abdominal wall (see).

Treatment of tumors of an uric channel only operational. All tumors of an uric channel are not sensitive to radiation therapy and antineoplastic means. Short-term results of operational treatment good. The long-term results are studied a little. A recurrence appears within 3 years, and in later terms is observed at certain patients.

See also Abdominal wall , Stomach .


Bibliography: Babayan A. B. and Sosnina T. P. Anomalies of development and a disease of the bodies connected with an umbilical ring, Tashkent, 1967; Doletsky S. Ya. and Isakov Yu. F. Children's surgery, p. 2, page 577, M., 1970; D au-letsky S. Ya., Gavryushov V. V. and Akopyan V. G. Surgery of newborns, M., 1976; Doletsky S. Ya., etc. Contrast researches of system of a portal vein and aorta through umbilical vessels at children, M., 1967; Operational surgery with topographical anatomy of children's age, under the editorship of Yu. F. Isakov and Yu. M. Lopukhin, M., 1977; About St rover x about in G. E. and Nikolsky A. D. To the equipment of a portografiya, Vestn. hir., t. 92, No. 4, page 36, 1964; Round A. F. Fiziologiya and pathology of the period of Novoroshdennosti, page 213, L., 1955; Surgical anatomy of a stomach, under the editorship of A. N. Maksimenkov, page 52, L., 1972; Surgery of malformations at children, under the editorship of G. A. Bairov, L., 1968.


V. A. Tabolin; V. V. Gavryushov (malformations), A. A. Travin (An.).

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