Hugo Bonatti, MD, Aboubakr Khairat, MD, Stephen Kavic, MD. University of Maryland.
Background: The persistent omphaloenteric remnant is a rare condition, which is most commonly diagnosed at child hood. Symptoms usually occur at an early age and may include chronic abdominal wall infections, abdominal pain and small bowel obstruction. It is rarely seen in adults and only few cases of laparoscopic management have been reported thus far.
Case report: A 32 year old male underwent open primary repair of an umbilical hernia without MESH at an outside hospital. Within few weeks after the procedure he developed a chronic infection of his umbilicus, which was treated with antibiotics and dressing changes. The infection however progressed and the patient presented with a phlegmone of his abdominal wall. On CT-scan a tubular structure adherent to the inner surface of the abdominal wall was seen and it was suspected that the patient had a urachus cyst, which was the cause of his chronic infection. He was treated with antibiotics and after resolution of the acute infection he was prepared for laparoscopic exploration and removal of the pathology. At this point he had a persistent purulent leakage from his umbilicus. During laparoscopy first adhesions of the omentum and the abdominal wall were divided. The reported tubular structure was identified and found to have no relationship with the bladder but instead could be followed towards the mesenterium and mimicking a small bowel loop. Now, as an omphaloenteric duct was suspected, the small bowel was run starting at the terminal ileum and at 100cm the origin of the remnant was identified. After intraabdominal mobilization and ligation of the feeding artery, a 4 cm incision was made below the umbilicus. The chronic fistula including three prolene stitches, which had been placed during his primary procedure, was excised. By this the entire duct could be brought out of the abdominal cavity. At the origin, the bowel was excised in a longitudinal fashion and the enterotomy was closed transversely in two layers. The abdominal wall was closed with interrupted absorbable sutures, the skin was left open. The patient recovered well from his operation; however, a surgical site infection developed despite perioperative prophylaxis and required local therapy for 4 weeks. The patient is well 3 months after surgery.
Discussion: Surgeons should be aware of this rare condition. The omphaloenteric remnant is suitable for laparoscopic repair.