{"paper_id":"7e96cf38-5714-4872-ab62-0757071ef553","body_text":"Obstet Gynecol Res 2018; 1 (3): 072-074  DOI: 10.26502/ogr011 \nObstetrics and Gynecology Research - Vol. 1 No. 3 - Sep 2018.  72 \nCase Report \nUmbilical Endometriosis: Case Report and Review of Current \nManagement \nAkhter F, Mallick R*, Ball E \nRoyal London\n Hospital, London, England, UK \n*Corresponding Author: Mallick R, Royal London Hospital, London, England, UK, Tel: 07411617143; E-mail:\nrmallick@doctors.org.uk  \nReceived: 02 May 2018; Accepted: 16 May 2018; Published: 18 May 2018 \nAbstract \nUmbilical endometriosis (UE) remains a rare occurrence with an incidence of approximately 0.5–1.0% in all cases \nof endometriosis. It can be subdivided into primary UE (Villar’s nodule), developing spontaneously, or secondary \nfollowing previous abdominal surgery and is usually due to the iatrogenic seeding of endometrial tissue. We present \nthe case of a 35-year-old patient who presented with a large umbilical nod ule that was successfully  treated with \ncomplete surgical excision and reconstruction of the umbilicus and review the wider literature. \nKeywords: Umbilical; Endometriosis \n1. Introduction\nEndometriosis is defined as the presence of endometrial tissue out with the uterine cav ity and it affects between 6–\n10% of all women of reproductive age [1]. The areas most commonly affected  include the uterosacral ligaments, \nrecto-sigmoid colon, recto-vaginal septum, vagina and bladder. Endometriosis can also develop in areas out with the \npelvis of which the umbilicus is the comment cutaneous s ite, however, it still remains a rare occurrence with an \nincidence of approximately 0.5–1.2% in all cases of endometriosis [2]. Primary umbilical endometriosis was first \ndescribed by Villar in 1886, and it represents 75% of all cases of umbilical endometriosis [2]. We describe a case of \nsecondary umbilical endometriosis, developing after a previous laparoscopy, and our surgical approach to \nmanagement involving radical excision with a laparoscopic assisted approach. \n2. Case Report\nA 35-year-old patient presented to the gynaecology clinic with a history of worsening pelvic pain and cyclical \numbilical bleeding on a background of grade 4 endometriosis, having undergoing a laparoscopy and excision of the \nendometriosis 2 years previously. Examination revealed a 3cm tender nodule in the umbilicus, a fixed uterus and \n\nObstet Gynecol Res 2018; 1 (3): 072-074        DOI: 10.26502/ogr011  \nObstetrics and Gynecology Research - Vol. 1 No. 3 - Sep 2018.  73 \nretro-cervical tenderness. Subsequent  MRI suggested an umbilical endometriotic nodule with retro-cervical \nendometriosis and findings at the time of her laparoscopy were of grade 4 endometriosis and a 3cm umbilical \nendometriotic nodue (Figure 1). Following laparoscopic excision of her pelvic endometriosis the umbilical nodule \nwas excised. A circumferential incision was made around the nodule using diathermy, ensuring full excision with \ngood margins. The underlying fascia was closed using 2/0 polyglactin (Vicryl ®) sutures and the umbilicus was then \nreconstructed using 2/0 poligl ecaprone (Monocryl ®) suture s giving a good aesthetic result. The whole procedure \nwas performed with laparoscopic assistance to ensure ade quate excision and complete closure of the excised area. \nHistology confirmed endometriosis and follow up 6 months later confirmed a good aesthetic result with no evidence \nof recurrence. \nFigure 1: Endometriotic umbilical nodue. \n3. Discussion\nPrimary umbilical endometriosis, the more common form of umbilical endometriosis, develops spontaneously in the \nabsence of any previous abdominal surgery. The exact pathogenesis is unknown, however possible theories include \nthe spread of endometrial cells to the umbilicus through the abdominal cavity, via the lymphatic system or through \nthe embryonic remnants in the umbilical folds [3-5]. Secondary umbilical endometriosis develops following \nprevious surgery (caesarean section, abdominal hysterectom y, appendicectomy, laparoscopy  etc.) Scholefield et al. \n[6] and is due to iatrogenic seeding of endometrial tissue. The clinical features include an umbilical swelling (90%), \noften associated with cyclical pain (81.5%) and bleeding (49.2%). The differential diagnoses include granuloma, \numbilical polyps, haemangioma, melanocytic nevus, seborrhoeic keratosis, granular cell tumour and umbilical \nhernia. Investigations may include an ultrasound to assess  the echogenicity and vascular involvement. MRI can also \nbe helpful, although no imaging modality is truly diagnos tic. Medical treatments such as the contraceptive pill or \nGnRH analogues are an option and can be effective in diminishing symptoms temporarily, however after cessation \nof hormonal treatment symptom recurrence is common [1]. The definitive management involves surgery, which can \nvary from superficial diathermy to the more radical omphalectomy with a concomitant laparoscopic approach. This \n\n\nObstet Gynecol Res 2018; 1 (3): 072-074        DOI: 10.26502/ogr011  \nObstetrics and Gynecology Research - Vol. 1 No. 3 - Sep 2018.  74 \nallows for total excision of the umbilicus and repair of the underlying fascia and reconstruction of the umbilicus. \nAnother option is local resection of the endometriotic tis sue and sparing of the umbilicus. Whilst there is no real \ndata on follow up of these surgically treated cases, Fedele  et al. [7] described in thei r case series recurrence of \numbilical endometriosis in those managed with superficial surgical approach [7]. They described a radical en bloc \nexcision of the umbilicus including the fascia and peroti neum, with subsequent histology confirming intrafascial \nendometriosis in all of those cases. This would support a more radical approach to surgery aided by laparoscopy to \nenable complete excision of umbilical endometriosis and reduce local recurrence. The use of laparoscopy also \nallows the extent of the nodule to be explored and ensures adequate excision of the lesion and the accurate \nreconstruction of the fascial planes, whilst also allowing concomitant pelvic disease to be treated.  \nDeclaration of Interest \nThe authors report no declaration of interest \nReferences \n1. Giudice LC, Kao LC. Endometriosis. Lancet 364 (2004): 1789-1799.\n2. Victory R, Diamond MP, Johns DA. Villar's nodule: a case report and systematic literature review of\nendometriosis externa of the umbilicus. J Minim Invasive Gynecol 14 (2007): 23-32.\n3. Efremidou EI, Kouklakis G, Mitrakas A, et al. Primary umbilical endometrioma: a rare case of spontaneous\nabdominal wall endometriosis. Int J Gen Med 5 (2012): 999-1002.\n4. Theunissen CIJM, Ijpma FFA. Primary umbilical endometriosis: a cause of a painful umbilical nodule.\nJournal of Surgical Case Reports (2015): rjv025.\n5. Fancellu A, Pinna A, Manca A, et al. Primary umb ilical endometriosis. Case report and discussion on\nmanagement options. Int J Surg Case Rep 4 (2013): 1145-1148.\n6. Scholefield HJ, Sajjad Y, Morgan PR. Cutaneous endometriosis and its associa tion with caesarean section\nand gynaecological procedures. J Obstet Gynaecol 22 (2002): 553-554.\n7. Fedele L, Frontino G, Bianchi S, et al. Umbilical endometriosis: a radical excision with laparoscopic\nassistance. Int J Surg 8 (2010): 109-111.\nThis article is an open access article distributed under the terms and conditions of the\nCreative Commons Attribution (CC-BY) license 4.0 \nCitation: Akhter F, Mallick R, Ball E. Umbilical Endometriosi s: Case Report and Review of Current Management. \nObstetrics and Gynecology Research 1 (2018): 072-074.","source_license":"CC0","license_restricted":false}