Umbilical endometriosis: a radical excision with laparoscopic assistance

1. Introduction Spontaneous primary (i.e. not secondary to prior surgery) umbilical endometriosis was first described by Villar in 1886 and represents 75% of all cases of umbilical localisations. The navel is the most common site of cutaneous endometriosis, occurring between 0.5% and 1.2% of all cases of endometriosis. Symptoms are characterised by local spontaneous cyclic bleeding, erythema, edema and pain. Although treatment is typically surgical, in literature the approach varies from simple excision under local anesthesia to omphalectomy. We here present seven cases of umbilical endometriosis treated with radical surgery with a laparoscopically-assisted approach with a complete and long-term disease-free follow-up. 2. Cases All patients (n = 7) operated by the first Author (L.F.) for resection of umbilical endometriosis between 1996 and 2000 at the University Hospital of Verona, and between 2001 and 2003 at the University Hospital of Milano, were assessed retrospectively at the tertiary referral centre for the study and treatment of endometriosis of the latter. Mean age of the patients was 31 years (range, 32–41). Preoperative work-up included a transcutaneous and transvaginal ultrasound scan (US). Main characteristics of the patients are described in Table 1. Four of the 7 patients were referred to our Centre for a relapse of umbilical endometriosis, respectively one and six years subsequently to their first surgery. All patients presented with an erythematous and edematous umbilical nodule, causing catamenial pain in all cases and bleeding in four, apparently involving the entire umbilicus at transcutaneous US. The surgical procedure consists in an omphalectomy with a concomitant laparoscopic approach. A periumbilical margin-free incision is performed and the fascia is reached, which is temporarily left intact. A Verres needle is inserted through the inferior margin of the incision and adequate pneumoperitoneum is obtained. A 10 mm trocar is inserted through this entrance, and lateral ancillary ports are also inserted, including a 10 mm port on the right. The pelvis is examined and eventually treated for endometriotic localisations or other lesions, and tubal patency can be tested in patients with associated infertility. Following the laparoscopic procedure, the trocar is moved into the right axillary access. Under laparoscopic vision the previous periumbilical incision is transcutaneously completed to include the fascia and peritoneum (Fig. 1A). The navel is excised en bloc (Fig. 1B), The peritoneum and fascia are then sutured, prior to fixation of the periumbilical skin to the latter. The skin is closed with interrupted absorbable 2–0 vicryl sutures. Histological examination confirmed the presence of intrafascial endometriosis in all cases. Follow-up consisted in semestral assessments in the first year and annual examinations subsequently. No relapses of the umbilical lesion have occurred, while endometriotic ovarian cysts recurred in only one patient. 3. Discussion This report appears to show that the radical excision of umbilical endometriotic lesions prevents recurrences and yields good aesthetic results at an extensive follow-up (Fig. 1C). The systematic use of laparoscopy aids in the adequate excision of the umbilical lesion and the accurate reconstruction of the fascial and subfascial planes, and also allows the surgeon to identify and eventually treat concomitant pelvic disease. Mechsner et al suggest laparoscopy in order to concomitantly treat eventual pelvic endometriotic lesions, which in our study were present in 2 patients, and uterine myomas. Symptomatic patients complaining of pelvic pain, menorrhagia or other exacerbating symptoms should be examined laparoscopically for exclusion of pelvic disease. The indication for this technique is corroborated by the presence of relapses after superficial treatments which are only rarely reported in the literature as a result of the absent or brief follow-up. The histopathological examination, in which the subfascial structures are shown to be involved, also supports omphalectomy. As there are no standard surgical techniques for the removal of umbilical endometriosis, follow-up studies on treated patients are warranted. The choice of such radical treatment also takes into account the two most ascribed etiopathogenetic theories. Accordingly, the endometriotic lesions may result from hematogenous or lymphatic spread. Lymphatic vessels indeed connect the peritoneal cavity to the umbilicus along the obliterated umbilical vessels. Scott proposed migration of pelvic contents to the umbilicus via the latter, after determining that dye injected into the pelvic cavity could be isolated in the umbilicus. Other studies have reported the presence of endometrial tissue in the periumbilical lymphatic tissue. Alternatively, endometriosis in this particular site may also develop through metaplasia of the urachus remnants. In our case series only two patients had concomitant pelvic endometriosis. Interestingly, this finding reflects the data in the literature in which the majority of patients (73.1%) had no history of pelvic endometriosis. Hormonal therapy with oral contraceptives, progestins and gonadotropin-releasing hormone analogues have been reported in the literature with inconsistent and incomplete success. Although a medical treatment can be considered, the treatment of choice in these patients should be that of excisional surgery so as to avoid lesion relapse and the risk of oncogenic transformation. Four of these cases had undergone a previous umbilical treatment, respectively by a general surgeon in two cases, a dermatologist and a gynecologist. Admittedly this is a preliminary study which is limited by the relative paucity of cases in a nonrandomized setting and by the dyshomogeneous clinical and surgical histories of the patients. Despite umbilical endometriosis is a rare finding, this relatively small case series treated by laparoscopically-assisted omphalectomy shows complete resolution of the lesion and symptoms, along with good aesthetic results at a long-term follow-up. Conflicts of interest The material contained in the manuscript has not been published nor is being submitted elsewhere for publication. None of the authors has any conflict of interest related to the material of the manuscript submitted. Funding None. Ethical approval Our study did not require approval from the local Institutional Review Board. 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