A case report on umbilical endometriosis

Kewithinwangbo Newme, Ranendra Hajong, Hajong R, Raguangjienlungle Newme, Newme R, Newme K, Keyikawangbo Newme
Journal of family medicine and primary care · 2021 · vol. 10(7) , pp. 2716–2717 · doi:10.4103/jfmpc.jfmpc_2375_20 · PMID:34568162 · PMC8415647 · W3191290453
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This case report documents an instance of umbilical endometriosis occurring after laparoscopic umbilical hernia repair.

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This case report describes a 42-year-old woman who developed an umbilical nodule with cyclic bleeding three months after undergoing laparoscopic cholecystectomy and hernia repair, despite no prior history of abdominal surgery. The patient presented with dysmenorrhea and blood discharge from the site, leading to a diagnosis of primary umbilical endometriosis, also referred to as vicarious menstruation from an umbilical adenoma. Although surgical excision is typically the treatment of choice for symptomatic cases due to low recurrence rates, this patient opted for conservative management and remained asymptomatic following menopause. This paper is centrally about endometriosis — specifically the rare presentation of primary umbilical endometriosis occurring without previous surgical intervention or known risk factors.

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Abstract

Endometriosis is generally common benign disease manifested by the presence of uterine tissue outside the uterus. Umbilical endometriosis as such is rare entity but many a time it may go unnoticed to general physician if no symptoms arises from it. The documented case of umbilical endometriosis case is below 100 as per the case reports research. Here, in the case report we present an umbilical endometriosis arises after a laparoscopic and umbilical hernia repair procedure.
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Cases

A 42-year-old lady came for laparoscopic cholecystectomy and umbilical hernia repair in our institution. The clinical examination was carried out preoperative day. Nothing physical abnormality was noted on examination except the small umbilical hernia. No history of prior surgery. The umbilical port is created through Hasson's method and the umbilical defect is approximately 1.5 cm in size. Laparoscopic cholecystectomy was performed first and after the removal of umbilical port, a primary repair of umbilical port was done using nonabsorbable suture. Intraoperatively, a quick glance on the liver, bowel, pelvic organs and cul-de sac was done and was looked normal. The procedure was uneventful and discharged after 2 days. After 3 months she came back in outpatient department, complaining of blood coming from umbilicus and had a history of dysmenorrhea. On examination, a small nodule approximately 1 cm × 1 cm in size was seen in the umbilicus just below the supraumbilical incision site [ Figure 1 ]. From there blood had stained the adjacent periumbilical region. A diagnosis of vicarious menstruation from umbilical adenoma was made which was concurred by opinions from the gynecologist. The patient was informed about treatment options including chances of developing malignancies in the long run, but she chose for conservative management. So she was being followed-up in outpatient department for 3 years and blood had stopped trickling out from there after she attained menopause recently. Till date the size of the nodule is static. Showing umbilical nodule with supraumbilical scar

Intro

Endometriosis is characterized by the presence of endometrial tissue outside the uterus.[ 1 ] The umbilical endometriosis is a rare entity and its incidence is approximately about 0.5–1%.[ 2 ] It is found that cutaneous endometriosis is more common at surgical sites, i.e., following cesarean sections, hysterectomy, laparoscopy surgery, and any other abdominal surgeries.[ 3 ] Without any history of prior surgery, umbilical endometriosis is rare.[ 4 ] There are many differential diagnosis for umbilical nodule, i.e., benign condition (granuloma, abscess, sebaceous cyst, lipoma, hemangima, umbilical hernia, umbilical endometriosis, keloid, desmoids tumor, and infection) and malignant condition (Sister Mary Joseph nodule, melanoma, adenocarcinoma, sarcoma, and lymphoma).[ 3 ]

Conclusion

From the many literatures and studies reviewed, it is noteworthy to say that umbilical endometriosis is not a common disease. Even though there is a lot of differential diagnosis for umbilicus disease, but umbilical endometriosis incidence is higher after any postoperative procedures. Therefore for the benefit of primary care physicians, umbilical endometriosis is considered to be as a differential in a young and menstruating female if a nodule appears in umbilicus with associated vicarious menstruation. Because umbilical endometriosis can turn malignant, the treatment options should be planned after due consultations with the patients. The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Nil. There are no conflicts of interest.

Discussion

According to some theory, endometriosis commonly involves ovaries, pouch of Douglas, fallopian tubes, sigmoid colon, broad ligament, appendix, and round ligaments. And it is estrogen dependent. It is found that umbilical endometriosis incidence is high after c-section operation.[ 5 ] Another theory says that it could be due to migration of endometrial cells into the umbilicus through urachus, umbilical vessels, lymphatic system, and abdominal cavity.[ 2 ] In primary umbilical endometriosis, the etiology is unknown; it is termed secondary when it arises in scar tissue after any abdominal surgeries. The presenting symptoms is umbilical swelling, pain, menstrual disorder at the same time, bleeding from umbilicus, and sometime asymptomatic.[ 6 ] Malignant transformation has been reported in 0.3–1% of cutaneous endometriosis. It affects mostly reproductive age groups.[ 7 ] Umbilical nodule could be dark or brown in color. Ultrasonography could give information regarding the size, nature of lesion, and relation with the adjacent tissues in cutaneous endometriosis. Computed tomography usually showed a solid well-circumscribed lesion and its extension, in case of umbilical endometriosis.[ 8 ] Magnetic resonance imaging gives a valuable information regarding a pelvic endometriosis and to exclude others disease involving a umbilicus like granuloma, sister Mary Joseph nodule.[ 9 ] Surgical excision is considered to be a treatment of choice in symptomatic umbilical endometriosis.[ 2 ] It is noted that after excision recurrence is rare.[ 6 ] Hormonal therapy is being advocated for relief of symptom, i.e., size of lesion and pain especially in case of pelvic endometriosis, but its recurrence is high.[ 10 ]

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