Abstract
Umbilical hernias are rather common in the General Surgery clinic; however, endometriosis of an umbilical hernia is rare. It is especially unusual to have endometriosis of an umbilical hernia spontaneously occur compared to occurring at a site of a prior surgery. We present a case of spontaneous endometriosis of an umbilical hernia without prior surgery to her umbilicus. She had not presented with the usual symptoms of endometriosis and it was not considered as a diagnosis prior to surgery. Umbilical endometriosis is rare but usually occurs after prior laparoscopic surgery. We believe this is the second reported case in the English literature and the first such case reported from North America of spontaneous endometriosis of an umbilical hernia. This case highlights the importance of a full review of systems and qualifying the type and occurrence of pain. Additionally, it is always important to analyze surgical specimens in pathology to avoid errors in diagnosis.
Keywords: umbilical hernia, endometriosis, primary hernia, umbilical
Introduction
Umbilical hernia repairs are very common procedures for general surgeons. It is the second most common hernia procedure after inguinal hernia repairs.1 Ninety percent of adult umbilical hernias are acquired. Risk factors for an umbilical hernia include conditions that increase intra-abdominal pressure such as COPD, constipation, obesity, and multiparity. Endometriosis of an umbilical hernia is exceptionally rare, noted to only occur in 0.5–1% of all patients with endometrial ectopia.2 Here we discuss such a case.
Case Presentation
A 34-year-old woman presented to the general surgery clinic with a six year history of an umbilical bulge and pain two to three times per month. Her only pertinent medical history was two prior Cesarean sections with the last performed ten years prior. She denied any prior laparoscopic procedures or surgeries on her umbilicus. The bulge had not grown in size, but had become more bothersome over time. Physical exam revealed a 1 cm non-reducible hernia at the umbilicus. Abdominal ultrasound (Figure 1) showed a 1.7 × 1.5 × 1.3 cm fat containing hernia arising from a sub-centimeter fascial defect.
Figure 1.
The ultrasound demonstrates a 1.7 × 1.5 × 1.3cm pocket containing herniated tissue contiguous and isoechoic to the peritoneal fat via a subcentimeter fascial defect. No signs of incarcerated bowel. Impresssion: Uncomplicated fat-containing umbilical hernia.
The patient went to the operating room for an elective open umbilical hernia repair. There appeared to be a small amount of incarcerated pre-peritoneal fat within a 1 cm fascial defect. The fat could not be reduced and was thus resected and sent to pathology. The hernia itself was primarily repaired without difficulty.
Unexpectedly, pathology analysis (Figure 2) revealed endometriosis involving fat and connective tissue. Upon further questioning at her post-operative visit, the patient noted that her umbilical pain did significantly worsen during her menstrual cycles with associated lower abdominal and pelvic pain. She was ultimately referred to the gynecology service for further management of her endometriosis.
Figure 2.
The excised tissue has scattered foci of endometrial tissue, including gland epithelium and stroma, with associated inflammation and scarring.
Discussion
Endometriosis is a benign condition with endometrial glands and stroma outside the normal uterine cavity.3 Endometriosis is estimated to affect approximately 5%–15% of women, and most patients are in their fourth decade of life. It is often accompanied with infertility and catamenial abdominal pain3. Endometriosis most commonly occurs in the pelvis, involving the ovaries, broad ligament, recto-sigmoid colon, and the appendix. The condition can also develop in surgical scars, especially after C-sections and in laparoscopic port sites, but occasionally occurs spontaneously. Umbilical endometriosis is only estimated to occur in 0.5%–1% of all patients with endometrial ectopia2.
Although there have been over 120 cases of umbilical endometriosis reported, this is only the fifth reported case of spontaneous umbilical endometriosis within a primary umbilical hernia.2,5 However, this is only the second reported case in the English literature and the first such case reported from North America.
Conclusion
Surgical site associated umbilical endometriosis is rare and spontaneous umbilical endometriosis is even more so. It is important to elicit a thorough history from the patient, specifically inquiring about the occurrence of pain, whether it is cyclic and worse during her menstrual cycles. Endometriosis can be easily mistaken for incarcerated pre-peritoneal fat and any suspicion should prompt a resection and pathologic examination. This patient will be referred to gynecology for further evaluation of endometriosis as a cause of her cyclic pelvic pain.
Disclaimer
The views expressed in this case report are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
Conflict of Interest
The authors declare that there are no conflicts of interest regarding the publication of this paper.
References
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