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Herniation of the appendix through the umbilical ring following umbilical artery catheterization
Herniation of the Appendix Through the Umbilical Ring Following Umbilical Artery Catheterization By J. Biagtan, W. Rosenfeld, D. Salazar, and F. Velcek Brooklyn, N e w York 9 A case of herniation of the appendix through the umbilical ring following transection of the umbilical cord for arterial catheterization is described, After the appendix was returned into the abdominal cavity and the peritoneal edges closed, the patient had no further difficulty. "[his rare complication of catheterization can be avoided by careful palpation of the umbilical stump and use of a moist bias tape around the base of the umbilicus prior to transection of the cord.
I N C E u m b i l i c a l vessel c a t h e t e r i z a t i o n has b e c o m e a c o m m o n , r e a d i l y - p e r f o r m e d proc e d u r e in n e o n a t a l c e n t e r s , c o m p l i c a t i o n s often arise. S t u d i e s o f l a r g e n u m b e r s of cases r e p o r t a c o m p l i c a t i o n r a t e v a r y i n g f r o m 3% to 17%. 1'2 Most commonly included are infection, thrombosis, i n f a r c t i o n , a n d p e r f o r a t i o n b u t t h e r e is a g r o w i n g list of i n f r e q u e n t and u n u s u a l c o m p l i c a tions to w h i c h this c a s e o f a p p e n d i c i a l h e r n i a t i o n is a d d e d .
followed by protrusion of a fingerlike projection 1 cm long and 0.5 cm in diameter that expanded to 2-3 cm in length when the patient cried. It was thought this mass was appendix (Fig. 1). The catheterization was completed with a purse-string suture surrounding the mass and three umbilical vessels loosely placed in Wharton's Jelly. X-ray of the abdomen demonstrated that the catheter was in the artery and the tip was at the level of T 9. The pediatric surgery consultant (FV) verified that this protrusion was the vermiform appendix by identification of the ileocecal junction and the mesoappendix. Following preparation with povodine-iodine solution, the catheter was removed and the appendix gently returned to the abdominal cavity. The peritoneal edges was approximated with 4-0 slid suture. The patient was started on antibiotics. The 1RDS was mild and required only increased ambient oxygen concentration by oxygen hood. The abdomen remained soft and nondistended. Serial abdominal x-rays were unremarkable and the patient was started on oral feedings on the fourth day of life. At discharge and at 1 mo follow-up, the patient's physical examination was unremarkable. There was no evidence of an umbilical hernia or intestinal obstruction.
CASE REPORT
DISCUSSION
Baby W was a 1600-g female born by cesarean section at 34 wk gestation to a 17-yr-old primagravida. The pregnancy was complicated by severe toxemia 1 day prior to delivery. Apgar scores were 6 and 9 at 1 and 5 min. Physical examination on admission to the NICU revealed an AGA neonate with mild respiratory distress. Physical examination was otherwise unremarkable and no umbilical defect was apparent. Chest x-ray was consistent with Idiopathic Respiratory Distress Syndrome (IRDS) and because of increasing oxygen requirements, an arterial catheterization was performed at 1 hr of age. The umbilical cord was transected at 1 cm above the base. Three vessels were noted and the cord appeared grossly normal. Following insertion and while the 5 French catheter was being advanced into the artery, a small volume of clear fluid was noted oozing from the cord stump. This was
Herniation of the appendix through the u m b i l i c a l ring f o l l o w i n g t r a n s e c t i o n o f the c o r d has b e e n r e p o r t e d t w i c e previously, b u t in b o t h c a s e s grossly a p p a r e n t c o r d a b n o r m a l i t i e s w e r e p r e s e n t . In 1937 N e f f 3 r e p o r t e d a p a t i e n t w h o s e a p p e n d i x was p r e s e n t in t h e c o r d a n d an a p p e n d i c e a l fistula was c r e a t e d w h e n t h e cord was clamped and transected. Simpson 4 recently d e s c r i b e d a p a t i e n t in w h o m a s w e l l i n g at t h e c o r d base was i n c o r r e c t l y d i a g n o s e d as infilt r a t e d s o d i u m b i c a r b o n a t e s o l u t i o n following a n unsuccessful intravenous infusion through the cord. In reality, this s w e l l i n g was a s m a l l o m p h a locele t h a t c o n t a i n e d t h e a p p e n d i x w h i c h was s u b s e q u e n t l y t r a n s e c t e d at t h e t i m e o f c a t h e t e r ization. I n t h e p r e s e n t c a s e no gross a b n o r m a l i t i e s o f t h e c o r d w e r e n o t e d p r i o r to c a t h e t e r i z a t i o n or on reexamination following the procedure. The m o s t likely e x p l a n a t i o n o f t h e h e r n i a t i o n of t h e a p p e n d i x was t h e p r e s e n c e of a s m a l l fascial r i n g d e f e c t t h r o u g h w h i c h t h e p e r i t o n e a l sac m u s t have protruded.
I N D E X W O R D S : Umbilical artery catheterization.
S
From the Department of Pediatrics, Division of Newborn Medicine Department of Pediatric Surgery, Jewish Hospital and Medical Center of Brooklyn and the Downstate University of Medicine, Brooklyn, N.Y. Address reprint requests to Warren Rosenfeld, M.D., Department of Pediatrics, Neonatal Intensive Care Unit, Jewish Hospital and Medical Center of Brooklyn, 555 Prospect Place, Brooklyn, N.Y. 11238. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1505~017501.00/0 672
Journal of Pediatric Surgery, Vol. 15, No. 5 (October), 1980
UMBILICAL ARTERY CATHETERIZATION
673
Fig. 2. Moist bias tape surrounding the umbilical stump during catheterization prevents herniation, stabilizes stump for easier insertion, and provides hemotasis.
Fig. 1. Appearance of herniated appendix following catheter removal and prior to closure of the defect.
To prevent this complication, we recommend careful palpation of the umbilical ring prior to catheterization especially in preterm and black infants who have a high incidence of umbilical ring defects. Vohr et al. ~ reported that 75% of patients less than 1500 g had umbilical hernias at or before 3 mo of age. Crump 6 detected umbilical hernias in 44 of 97 (45.4%) black infants less than 1 yr of age who weighed less
than 2500 g at birth and in 182 of 437 (41.6%) weighing greater than 2500 g at birth. Another recommendation to prevent herniation of abdominal viscera through the umbilical ring is the routine use of a sterile, moist, bias tape that should be placed snugly around the umbilical stump and secured with a single tie prior to catheterization (Fig. 2). 7 This tape will not only prevent peritoneal protrusion but also provide hemostasis and stabilization of the cord stump during catheterization. This maneuver, which was not used in this case, is now a standard part of the catheterization procedure used in our unit.
REFERENCES 1. Cochran WD, Davis AT, Smith CA: Advantage and
complications of umbilical artery catheterization in the Newborn. Pediatrics 43:769, 1968 2. Symansky MR, Fox HA: Umbilical vessel catheterization: Indications, management and evaluation of the technique. J Pediatr 80:820-826, 1972 3. Neff G: Das Mechelsche Divertikel, Ergibn. d. Cher. u Orthop. 30:227, 1937
4. Simpson JS: Misdiagnosis complicating umbilical vessel catheterization. Clin Pediatr 14:727, 1975 5. Jackson DJ Moglen LH: Umbilical hernia. A retrospective study. Calif Med 113:8-11, 1970 6. Crump EP: Umbilical hernia. J Pediatr 40:214-223, 1952 7. Fox HA: personal communication
I N C E u m b i l i c a l vessel c a t h e t e r i z a t i o n has b e c o m e a c o m m o n , r e a d i l y - p e r f o r m e d proc e d u r e in n e o n a t a l c e n t e r s , c o m p l i c a t i o n s often arise. S t u d i e s o f l a r g e n u m b e r s of cases r e p o r t a c o m p l i c a t i o n r a t e v a r y i n g f r o m 3% to 17%. 1'2 Most commonly included are infection, thrombosis, i n f a r c t i o n , a n d p e r f o r a t i o n b u t t h e r e is a g r o w i n g list of i n f r e q u e n t and u n u s u a l c o m p l i c a tions to w h i c h this c a s e o f a p p e n d i c i a l h e r n i a t i o n is a d d e d .
followed by protrusion of a fingerlike projection 1 cm long and 0.5 cm in diameter that expanded to 2-3 cm in length when the patient cried. It was thought this mass was appendix (Fig. 1). The catheterization was completed with a purse-string suture surrounding the mass and three umbilical vessels loosely placed in Wharton's Jelly. X-ray of the abdomen demonstrated that the catheter was in the artery and the tip was at the level of T 9. The pediatric surgery consultant (FV) verified that this protrusion was the vermiform appendix by identification of the ileocecal junction and the mesoappendix. Following preparation with povodine-iodine solution, the catheter was removed and the appendix gently returned to the abdominal cavity. The peritoneal edges was approximated with 4-0 slid suture. The patient was started on antibiotics. The 1RDS was mild and required only increased ambient oxygen concentration by oxygen hood. The abdomen remained soft and nondistended. Serial abdominal x-rays were unremarkable and the patient was started on oral feedings on the fourth day of life. At discharge and at 1 mo follow-up, the patient's physical examination was unremarkable. There was no evidence of an umbilical hernia or intestinal obstruction.
CASE REPORT
DISCUSSION
Baby W was a 1600-g female born by cesarean section at 34 wk gestation to a 17-yr-old primagravida. The pregnancy was complicated by severe toxemia 1 day prior to delivery. Apgar scores were 6 and 9 at 1 and 5 min. Physical examination on admission to the NICU revealed an AGA neonate with mild respiratory distress. Physical examination was otherwise unremarkable and no umbilical defect was apparent. Chest x-ray was consistent with Idiopathic Respiratory Distress Syndrome (IRDS) and because of increasing oxygen requirements, an arterial catheterization was performed at 1 hr of age. The umbilical cord was transected at 1 cm above the base. Three vessels were noted and the cord appeared grossly normal. Following insertion and while the 5 French catheter was being advanced into the artery, a small volume of clear fluid was noted oozing from the cord stump. This was
Herniation of the appendix through the u m b i l i c a l ring f o l l o w i n g t r a n s e c t i o n o f the c o r d has b e e n r e p o r t e d t w i c e previously, b u t in b o t h c a s e s grossly a p p a r e n t c o r d a b n o r m a l i t i e s w e r e p r e s e n t . In 1937 N e f f 3 r e p o r t e d a p a t i e n t w h o s e a p p e n d i x was p r e s e n t in t h e c o r d a n d an a p p e n d i c e a l fistula was c r e a t e d w h e n t h e cord was clamped and transected. Simpson 4 recently d e s c r i b e d a p a t i e n t in w h o m a s w e l l i n g at t h e c o r d base was i n c o r r e c t l y d i a g n o s e d as infilt r a t e d s o d i u m b i c a r b o n a t e s o l u t i o n following a n unsuccessful intravenous infusion through the cord. In reality, this s w e l l i n g was a s m a l l o m p h a locele t h a t c o n t a i n e d t h e a p p e n d i x w h i c h was s u b s e q u e n t l y t r a n s e c t e d at t h e t i m e o f c a t h e t e r ization. I n t h e p r e s e n t c a s e no gross a b n o r m a l i t i e s o f t h e c o r d w e r e n o t e d p r i o r to c a t h e t e r i z a t i o n or on reexamination following the procedure. The m o s t likely e x p l a n a t i o n o f t h e h e r n i a t i o n of t h e a p p e n d i x was t h e p r e s e n c e of a s m a l l fascial r i n g d e f e c t t h r o u g h w h i c h t h e p e r i t o n e a l sac m u s t have protruded.
I N D E X W O R D S : Umbilical artery catheterization.
S
From the Department of Pediatrics, Division of Newborn Medicine Department of Pediatric Surgery, Jewish Hospital and Medical Center of Brooklyn and the Downstate University of Medicine, Brooklyn, N.Y. Address reprint requests to Warren Rosenfeld, M.D., Department of Pediatrics, Neonatal Intensive Care Unit, Jewish Hospital and Medical Center of Brooklyn, 555 Prospect Place, Brooklyn, N.Y. 11238. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1505~017501.00/0 672
Journal of Pediatric Surgery, Vol. 15, No. 5 (October), 1980
UMBILICAL ARTERY CATHETERIZATION
673
Fig. 2. Moist bias tape surrounding the umbilical stump during catheterization prevents herniation, stabilizes stump for easier insertion, and provides hemotasis.
Fig. 1. Appearance of herniated appendix following catheter removal and prior to closure of the defect.
To prevent this complication, we recommend careful palpation of the umbilical ring prior to catheterization especially in preterm and black infants who have a high incidence of umbilical ring defects. Vohr et al. ~ reported that 75% of patients less than 1500 g had umbilical hernias at or before 3 mo of age. Crump 6 detected umbilical hernias in 44 of 97 (45.4%) black infants less than 1 yr of age who weighed less
than 2500 g at birth and in 182 of 437 (41.6%) weighing greater than 2500 g at birth. Another recommendation to prevent herniation of abdominal viscera through the umbilical ring is the routine use of a sterile, moist, bias tape that should be placed snugly around the umbilical stump and secured with a single tie prior to catheterization (Fig. 2). 7 This tape will not only prevent peritoneal protrusion but also provide hemostasis and stabilization of the cord stump during catheterization. This maneuver, which was not used in this case, is now a standard part of the catheterization procedure used in our unit.
REFERENCES 1. Cochran WD, Davis AT, Smith CA: Advantage and
complications of umbilical artery catheterization in the Newborn. Pediatrics 43:769, 1968 2. Symansky MR, Fox HA: Umbilical vessel catheterization: Indications, management and evaluation of the technique. J Pediatr 80:820-826, 1972 3. Neff G: Das Mechelsche Divertikel, Ergibn. d. Cher. u Orthop. 30:227, 1937
4. Simpson JS: Misdiagnosis complicating umbilical vessel catheterization. Clin Pediatr 14:727, 1975 5. Jackson DJ Moglen LH: Umbilical hernia. A retrospective study. Calif Med 113:8-11, 1970 6. Crump EP: Umbilical hernia. J Pediatr 40:214-223, 1952 7. Fox HA: personal communication