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Vesico-umbilical fistula: A complication of umbilical artery cutdown
Vesico-Umbilical Fistula: A Complication of Umbilical Artery Cutdown By Feizal Waffarn, Udayakumar P. Devaskar, and Joan E. Hodgman Los Angeles, California 9 A vesico-umbilical fistula occurred following cut down for catheterization of the umbilical artery in a premature infant; a previously unreported complication. Knowledge of the variations in anatomical s t r u c t u r e of the u r a c h u s a n d umbilical a r t e r i e s a t birth will help to prevent this complication.
BUN, and creatinine were normal throughout the period of hospitalization. The infant was treated for respiratory distress and hyperbilirubinemia. On the 14tb day, an intravenous pyelogram and excretory urogram were normal. She was discharged in good health and at 6 mo follow-up had normal renal function and a negative urine culture.
INDEX WORDS: Umbilical a r t e r i a l cutdown; v e s i c o umbilical fistula; urachus.
DISCUSSION
r H E N U M B I L I C A L arterial catheteriza-
tion is unsuccessful, a paraumbilical W cutdown is an alternative method for establishing an arterial line to facilitate intensive care of the sick neonate. Details of the procedure have been recently described by Sherman. ~ CASE REPORT A 2260-g female was born to gravida 1, para 0 mother at 36 wk gestation, with an Apgar score of 8 at 1 and 5 min of age. Respiratory Distress Syndrome (RDS) developed 6 hr following delivery. Attempts at umbilical arterial catheterization were unsuccessful following which an arterial cutdown through an infraumbilical incision was performed. An Argyle 5 french catheter (Sherwood Medical Industries, St. Louis, Mo.) was advanced for a distance of 5 cm through the left umbilical artery that yielded no blood return on aspiration. The right umbilical artery was dissected but no attempt made at catheterization due to multiple defects in the vessel wall from previous attempts at catheterization. The catheter was withdrawn and the abdominal incision sutured. Three hours after the procedure, a light red serosanguineous discharge was noted from the umbilicus. The abdomen was distended and tender and a radiograph of the abdomen demonstrated dilated bowel loops without signs of peritoneal air suggestive of adynamic ileus. Increasing amounts of fluid were noted to be leaking from the umbilical stump over the next few hours. The fluid was blood-tinged and had a pH of 6, 380 m g / 1 0 0 ml of protein, 68 rag/100 ml of urea arid was negative for glucose. A diagnosis of vesicoumbilical fistula was confirmed by demonstrating indigocarmine dye leaking from the umbilical stump. The umbilical stump was reexplored, the fistula identified, traced to the apex of the bladder, and ligated. The defect was then closed in three layers. The wound healed without complications. Following surgical closure, the umbilical discharge ceased and signs of ileus disappeared during the next 12 hr. An indwelling urethral catheter was maintained for 8 days to keep the bladder decompressed. Urinalysis, urine culture,
Journal of Pech'atricSurgery, Vol. 15, No. 2 (April), 1980
In the case reported here, two possibilities exist for the creation of the vesico-umbilical fistula. The urachal lumen may have been mistaken for the lumen of the umbilical artery or the urachus may have merged with the umbilical artery resulting in the catheter entering the urachus instead of following the arterial lumen. A vesico-umbilical fistula was created secondary to recanalization of the urachus. This probably occurred during the cutdown as the leakage and abdominal distension appeared following this procedure. The urachus, particularly in the premature infant, is usually patent up to the infra-umbilical area and significant variation in its relationship to the umbilical arteries can be expected.2, 3 A knowledge of the anatomy of the infra-umbilical structures and their variations will minimize complications and increase the safety of umbilical arterial cutdown. REFERENCES 1. Sherman N J: Umbilical artery cutdown. J Pediatr surg 12:734, 1977 2. Begg RC: The urachus and umbilical fistulae. Surg Gynecol Obstet 45:165, 1927 3. H a m m o n d G, Yglesias L: The urachus: Its anatomy and associated fasciae. Anat Rec 80:271, 1941
From The Department o f Pediatrics, University o f Southern California School o f Medicine and the Newborn Division o f the Los Angeles County, University o f Southern California Medical Center, Los Angeles, Calif. Address reprint requests to Women's Hospital L925, 1240 No. Mission Road, Los Angeles, Calif. 90033. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1502~)020501.00/0
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BUN, and creatinine were normal throughout the period of hospitalization. The infant was treated for respiratory distress and hyperbilirubinemia. On the 14tb day, an intravenous pyelogram and excretory urogram were normal. She was discharged in good health and at 6 mo follow-up had normal renal function and a negative urine culture.
INDEX WORDS: Umbilical a r t e r i a l cutdown; v e s i c o umbilical fistula; urachus.
DISCUSSION
r H E N U M B I L I C A L arterial catheteriza-
tion is unsuccessful, a paraumbilical W cutdown is an alternative method for establishing an arterial line to facilitate intensive care of the sick neonate. Details of the procedure have been recently described by Sherman. ~ CASE REPORT A 2260-g female was born to gravida 1, para 0 mother at 36 wk gestation, with an Apgar score of 8 at 1 and 5 min of age. Respiratory Distress Syndrome (RDS) developed 6 hr following delivery. Attempts at umbilical arterial catheterization were unsuccessful following which an arterial cutdown through an infraumbilical incision was performed. An Argyle 5 french catheter (Sherwood Medical Industries, St. Louis, Mo.) was advanced for a distance of 5 cm through the left umbilical artery that yielded no blood return on aspiration. The right umbilical artery was dissected but no attempt made at catheterization due to multiple defects in the vessel wall from previous attempts at catheterization. The catheter was withdrawn and the abdominal incision sutured. Three hours after the procedure, a light red serosanguineous discharge was noted from the umbilicus. The abdomen was distended and tender and a radiograph of the abdomen demonstrated dilated bowel loops without signs of peritoneal air suggestive of adynamic ileus. Increasing amounts of fluid were noted to be leaking from the umbilical stump over the next few hours. The fluid was blood-tinged and had a pH of 6, 380 m g / 1 0 0 ml of protein, 68 rag/100 ml of urea arid was negative for glucose. A diagnosis of vesicoumbilical fistula was confirmed by demonstrating indigocarmine dye leaking from the umbilical stump. The umbilical stump was reexplored, the fistula identified, traced to the apex of the bladder, and ligated. The defect was then closed in three layers. The wound healed without complications. Following surgical closure, the umbilical discharge ceased and signs of ileus disappeared during the next 12 hr. An indwelling urethral catheter was maintained for 8 days to keep the bladder decompressed. Urinalysis, urine culture,
Journal of Pech'atricSurgery, Vol. 15, No. 2 (April), 1980
In the case reported here, two possibilities exist for the creation of the vesico-umbilical fistula. The urachal lumen may have been mistaken for the lumen of the umbilical artery or the urachus may have merged with the umbilical artery resulting in the catheter entering the urachus instead of following the arterial lumen. A vesico-umbilical fistula was created secondary to recanalization of the urachus. This probably occurred during the cutdown as the leakage and abdominal distension appeared following this procedure. The urachus, particularly in the premature infant, is usually patent up to the infra-umbilical area and significant variation in its relationship to the umbilical arteries can be expected.2, 3 A knowledge of the anatomy of the infra-umbilical structures and their variations will minimize complications and increase the safety of umbilical arterial cutdown. REFERENCES 1. Sherman N J: Umbilical artery cutdown. J Pediatr surg 12:734, 1977 2. Begg RC: The urachus and umbilical fistulae. Surg Gynecol Obstet 45:165, 1927 3. H a m m o n d G, Yglesias L: The urachus: Its anatomy and associated fasciae. Anat Rec 80:271, 1941
From The Department o f Pediatrics, University o f Southern California School o f Medicine and the Newborn Division o f the Los Angeles County, University o f Southern California Medical Center, Los Angeles, Calif. Address reprint requests to Women's Hospital L925, 1240 No. Mission Road, Los Angeles, Calif. 90033. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1502~)020501.00/0
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