Patent umbilical artery in medial umbilical fold: Cadaveric study and clinical implications

Minimally invasive surgery has become one of the most accepted surgical options across the globe. In most laparoscopic surgeries, medial umbilical fold (MUF) containing the umbilical artery (UA) serves as an important landmark for creation of peritoneal flap. 50% of gynaecological laparoscopic injuries occur at the time of entry into the anterior abdominal wall, as it involves blind insertion of the trochar or veress needle in the peritoneal cavity. Any variation in the structures of the anterior abdominal wall may affect the placement location of the trocar, which is a crucial aspect to ease the surgeon’s ability to manoeuvre the abdominal cavity. The presence of cords and/or dense ligamentous structures in the anterior abdominal wall may complicate trocar insertion and restrict the probe movement during laparoscopic procedures. Hence, the aim of the present study was to classify and observe the variations in the MUF in the anterior abdominal wall. The cadavers in the study were formalin fixed through femoral artery perfusion method. Out of the 35 (23 males; 12 female) cadavers (70 MUF), studied, 34 cadavers (69 MUF) followed the pattern of the existing classification proposed by Tokar and Yucel, (2009). However, the right MUF of one male cadaver presented, patent umbilical artery (PUA) associated with a long mesentery. Based on safe presentations for laparoscopic exploration, MUF was given grades. Grades 0 and 1 were categorised as safe as compared to grade 2 and the novel variant observed, based on the morphology of MUF. No significant difference was noted in the occurrence of safe presentations of MUF amongst males and females. MUF with a patent vessel and a mesentery may cause technical difficulties to the surgeon by decreasing the laparoscopic port work space and obscuring the view of lateral pelvic wall during surgeries. Furthermore, persistent UA can compress the ureter and vas deferens resulting in myriad of symptoms ranging from unexplainable flank pain, hydronephrosis to male infertility. Awareness of such variants is of relevance to urologists in determining the cause of these unexplained symptoms and to surgeons in determining the site of safe trocar insertion. The findings also, highlight the fact that anterior abdominal wall anatomy is not mirror image on both the sides.