Book - Umbilicus (1916) 14
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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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Chapter XIV. Persistence of the Omphalomesenteric Vessels
Historic sketch.
Remnants of the omphalomesenteric vessels at the mesentery.
Omphalomesenteric vessels accompanying Meckel's diverticulum or a patent omphalomesenteric
duct. Persistence of the omphalomesenteric artery in the bases of umbilical polyps. An omphalomesenteric vessel lying perfectly free in the abdomen. Fatal obstruction due to remnants of the omphalomesenteric vessels.
In the earliest stages of the embryo the omphalomesenteric arteries are two in number. They arise from a plexus of from two to four small vessels, coming directly from the aorta, and pass out one on each side of the yolk-sac.
The left artery disappears, the right persists and follows the omphalomesenteric duct, to terminate in a network which covers the entire yolk-sac. The proximal portion of the right omphalomesenteric artery later becomes the superior mesenteric artery.
The omphalomesenteric veins, in the beginning, are two in number. The right disappears, but the left collects the blood from the entire yolk-sac and from the omphalomesenteric duct, and in the liver anastomoses with the left umbilical vein. Before entering the liver it receives tributaries from the intestine — from the superior mesenteric vein (Fig. 7).
A reference to Fig. 6, p. 6, Fig. 7, p. 7, Fig. 8, p. 8, Fig. 10, p. 10, Fig. 11, p. 11, Fig. 12, p. 12, Fig. 13, p. 13, Fig. 14, p. 14, Fig. 15, p. 15, and Fig. 33, p. 32, will serve to give a very clear idea of the origin and course of the omphalomesenteric vessels during the various months of fetal life.
The omphalomesenteric vessels, as a rule, totally disappear, but occasionally persist, sometimes independently, sometimes associated with remnants of the omphalomesenteric duct (Fig. 145). When one realizes that in every human being these structures were at one time present, it is remarkable that remnants of them are not more frequently found.
According to Fitz, Meckel was familiar with remnants of the omphalomesenteric vessels.
An observation made by Ruge in 1877 is of interest. He rejDorts the discovery, in the body of a new-born child, of a cord the thickness of a linen thread for 2 cm., and then of hair-like thinness for 1.5 cm. ; it ran between the mesentery of the small bowel and the tissue around the right umbilical artery, just before its entrance into the abdominal wall. Ruge further described the projection of a delicate, thread-like process with a knobbed end, from the mesentery near the intestine, and a short distance above the cecum. He then makes the statement that floating threads with rounded ends may often be found on the mesentery or near the navel, and are derived from the omphalomesenteric vessels or the duct.
Tillmanns, in 1882, said that occasionally remains of the fetal omphalomesenteric
242
PERSISTENCE OF THE OMPHALOMESENTERIC VESSELS.
243
vessels are seen as strings of various forms — threads or canals extending from the
inner surface of the umbilicus, not to the point of the diverticulum, but directly to the
mesentery. Thus, Schroeder had relatively often observed such pictures in new-born
cats, dogs, and rabbits, although he acknowledged that they are more rare in man.
Fitz, writing in 1884, said that the vitelline duct is not only composed of layers of tissue equivalent to those forming the coats of the intestine, but is also accompanied by blood-vessels. These are the omphalomesenteric or vitelline arteries and veins, which course along its surface and ramify over the walls of the umbilical vesicle. Coincidently with the atrophy of the vitelline duct these vessels also become atrophied and eventually disappear, with the elimination of the former. The progressive shrinkage and eventual disappearance of the vitelline duct, however, do not necessitate the atrophy of these vessels.
In Fig. 21, p. 20, from a human embryo 12 cm. long, is seen a small filament attached at one end to the umbilicus, and at the other end lying perfectly free. It is a remnant of the omphalomesenteric vessels.
Remnants of the Omphalomesenteric Vessels at the Mesentery. — Fitz says that soon after his attention had been drawn to persistence of the omphalomesenteric vessels he examined the body of a man who had died of chronic tuberculosis at the Massachusetts General Hospital. There were two tuft-like projections from the upper surface of the mesentery, each half an inch long and about half an inch apart. They were about two inches distant from the portion of the ileum lying some three feet above the ileocecal valve. The peritoneum, covering them was normal in appearance, and the mesentery elsewhere was free from all abnormal changes. The peritoneum in the vicinity of the navel was examined, but with negative results. Fitz says that since then repeated examinations have been made
with reference to what might be regarded as vitelline remains, but with indifferent success.
Omphalomesenteric Vessels Accompanying Meckel's Diverticulum or a Patent Omphalomesenteric Duct. — Fig. 25, p. 24, and Fig. 26, p. 24, show very clearly the relation of the omphalomesenteric vessels to Meckel's diverticulum. Fig. 27, p. 24, represents the same vessels passing from their point of origin to the umbilicus, when no trace of the vitelline duct remains.
Fitz says that the existence of the omphalomesenteric vessels, their relation to the omphalomesenteric duct, and their occasional persistence, entire or in part, were well known to Meckel. Their transformation into fibrous cords was likewise familiar to this author. He quotes Meckel* as saying: " Quite recently I found them in a child of three months, arising, as usual, from the superior mesenteric
- Meckel: Arch. f. d. Physiologie, 1809, ix, 439.
Fig. 145. — An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord. (Schematic.)
This picture illustrates a condition that occasionally exists. The diverticulum, as a rule, springs from the outer or convex surface of the bowel. The origin of the omphalomesenteric vessels from those of the mesentery is clearly seen. Where the omphalomesenteric duct is attached to the umbilicus by a fibrous cord, this usually represents the obliterated portion of one of the omphalomesenteric vessels.
244 THE UMBILICUS AND ITS DISEASES.
artery and vein, running along the entire length of the diverticulum, and converted at its end into a solid thread several inches long and hanging free. "
Hue, when making an autopsy on a child dead of prolapsus of the bowel through a patent omphalomesenteric duct, found a persistence of the omphalomesenteric artery. Deve, who took part in the discussion on Hue's case, mentioned a case in which the artery also persisted. Stierlin, while removing a patent omphalomesenteric duct, noted that an artery was injured. It was isolated, tied off, and dropped back into the abdomen. It was a patent omphalomesenteric artery.
PERSISTENCE OF THE OMPHALOMESENTERIC ARTERY IN THE BASES OF
UMBILICAL POLYPS.
Quite frequently, when these small growths are being cut off, a vessel spurts, which is undoubtedly a patent omphalomesenteric artery. In Case 2, recorded by Lannelongue and Fremont, when the polyp was cut off, there was hemorrhage from a small artery. Pestalozza, in 1889, reported a case in which the omphalomesenteric vein in the cord of a child at term was still patent.
AN OMPHALOMESENTERIC VESSEL LYING PERFECTLY FREE IN THE ABDOMEN.
One of the most interesting cases of this character was reported by Spangenberg* in 1819. In the body of a young man, twenty years old, he found what he regarded as an open omphalomesenteric vessel. It could be followed to within half an inch of the navel, where it became a delicate ligament and was lost in the umbilical ring. It descended from the navel between the epigastric veins, on the posterior surface of the peritoneum, to which it was united by fibrous tissue, to nearly midway between the umbilicus and pubes; then, leaving the wall of the abdomen as a thin round cord, it crossed the abdominal cavity between the coils of small intestine, passed beneath the intestines toward the spine, somewhat to the left, and emptied into a bifurcation of the main trunk of the superior mesenteric vein. The vessel was wholly free throughout its entire course, nowhere adhering to the intestine, and was enveloped in a fibrous sheath. It was open to within two inches of the navel, and a small quantity of thin blood from the mesenteric vein was admitted as far as its middle. Its walls for three inches from its origin from the mesentery were collapsed, like those of any other vein, but from this point onward the vessel was of denser structure and very smooth externally. It had no branches, and in texture it resembled in all respects the umbilical vein, which later was found open through half its course. The appearance of the navel as seen from without did not vary from that of other normally formed umbilical depressions.
From the cases just cited it is perfectly clear that one or both of the omphalomesenteric vessels may persist in part or as a whole.
FATAL OBSTRUCTION DUE TO REMNANTS OF OMPHALOMESENTERIC VESSELS.
Falk, King, and Mahomed have each recorded a case in which the remnant of an omphalomesenteric vessel appeared to be the cause of intestinal obstruction.
Fitz referred to the case reported by Falkf in 1835. The patient was a man,
- Spangenberg: Deutsches Arch. f. d. Physiologie, 1819, v, 87.
t Falk: De Ileo e Diverticulis, adieeta Morbi Historia, 1835, 18.
PERSISTENCE OF THE OMPHALOMESENTERIC VESSELS.
245
twenty years of age, who had a diverticulum 43^ inches long. Two feet above the ileocecal valve a solid, pseudomembranous ligament, V/^ inches long, ran from its apex to the abdominal wall, an inch from the umbilicus. Uniting the diverticulum and the mesentery was a band, and this apparently had caused an intestinal obstruction. Falk states that diverticula in themselves are not of much importance in producing disturbances of the intestine. But where the umbilical vessels are still adherent and hang off as threads in the abdominal cavity, they may become agglutinated to the organs of the abdomen and thus cause volvulus.
In 1843, King described a case of fatal intestinal obstruction in which an adventitious cord was found passing from the mesentery to Meckel's diverticulum. The patient was a boy fourteen months old. After the cord came away on the eleventh day there was a thin, yellow, slightly odorous discharge from the umbilicus. Poultices were used for three months, and caustics were applied to destroy the surface. The edges of the fistula were pared and strapped. The opening communicated with a deep sinus into which a probe passed two inches, evidently into the small bowel. About seventeen days later there was an escape of feces.
An ovoid incision was made, and the parts were brought together with pins and plaster. The child was well in a little over two weeks. He died later of intestinal obstruction. At autopsy the diverticulum was found to be three inches long and adherent to the umbilicus. An adventitious cord had apparently compressed the ileum just below its connection with the diverticulum.
Fig. 146 is from another case recorded by King. This patient also died from intestinal obstruction apparently due to a remnant of an omphalomesenteric vessel.
Mahomed's case, published in 1875, leaves absolutely no doubt that the omphalomesenteric artery was responsible for the fatal obstruction.
The patient was a boy eighteen years old who was admitted to the hospital with signs of obstruction, after having eaten a meal of badly cooked potatoes. He died with typical signs of intestinal obstruction eleven days after the illness began.
Autopsy. — A fibrous band was found extending from the middle of the abdominal wall, midway between the pubes and the umbilicus, backward toward the right iliac fossa. It had carried out with it from the abdominal wall a triangular fold of peritoneum. The cord was found passing amid the distended coils of small intestine to the lower part of the ileum, where it formed a noose encircling a loop of ileum 33 inches in length. It had passed one and a half times around the gut at the point of constriction, and was then found to extend to the mesentery of the ileum, about
Fig. 146. — A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction. (After King.)
The figure represents a Meckel's diverticulum attached to the convex surface of a loop of small bowel. An adventitious cord extends from the mesentery over the small bowel to the side of the diverticulum. It represents what remained of one of the omphalomesenteric vessels. It was the cause of fatal intestinal obstruction.
246 THE UMBILICUS AND ITS DISEASES.
three feet from the ileocecal valve. On being traced between the layers of peritoneum forming the mesentery, the cord was discovered terminating in the large branch of the ileocolic artery.
In its course forward the fibrous cord was found to bifurcate at the apex of the triangular fold of peritoneum, which it had carried out from the abdominal wall. One branch ascended to the umbilicus, accompanying the obliterated hypogastric artery of the right side ; the other branch descended toward the bladder and terminated in the left superior vesical artery.
The "committee" were of the opinion that the case was one of persistence of the fetal omphalomesenteric artery, which sends off branches of communication with the left superior vesical or hypogastric artery, the latter having been probably smaller than normal, and having its distribution supplemented by the former.
On page 169 is a very interesting account of a case of fatal intestinal obstruction coming under the care of Sheen. A large quantity of small bowel had passed through a hole in the mesentery of a Meckel's diverticulum, and become strangulated (Fig. 102, p. 170). A note was made that the strength of the constricting cord of mesentery was largely due to the presence of a vessel that crossed it. This, of course, was one of the omphalomesenteric vessels.
From the preceding cases it is clearly evident that remnants of the omphalomesenteric vessels are from time to time found, and that these may lead to fatal intestinal obstruction.
LITERATURE CONSULTED ON PERSISTENCE OF THE OMPHALOMESENTERIC
VESSELS. Fitz, R. H.: Persistent Omphalomesenteric Remains. Their Importance in the Causation of
Intestinal Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci., 1884,
lxxxviii, 30. Falk, J.: De Ileo e Diverticulis, adiecta Morbi Historia, 1835, 18. Hue, F. : Prolapsus ombilical diverticulaire. La Normandie medicale, 1906, xxi, 162. King: Feculent Discharge at the Umbilicus from Communication with the Diverticulum Ilei.
Guy's Hospital Reports, 1843, 2. series, i, 467. Mahomed, F. A.: Case of Intestinal Obstruction Produced by the Abnormal Remains of a Fetal
Vessel. Trans. Path. Soc. London, 1875, xxvi, 117. Pestalozza, E.: Persistenza di un vaso onfalomesenterico nel cordone ombelicale di un feto
a termine. Bull, della soc. medico-chir. di Pavia, 1889, 11. Ruge, C. : Ueber die Gebilde im Nabelstrang. Zeitschr. f . Geb. u. Gyn., 1877, i, 7. Spangenberg, G.: Beitrag zur Entwicklungsgeschichte des Darmkanals. Deutsches Arch. f.
d. Physiologie, 1819, v, 87. Tillmanns, H. : Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia ventriculi), und liber sonstige Geschwlilste und Fisteln des Nabels. Deutsche Zeitschr.
f. Chir., 1882-83, xviii, 161.
Reference
Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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Cite this page: Hill, M.A. (2024, April 19) Embryology Book - Umbilicus (1916) 14. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Umbilicus_(1916)_14
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