Anatomical variations of medial umbilical ligament: clinical significance in laparoscopic exploration of children

Abstract

The anatomy and clinical significance of obliterated umbilical artery called as medial umbilical ligament (MUL) have not been documented well in literature. In this study, we investigated anatomical variations of MUL determined by laparoscopic exploration of abdomen in children and anatomy dissection on cadaver. The anatomy of MUL was investigated in a total of 126 patients including 41 retrospective cases. All 126 patients had laparoscopic exploration for a lower abdominal pathology. In retrospective group, videos demonstrating clearly both MULs and the region during laparoscopic exploration were selected. A dissection on an adult male cadaver was also performed. A preliminary grading scale of anatomical appearance of MUL was obtained. In grade 0, patients had no visible ligament (n = 14); in grade 1, MUL was a fibrous cord without a web formation (n = 63); in grade 2, MUL was a fibrous cord with a web (n = 49). MULs on both sides of the lower abdominal wall were symmetrical in all cases except one having a cloacal anomaly. This case had a solitary MUL on the right side. A MUL with a fibrous cord and significant web may cause technical difficulties and narrow the working space in laparoscopic exploration of children. It may also affect the surgeon's preference on trocar locations. In all grades of anatomical variation of MUL, formation of the ligament on both sides of the lower abdominal wall is similar. If there is a single umbilical artery, it becomes a solitary MUL after birth, and the possibility of associated malformations, especially urogenital abnormalities increases in such cases.