Dh. Oelsner et al., SUBUMBILICAL MIDLINE VASCULARITY OF THE ABDOMINAL-WALL IN PORTAL-HYPERTENSION OBSERVED AT LAPAROSCOPY, Gastrointestinal endoscopy, 47(5), 1998, pp. 388-390
Background: Large volume paracentesis is a common treatment of ascites
. Injury to abdominal wall collateral veins during this procedure can
lead to hemoperitoneum. Because of this concern, the midline below the
umbilicus is often recommended as a site for paracentesis because of
its presumed avascularity. Methods: We examined the subumbilical perit
oneal surface in 20 consecutive patients with liver disease undergoing
diagnostic laparoscopy. This area was visualized by table tilting and
confirmed by external finger compression. Nineteen patients had cirrh
osis of various etiologies, and one had advanced fibrosis with evidenc
e of portal hypertension. Results: In these 20 patients, only 7 had av
ascular midlines below the umbilicus. Seven had small but definite vei
ns running along the path of the urachus (median umbilical fold), and
6 had more prominent veins in this region. The internal landmarks in t
his region (median and medial folds) were frequently asymmetric with r
egard to the external appearance of the midline. Conclusion: The subum
bilical midline in patients with portal hypertension is commonly vascu
lar. When using this site for paracentesis, care should be exercised t
o identify venous structures with the narrow-gauge needle used to inje
ct local anesthetic agent before placement of larger paracentesis need
les.