Kenneth Azarow
446 statements · 7 topics · summaries given as host listed separately
Abdominal Wall Defects
· guest expert
Etiologies (Gastroschisis/NEC/Atresia/Volvulus)
· guest expert
Intestinal Rehab
· guest expert
Featured statements
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
quote ·
Abdominal Wall Defects
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
quote ·
Abdominal Wall Defects
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
it's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.
if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.
quote ·
Gastroschisis
Very rarely will the intestine ever be an issue through a 5 millimeter defect. In fact, almost never.
quote ·
Gastroschisis
Nothing matches these filters — clear the search or widen the filters.
Kenneth's statements about Abdominal Wall Defects 54 statements
Open the Abdominal Wall Defects collection →
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Most umbilical hernias will close spontaneously in the first year and some in the second year.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5).
Open
Statement
A long proboscis does not affect the decision to operate early on an umbilical hernia.
Open
Statement
Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.
Open
Statement
True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).
Open
Statement
Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.
Open
Statement
Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.
Open
Statement
Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.
Open
Quotation
if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.
Open
Statement
PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field).
Open
Statement
Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.
Open
Statement
Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.
Open
Statement
Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring).
Open
Quotation
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.
Open
Statement
Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.
Open
Quotation
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
Open
Statement
If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.
Open
Statement
Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.
Open
Statement
Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.
Open
Statement
A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.
Open
Statement
Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.
Open
Statement
A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.
Open
Quotation
if you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.
Open
Statement
Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.
Open
Statement
Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery.
Open
Statement
Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.
Open
Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.
Open
Statement
For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome.
Open
Statement
The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.
Open
Statement
A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.
Open
Quotation
we looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did
Open
Statement
Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.
Open
Statement
After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.
Open
Statement
Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.
Open
Statement
Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.
Open
Statement
Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.
Open
Statement
Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.
Open
Statement
Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.
Open
Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
Open
Kenneth's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 68 statements
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
Quotation
part of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.
Open
Quotation
There's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.
Open
Quotation
it's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.
Open
Statement
A low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.
Open
Statement
If a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.
Open
Statement
Current trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.
Open
Statement
Managing solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.
Open
Quotation
we were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.
Open
Statement
Tachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.
Open
Statement
Patients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.
Open
Statement
A patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.
Open
Statement
Once a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.
Open
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Most umbilical hernias will close spontaneously in the first year and some in the second year.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5).
Open
Statement
A long proboscis does not affect the decision to operate early on an umbilical hernia.
Open
Statement
Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.
Open
Statement
True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).
Open
Statement
Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.
Open
Statement
Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.
Open
Statement
Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.
Open
Quotation
if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.
Open
Statement
PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field).
Open
Statement
Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.
Open
Statement
Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.
Open
Statement
Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring).
Open
Quotation
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.
Open
Statement
Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.
Open
Statement
If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.
Open
Quotation
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
Open
Statement
Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.
Open
Statement
Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.
Open
Statement
A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.
Open
Statement
Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.
Open
Statement
A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.
Open
Quotation
if you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.
Open
Statement
Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.
Open
Statement
Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery.
Open
Statement
Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.
Open
Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.
Open
Statement
For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome.
Open
Statement
The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.
Open
Statement
A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.
Open
Quotation
we looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did
Open
Statement
Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.
Open
Statement
After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.
Open
Statement
Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.
Open
Statement
Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.
Open
Statement
Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.
Open
Statement
Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.
Open
Statement
Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.
Open
Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
Open
Kenneth's statements about Gastroschisis 115 statements
Open the Gastroschisis collection →
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, with preference for waiting until before school entry
Open
Statement
Most umbilical hernias will close on their own in the first year and some in the second year
Open
Statement
Larger umbilical defects (>1cm) are less likely to close spontaneously but this does not justify early operation
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair
Open
Statement
Red lumps at the umbilicus are typically incarcerated omentum, preperitoneal fat, or infected urachal cysts, not incarcerated intestine
Open
Statement
Incarcerated omentum can be treated with NSAIDs and urachal infections with antibiotics, rarely requiring surgery
Open
Statement
Truly incarcerated umbilical hernias requiring emergent surgery are extremely rare; Dr. Azarow cannot remember performing one
Open
Statement
A child with an incarcerated umbilical hernia who is eating well without GI symptoms does not have intestine incarcerated and does not need emergent surgery
Open
Statement
The presence of vomiting/bowel obstruction symptoms is the key differentiator for true incarceration requiring surgery
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
Umbilical hernia repair can be performed with LMA if adequate abdominal wall relaxation is achieved, though general anesthesia with paralysis makes it technically easier
Open
Quotation
if you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you.
Open
Statement
PDS or Maxon suture is preferred over Vicryl for umbilical hernia repair because it lasts twice as long and is non-braided
Open
Statement
Dr. Azarow uses antibiotics for umbilical repairs but not for inguinal hernias, though acknowledges this is anecdotal
Open
Statement
Umbilicoplasty is necessary to avoid extremely unhappy parents when there is excess skin after umbilical hernia repair
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above and below, avoiding completely circumferential incision
Open
Statement
Tacking the undersurface of umbilical skin to fascia with Vicryl suture creates an inflammatory response that helps flatten the umbilicus
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Statement
Dr. Azarow has only had to repair one umbilical hernia (at age 5) in gastroschisis patients, with others closing spontaneously over 2-3 years
Open
Statement
Over half of gastroschisis patients closed with sutureless technique will have large umbilical hernias initially
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a separate defect to the right of the cord, because the natural history is for the hole to close on its own
Open
Quotation
it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Placing sutures during gastroschisis closure makes the umbilical ring edge ischemic and destroys ring integrity, leading to hernias that won't close
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Omphaloceles should not be operated on early; waiting longer allows for primary closure without mesh in many cases
Open
Statement
The sign that an omphalocele is ready for repair is when the child lying flat shows flanks bulging out, indicating the abdominal girth is enlarging
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in teenagers where primary closure is not possible, laparoscopic repair with mesh is an option, though rare
Open
Quotation
Very rarely will the intestine ever be an issue through a 5 millimeter defect. In fact, almost never.
Open
Statement
Small pieces of fat can get caught in 5mm umbilical defects and cause discomfort, which may warrant repair
Open
Statement
A 5mm umbilical hernia is not an absolute indication for surgery; intestine will almost never be an issue through such a small defect
Open
Statement
Operating on umbilical drainage in infants in the first 3 months increases complication rates
Open
Statement
Dr. Azarow has stopped operating in the first 6 months for small amounts of umbilical drainage or material
Open
Statement
A Nebraska study showed that waiting until after 6 months for umbilical drainage results in spontaneous resolution in many cases
Open
Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites
Open
Statement
The distal part of the urachal remnant that is weeping or losing epithelium must be excised from the umbilical skin without devascularizing the umbilicus
Open
Statement
Persistent umbilical drainage at 6-12 months is treated like a urachal remnant with umbilical exploration through a small umbilical incision
Open
Statement
A small wedge or ellipse can be taken from the center of the umbilicus as long as good pedicle blood supply is maintained
Open
Statement
Making a small nick in the fascia during umbilical exploration makes it easier to see the urachal track and doesn't complicate closure
Open
Statement
A Nebraska study of 10-15 years of data showed no VCUG or ultrasound findings changed management of urachal remnants
Open
Statement
True urachal abscesses require antibiotics, drainage, and elective removal of the congenital remnant to prevent recurrence
Open
Statement
Most urachal cysts/abscesses can be treated with antibiotics alone in an elective situation
Open
Statement
Elective urachal remnant removal after abscess can be done laparoscopically with stapling at the dome of the bladder and extraction through the umbilicus
Open
Statement
For laparoscopic urachal remnant removal, first port is super-umbilical and second port is right or left side upsized to 12mm for stapler access
Open
Statement
Patent omphalomesenteric duct has a loop of intestine underneath that could be a source for volvulus if the fistula has any length
Open
Statement
Patent omphalomesenteric duct with stool from umbilicus will not close on its own and requires surgery before hospital discharge
Open
Statement
Patent omphalomesenteric duct can be approached through umbilical exploration, bringing ileum out and performing essentially a large Meckel's diverticulectomy
Open
Statement
Epigastric hernias should be called epiploceles because they are always preperitoneal fat through a pinhole, not true hernias
Open
Statement
Epigastric hernias are purely elective and typically will not go away unless fat twists and becomes necrotic
Open
Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
Open
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Most umbilical hernias will close spontaneously in the first year and some in the second year.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5).
Open
Statement
A long proboscis does not affect the decision to operate early on an umbilical hernia.
Open
Statement
Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.
Open
Statement
True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).
Open
Statement
Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.
Open
Statement
Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.
Open
Statement
Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.
Open
Quotation
if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.
Open
Statement
PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field).
Open
Statement
Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.
Open
Statement
Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.
Open
Statement
Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring).
Open
Quotation
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.
Open
Statement
Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.
Open
Statement
If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.
Open
Quotation
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
Open
Statement
Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.
Open
Statement
Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.
Open
Statement
A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.
Open
Statement
Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.
Open
Statement
A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.
Open
Quotation
if you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.
Open
Statement
Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.
Open
Statement
Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery.
Open
Statement
Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.
Open
Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.
Open
Statement
For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome.
Open
Statement
The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.
Open
Statement
A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.
Open
Quotation
we looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did
Open
Statement
Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.
Open
Statement
After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.
Open
Statement
Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.
Open
Statement
Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.
Open
Statement
Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.
Open
Statement
Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.
Open
Statement
Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.
Open
Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
Open
Kenneth's statements about Intestinal Rehab 68 statements
Open the Intestinal Rehab collection →
Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
Quotation
part of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.
Open
Quotation
There's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.
Open
Statement
A low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.
Open
Quotation
it's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.
Open
Statement
If a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.
Open
Statement
Current trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.
Open
Statement
Managing solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.
Open
Quotation
we were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.
Open
Statement
Tachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.
Open
Statement
Patients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.
Open
Statement
A patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.
Open
Statement
Once a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.
Open
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Most umbilical hernias will close spontaneously in the first year and some in the second year.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5).
Open
Statement
A long proboscis does not affect the decision to operate early on an umbilical hernia.
Open
Statement
Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.
Open
Statement
True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).
Open
Statement
Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.
Open
Statement
Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.
Open
Statement
Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.
Open
Quotation
if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.
Open
Statement
PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field).
Open
Statement
Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.
Open
Statement
Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.
Open
Statement
Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring).
Open
Quotation
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.
Open
Statement
Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.
Open
Statement
If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.
Open
Quotation
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
Open
Statement
Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.
Open
Statement
Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.
Open
Statement
A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.
Open
Statement
Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.
Open
Statement
A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.
Open
Quotation
if you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.
Open
Statement
Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.
Open
Statement
Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery.
Open
Statement
Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.
Open
Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.
Open
Statement
For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome.
Open
Statement
The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.
Open
Statement
A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.
Open
Quotation
we looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did
Open
Statement
Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.
Open
Statement
After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.
Open
Statement
Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.
Open
Statement
Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.
Open
Statement
Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.
Open
Statement
Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.
Open
Statement
Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.
Open
Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
Open
Kenneth's statements about Malrotation 14 statements
Open the Malrotation collection →
Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
Quotation
part of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.
Open
Quotation
There's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.
Open
Quotation
it's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.
Open
Statement
A low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.
Open
Statement
If a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.
Open
Statement
Current trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.
Open
Statement
Managing solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.
Open
Quotation
we were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.
Open
Statement
Tachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.
Open
Statement
Patients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.
Open
Statement
A patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.
Open
Statement
Once a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.
Open
Kenneth's statements about Splenic Injury 12 statements
Open the Splenic Injury collection →
Solid Organ Injury Rapid Fire Session: Update Course 2015
Statement
The patient was a 15-year-old involved in a collision during a baseball game, with the right fielder's knee impacting the left upper quadrant.
Open
Statement
The CT scan showed a complete crush injury of the spleen involving down to the hilum with a blush and blood around the liver.
Open
Statement
The patient had vital signs of 125/80 blood pressure and pulse of 85, which was considered stable despite the grade 5 injury.
Open
Statement
Current management trend is to treat based on hemodynamics rather than injury grade, allowing patients to be discharged much quicker than traditional protocols.
Open
Statement
Tachycardia must be evaluated to determine if it is due to pain, overlying broken rib, blood in abdomen, or low hematocrit before determining ICU vs ward placement.
Open
Statement
The early discharge protocol is applied only to local patients, not those transferred from across the state.
Open
Statement
Pain control is necessary to accurately assess whether tachycardia is due to the injury or other causes.
Open
Statement
Patients with less severe injuries are being discharged in less than 24 hours at the speaker's institution.
Open
Statement
The patient with grade 5 splenic injury was discharged within 48 hours using the hemodynamic-based protocol.
Open
Quotation
I do, for that part, I still follow the old rules, uh, because unlike the fact that we keep, I mean, I don't give any restrictions after surgery. I tell people that if it hurts, don't do it, they can do anything, but for this, I give restrictions because I've seen rebleeds.
Open
Statement
The speaker follows activity restrictions of grade plus 2 weeks for solid organ injuries because rebleeds have been observed.
Open
Statement
After surgery, the speaker gives no restrictions and tells patients if it hurts, don't do it, but for solid organ injuries, specific time-based restrictions are given.
Open
Kenneth's statements about Umbilical Hernia 115 statements
Open the Umbilical Hernia collection →
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, with preference for waiting until before school entry
Open
Statement
Most umbilical hernias will close on their own in the first year and some in the second year
Open
Statement
Larger umbilical defects (>1cm) are less likely to close spontaneously but this does not justify early operation
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair
Open
Statement
Truly incarcerated umbilical hernias requiring emergent surgery are extremely rare; Dr. Azarow cannot remember performing one
Open
Statement
Incarcerated omentum can be treated with NSAIDs and urachal infections with antibiotics, rarely requiring surgery
Open
Statement
Red lumps at the umbilicus are typically incarcerated omentum, preperitoneal fat, or infected urachal cysts, not incarcerated intestine
Open
Statement
A child with an incarcerated umbilical hernia who is eating well without GI symptoms does not have intestine incarcerated and does not need emergent surgery
Open
Statement
The presence of vomiting/bowel obstruction symptoms is the key differentiator for true incarceration requiring surgery
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
Umbilical hernia repair can be performed with LMA if adequate abdominal wall relaxation is achieved, though general anesthesia with paralysis makes it technically easier
Open
Quotation
if you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you.
Open
Statement
PDS or Maxon suture is preferred over Vicryl for umbilical hernia repair because it lasts twice as long and is non-braided
Open
Statement
Dr. Azarow uses antibiotics for umbilical repairs but not for inguinal hernias, though acknowledges this is anecdotal
Open
Statement
Umbilicoplasty is necessary to avoid extremely unhappy parents when there is excess skin after umbilical hernia repair
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above and below, avoiding completely circumferential incision
Open
Statement
Tacking the undersurface of umbilical skin to fascia with Vicryl suture creates an inflammatory response that helps flatten the umbilicus
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Quotation
it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a separate defect to the right of the cord, because the natural history is for the hole to close on its own
Open
Statement
Over half of gastroschisis patients closed with sutureless technique will have large umbilical hernias initially
Open
Statement
Dr. Azarow has only had to repair one umbilical hernia (at age 5) in gastroschisis patients, with others closing spontaneously over 2-3 years
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Placing sutures during gastroschisis closure makes the umbilical ring edge ischemic and destroys ring integrity, leading to hernias that won't close
Open
Statement
Omphaloceles should not be operated on early; waiting longer allows for primary closure without mesh in many cases
Open
Statement
The sign that an omphalocele is ready for repair is when the child lying flat shows flanks bulging out, indicating the abdominal girth is enlarging
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in teenagers where primary closure is not possible, laparoscopic repair with mesh is an option, though rare
Open
Quotation
Very rarely will the intestine ever be an issue through a 5 millimeter defect. In fact, almost never.
Open
Statement
Small pieces of fat can get caught in 5mm umbilical defects and cause discomfort, which may warrant repair
Open
Statement
A 5mm umbilical hernia is not an absolute indication for surgery; intestine will almost never be an issue through such a small defect
Open
Statement
Operating on umbilical drainage in infants in the first 3 months increases complication rates
Open
Statement
Dr. Azarow has stopped operating in the first 6 months for small amounts of umbilical drainage or material
Open
Statement
A Nebraska study showed that waiting until after 6 months for umbilical drainage results in spontaneous resolution in many cases
Open
Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites
Open
Statement
Persistent umbilical drainage at 6-12 months is treated like a urachal remnant with umbilical exploration through a small umbilical incision
Open
Statement
A small wedge or ellipse can be taken from the center of the umbilicus as long as good pedicle blood supply is maintained
Open
Statement
The distal part of the urachal remnant that is weeping or losing epithelium must be excised from the umbilical skin without devascularizing the umbilicus
Open
Statement
Making a small nick in the fascia during umbilical exploration makes it easier to see the urachal track and doesn't complicate closure
Open
Statement
A Nebraska study of 10-15 years of data showed no VCUG or ultrasound findings changed management of urachal remnants
Open
Statement
True urachal abscesses require antibiotics, drainage, and elective removal of the congenital remnant to prevent recurrence
Open
Statement
Most urachal cysts/abscesses can be treated with antibiotics alone in an elective situation
Open
Statement
Elective urachal remnant removal after abscess can be done laparoscopically with stapling at the dome of the bladder and extraction through the umbilicus
Open
Statement
For laparoscopic urachal remnant removal, first port is super-umbilical and second port is right or left side upsized to 12mm for stapler access
Open
Statement
Patent omphalomesenteric duct with stool from umbilicus will not close on its own and requires surgery before hospital discharge
Open
Statement
Patent omphalomesenteric duct has a loop of intestine underneath that could be a source for volvulus if the fistula has any length
Open
Statement
Patent omphalomesenteric duct can be approached through umbilical exploration, bringing ileum out and performing essentially a large Meckel's diverticulectomy
Open
Statement
Epigastric hernias should be called epiploceles because they are always preperitoneal fat through a pinhole, not true hernias
Open
Statement
Epigastric hernias are purely elective and typically will not go away unless fat twists and becomes necrotic
Open
Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
Open
Umbilical Cord Defects with Dr. Kenneth Azarow
Quotation
no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.
Open
Statement
Most umbilical hernias will close spontaneously in the first year and some in the second year.
Open
Statement
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5).
Open
Statement
A long proboscis does not affect the decision to operate early on an umbilical hernia.
Open
Statement
Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.
Open
Statement
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.
Open
Statement
True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).
Open
Statement
Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.
Open
Statement
Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.
Open
Statement
Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.
Open
Quotation
First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.
Open
Statement
LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.
Open
Quotation
if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.
Open
Statement
PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field).
Open
Statement
Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.
Open
Statement
Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.
Open
Quotation
I think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.
Open
Statement
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.
Open
Statement
Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.
Open
Quotation
if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.
Open
Statement
Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring).
Open
Quotation
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
Open
Statement
Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.
Open
Statement
Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.
Open
Quotation
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
Open
Statement
Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.
Open
Statement
If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.
Open
Quotation
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
Open
Statement
Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.
Open
Quotation
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
Open
Statement
For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.
Open
Statement
Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.
Open
Statement
A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.
Open
Statement
Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.
Open
Statement
A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.
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Quotation
if you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.
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Statement
Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.
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Statement
Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery.
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Statement
Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.
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Statement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.
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Statement
For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome.
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Statement
The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.
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Quotation
we looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did
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Statement
A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.
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Statement
Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.
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Statement
After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.
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Statement
Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.
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Statement
Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.
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Statement
Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.
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Statement
Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.
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Statement
Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.
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Quotation
don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole
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Summaries Kenneth gave as host · 25 summaries
Recaps of other experts' statements, not Kenneth's own clinical position.
Summaries Kenneth gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 8 summaries
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
Host summary
Kenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.
Open
Host summary
Kenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.
Open
Host summary
Kenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.
Open
Host summary
Kenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.
Open
Host summary
Kenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.
Open
Host summary
Kenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.
Open
Host summary
Kenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.
Open
Host summary
Kenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.
Open
Summaries Kenneth gave as host · Intestinal Rehab 8 summaries
Open the Intestinal Rehab collection →
Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
Host summary
Kenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.
Open
Host summary
Kenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.
Open
Host summary
Kenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.
Open
Host summary
Kenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.
Open
Host summary
Kenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.
Open
Host summary
Kenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.
Open
Host summary
Kenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.
Open
Host summary
Kenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.
Open
Summaries Kenneth gave as host · Malrotation 8 summaries
Open the Malrotation collection →
Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015
Host summary
Kenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.
Open
Host summary
Kenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.
Open
Host summary
Kenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.
Open
Host summary
Kenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.
Open
Host summary
Kenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.
Open
Host summary
Kenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.
Open
Host summary
Kenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.
Open
Host summary
Kenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.
Open
Summaries Kenneth gave as host · Splenic Injury 1 summary
Open the Splenic Injury collection →
Solid Organ Injury Rapid Fire Session: Update Course 2015
Host summary
Kenneth Azarow summarizing the discussion: Basically throwing out the grade book, uh, in the management of isolated spleen and liver injuries.
Open