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Umbilical Cord Defects with Dr. Kenneth Azarow
With Dr. Kenneth Azarow · hosted by Dr. Todd Ponsky
Chapter 1 of 6 · Surgical Management
Repair timing
Introduction and Timing of Umbilical Hernia Repair
Cued at 2:28 · press play
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Most umbilical hernias will close on their own in the first year and some in the second year
Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, with preference for waiting until before school entry
Large proboscis does not affect the decision to operate early on umbilical hernias
Larger umbilical defects (>1cm) are less likely to close spontaneously but this does not justify early operation
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair
Truly incarcerated umbilical hernias requiring emergent surgery are extremely rare; Dr. Azarow cannot remember performing one
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
Red lumps at the umbilicus are typically incarcerated omentum, preperitoneal fat, or infected urachal cysts, not incarcerated intestine
Incarcerated omentum can be treated with NSAIDs and urachal infections with antibiotics, rarely requiring surgery
The presence of vomiting/bowel obstruction symptoms is the key differentiator for true incarceration requiring surgery
Umbilical hernia repair can be performed with LMA if adequate abdominal wall relaxation is achieved, though general anesthesia with paralysis makes it technically easier
PDS or Maxon suture is preferred over Vicryl for umbilical hernia repair because it lasts twice as long and is non-braided
The umbilicus is considered semi-dirty, making non-braided suture preferable
There is no literature supporting routine antibiotic use for umbilical hernia repair
Dr. Azarow uses antibiotics for umbilical repairs but not for inguinal hernias, though acknowledges this is anecdotal
Umbilicoplasty is necessary to avoid extremely unhappy parents when there is excess skin after umbilical hernia repair
Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above and below, avoiding completely circumferential incision
Tacking the undersurface of umbilical skin to fascia with Vicryl suture creates an inflammatory response that helps flatten the umbilicus
A pressure dressing should stay on for 3 days after umbilical hernia repair
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
Over half of gastroschisis patients closed with sutureless technique will have large umbilical hernias initially
Dr. Azarow has only had to repair one umbilical hernia (at age 5) in gastroschisis patients, with others closing spontaneously over 2-3 years
Placing sutures during gastroschisis closure makes the umbilical ring edge ischemic and destroys ring integrity, leading to hernias that won't close
Omphaloceles should not be operated on early; waiting longer allows for primary closure without mesh in many cases
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
For large umbilical hernias in teenagers where primary closure is not possible, laparoscopic repair with mesh is an option, though rare
A 5mm umbilical hernia is not an absolute indication for surgery; intestine will almost never be an issue through such a small defect
Small pieces of fat can get caught in 5mm umbilical defects and cause discomfort, which may warrant repair
Operating on umbilical drainage in infants in the first 3 months increases complication rates
A Nebraska study showed that waiting until after 6 months for umbilical drainage results in spontaneous resolution in many cases
Dr. Azarow has stopped operating in the first 6 months for small amounts of umbilical drainage or material
Most umbilical remnants are sinus tracts or granulomas, not true fistulas
Silver nitrate can make umbilical granulomas go away in the first few weeks
A prospective trial comparing silver nitrate to triamcinolone cream for umbilical granulomas was stopped early because triamcinolone showed drastically better improvement
Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites
Persistent umbilical drainage at 6-12 months is treated like a urachal remnant with umbilical exploration through a small umbilical incision
The distal part of the urachal remnant that is weeping or losing epithelium must be excised from the umbilical skin without devascularizing the umbilicus
A small wedge or ellipse can be taken from the center of the umbilicus as long as good pedicle blood supply is maintained
Making a small nick in the fascia during umbilical exploration makes it easier to see the urachal track and doesn't complicate closure
A Nebraska study of 10-15 years of data showed no VCUG or ultrasound findings changed management of urachal remnants
Dr. Azarow does not perform any preoperative imaging workup for urachal remnants
Most urachal cysts/abscesses can be treated with antibiotics alone in an elective situation
True urachal abscesses require antibiotics, drainage, and elective removal of the congenital remnant to prevent recurrence
Large urachal abscesses in the preperitoneal space can be drained percutaneously by interventional radiology
Elective urachal remnant removal after abscess can be done laparoscopically with stapling at the dome of the bladder and extraction through the umbilicus
For laparoscopic urachal remnant removal, first port is super-umbilical and second port is right or left side upsized to 12mm for stapler access
Patent omphalomesenteric duct with stool from umbilicus will not close on its own and requires surgery before hospital discharge
Patent omphalomesenteric duct has a loop of intestine underneath that could be a source for volvulus if the fistula has any length
Patent omphalomesenteric duct can be approached through umbilical exploration, bringing ileum out and performing essentially a large Meckel's diverticulectomy
If bowel is wrapped around a patent omphalomesenteric duct, laparoscopy can be used to untwist the bowel before completing umbilical approach
Epigastric hernias are purely elective and typically will not go away unless fat twists and becomes necrotic
Epigastric hernias should be called epiploceles because they are always preperitoneal fat through a pinhole, not true hernias
The defect in epigastric hernias is literally 1mm, yet fat manages to get through
PIPS hospital data shows the mean age for umbilical hernia repair across the country is 4 years
Anesthesia data suggesting avoiding surgery before age 2-3 years provides additional support for delayed umbilical hernia repair
A Canadian study by Dr. Baird's group showed more umbilical repairs were needed in gastroschisis patients closed with suture versus sutureless technique