# Neonatal & Infant Surgery — GCMD Library living collection Updated: n/a · 7 episodes · 146 cited statements ## Episodes ### Umbilical Pathologies - [Umbilical Pathologies Bonus Episode](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331) — podcast · 4:25 · [machine version](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331.md) - [Differential diagnosis and management of pediatric umbilical pathologies](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593) — podcast · 6:19 · [machine version](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593.md) - [Diagnosis and Management of Pediatric Umbilical Pathologies](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595) — podcast · 6:44 · [machine version](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595.md) - [Umbilical Pathology: Diagnosis and Management in Pediatric Surgery](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613) — video · 6:48 · [machine version](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613.md) ### Pyloric Stenosis - [Pyloric Stenosis Guideline Recap](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786) — video · [machine version](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786.md) ### Inguinal Hernia - [Pediatric inguinal hernia diagnosis, management, and complications](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594) — podcast · 15:59 · [machine version](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594.md) ### Vascular Anomalies - [Iatrogenic arteriovenous fistula in the Arm in an infant: Diagnostic and therapeutic considerations](https://library.globalcastmd.com/article/iatrogenic-arteriovenous-fistula-in-the-arm-in-an-infant-diagnostic-and-therapeu-16611) — article · [machine version](https://library.globalcastmd.com/article/iatrogenic-arteriovenous-fistula-in-the-arm-in-an-infant-diagnostic-and-therapeu-16611.md) ## Chapters - [0:02](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=2) Differential diagnosis of umbilical bulge in infants (Ep 1) - [1:00](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=60) Distinguishing features and surgical approach to patent urachus and omphalomesenteric duct (Ep 1) - [1:49](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=109) Umbilical granuloma versus umbilical polyp (Ep 1) - [2:34](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=154) Risk factors and natural history of umbilical hernias (Ep 1) - [3:27](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=207) Surgical technique for pediatric umbilical hernia repair (Ep 1) - [0:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=0) Introduction and Diagnosis of Pyloric Stenosis (Ep 5) - [1:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=60) Preoperative Resuscitation and Fluid Management (Ep 5) - [3:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=180) Operative Criteria and Postoperative Feeding (Ep 5) - [0:00](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=0) Introduction and differential diagnosis of umbilical bulge (Ep 2) - [1:08](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=68) Distinguishing features and surgical approach to urachal and omphalomesenteric remnants (Ep 2) - [2:08](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=128) Umbilical granuloma versus umbilical polyp (Ep 2) - [2:59](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=179) Risk factors and timing of umbilical hernia repair (Ep 2) - [4:12](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=252) Surgical technique for umbilical hernia repair (Ep 2) - [5:21](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=321) Key takeaways and conclusion (Ep 2) - [0:00](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=0) Introduction and Anatomy of Pediatric Inguinal Hernias (Ep 6) - [1:56](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=116) Embryology, Risk Factors, and Epidemiology (Ep 6) - [3:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=205) Differential Diagnosis and Timing of Elective Repair (Ep 6) - [5:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=311) Incarcerated Hernia: Presentation and Bedside Reduction (Ep 6) - [7:31](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=451) Surgical Repair: Timing, Approach, and Technical Considerations (Ep 6) - [10:48](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=648) Postoperative Complications and Special Scenarios (Ep 6) - [13:29](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=809) Special Cases: Undescended Testis and Absent Vas (Ep 6) - [0:00](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=0) Differential Diagnosis of Umbilical Bulge (Ep 3) - [1:33](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=93) Surgical Management of Patent Urachal and Omphalomesenteric Remnants (Ep 3) - [2:27](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=147) Distinguishing Umbilical Granulomas from Polyps (Ep 3) - [3:35](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=215) Umbilical Hernia Risk Factors and Timing of Repair (Ep 3) - [4:46](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=286) Umbilical Hernia Repair Technique (Ep 3) - [6:07](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=367) Key Takeaways (Ep 3) - [0:04](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=4) Differential Diagnosis of Umbilical Bulges (Ep 4) - [1:33](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=93) Surgical Management of Patent Urachal and Umbilical Duct Remnants (Ep 4) - [2:27](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=147) Distinguishing Umbilical Granulomas from Polyps (Ep 4) - [3:35](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=215) Umbilical Hernia Epidemiology and Timing of Repair (Ep 4) - [4:46](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=286) Surgical Technique for Pediatric Umbilical Hernia Repair (Ep 4) - [6:08](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=368) Key Takeaways on Umbilical Pathology (Ep 4) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - Umbilical hernia is the most common cause of umbilical bulge in infants. — Meera Kotagal (clinical) [Ep 1 · 0:34](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=34) - The differential diagnosis of umbilical bulge includes umbilical hernia, urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, and omphalitis (when significant erythema is present). — Meera Kotagal (clinical) [Ep 1 · 0:34](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=34) - Urine draining from the umbilicus is associated with a patent urachus. — Meera Kotagal (clinical) [Ep 1 · 1:00](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=60) - Succus draining from the umbilicus suggests a patent omphalomesenteric duct. — Meera Kotagal (clinical) [Ep 1 · 1:00](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=60) - An umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that can be excised. — Meera Kotagal (clinical) [Ep 1 · 1:56](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=116) - An umbilical granuloma is granulation tissue or asymptomatic pink tissue at the base of the umbilicus, often seen in very small infants shortly after umbilical cord separation, treated with silver nitrate. — Meera Kotagal (clinical) [Ep 1 · 1:56](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=116) - The primary risk factor for umbilical hernias is prematurity. — Meera Kotagal (epidemiological) [Ep 1 · 2:42](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=162) - African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians. — Meera Kotagal (epidemiological) [Ep 1 · 2:42](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=162) - 85% of infant umbilical hernias will close on their own. — Meera Kotagal (epidemiological) [Ep 1 · 3:09](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=189) - Small umbilical hernia defects are more likely to close spontaneously compared to larger defects (those over 1 to 1.5 centimeters). — Meera Kotagal (clinical) [Ep 1 · 3:09](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=189) - Routine pediatric umbilical hernias are repaired as an outpatient procedure. — Meera Kotagal (clinical) [Ep 1 · 3:28](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=208) - Pediatric umbilical hernia repair does not use mesh, unlike adult repairs. — Meera Kotagal (clinical) [Ep 1 · 3:28](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=208) - During pediatric umbilical hernia repair, it is important to close normal fascia to normal fascia, not hernia sac to hernia sac. — Meera Kotagal (clinical) [Ep 1 · 3:28](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=208) - Pyloric stenosis presents with progressive nonbilious emesis and sometimes a palpable olive in the epigastrium. — Meera Kotagal (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=0) - Labs in pyloric stenosis most often demonstrate a hypochloremic, hypokalemic metabolic alkalosis. — Meera Kotagal (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=0) - Ultrasound criteria for pyloric stenosis are muscle width greater than 3 millimeters and length greater than 14 millimeters. — Meera Kotagal (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=0) - Maintenance IV fluid is started at one and a half times the maintenance rate in pyloric stenosis patients. — Meera Kotagal (guideline) [Ep 5 · 2:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=120) - Potassium is added to IV fluids once urine output has been confirmed. — Meera Kotagal (guideline) [Ep 5 · 2:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=120) - There is a trend in the literature that isotonic fluids should be used instead of hypotonic fluids in pediatric patients, though evidence is still developing in this age population. — Meera Kotagal (opinion) [Ep 5 · 2:30](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=150) - Patients go to the OR for pyloromyotomy once their bicarb level is less than 30, their chloride is greater than 100, and their potassium is normal. — Meera Kotagal (guideline) [Ep 5 · 3:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=180) - Postoperative management includes a short NPO period of around two hours followed by ad lib feeding with breast milk or formula. — Meera Kotagal (guideline) [Ep 5 · 3:30](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=210) - The differential diagnosis for a pediatric umbilical bulge includes umbilical hernia (most common), urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, and omphalitis if significant erythema is present. — Meera Kotagal (clinical) [Ep 2 · 0:49](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=49) - Urine draining from the umbilicus is associated with a patent urachus. — Meera Kotagal (clinical) [Ep 2 · 1:17](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=77) - Succus draining from the umbilicus suggests a patent omphalomesenteric duct. — Meera Kotagal (clinical) [Ep 2 · 1:22](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=82) - For excision of urachal or omphalomesenteric remnants, a curvilinear infra-umbilical incision is made, attachments from umbilicus to bladder or intestine are identified and tracked down, then divided. — Meera Kotagal (clinical) [Ep 2 · 1:46](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=106) - An umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that can be excised by tying it off and ligating it in clinic, then dividing it or letting it fall off over time. — Meera Kotagal (clinical) [Ep 2 · 2:15](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=135) - An umbilical granuloma is granulation tissue or asymptomatic pink tissue at the base of the umbilicus, often seen in very small infants shortly after cord separation, and is treated with silver nitrate. — Meera Kotagal (clinical) [Ep 2 · 2:29](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=149) - On physical exam, an umbilical polyp has a stalk and can be moved around more freely, whereas granulomatous tissue is more stuck on at the base of the belly button. — Meera Kotagal (clinical) [Ep 2 · 2:49](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=169) - The primary risk factor for umbilical hernias is prematurity. — Meera Kotagal (epidemiological) [Ep 2 · 3:04](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=184) - African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians. — Meera Kotagal (epidemiological) [Ep 2 · 3:12](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=192) - 85% of infant umbilical hernias will close on their own. — Meera Kotagal (epidemiological) [Ep 2 · 3:30](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=210) - Small umbilical hernia defects are more likely to close spontaneously compared to larger defects (those over 1 to 1.5 cm). — Meera Kotagal (clinical) [Ep 2 · 3:34](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=214) - Really large umbilical hernias may be closed earlier if children are symptomatic or if they are so large that spontaneous closure is unlikely. — Meera Kotagal (clinical) [Ep 2 · 3:40](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=220) - Pediatric umbilical hernia repair is an outpatient procedure involving an infra-umbilical curvilinear incision. — Meera Kotagal (clinical) [Ep 2 · 4:12](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=252) - In umbilical hernia repair, the umbilical stalk is encircled and divided, the hernia sac is separated from skin and fascia to identify fascial edges, and the defect is closed primarily. — Meera Kotagal (clinical) [Ep 2 · 4:19](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=259) - Unlike in adults, mesh is not typically used to repair an umbilical hernia in a child. — Meera Kotagal (clinical) [Ep 2 · 4:33](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=273) - During umbilical hernia repair, it is important to ensure closure extends back to normal fascia and not hernia sac to hernia sac. — Meera Kotagal (clinical) [Ep 2 · 4:38](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=278) - Even with a prominent umbilical proboscis and excess skin, skin resection or formal umbilicoplasty is generally not needed. — Meera Kotagal (clinical) [Ep 2 · 4:52](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=292) - In instances with significant excess skin, umbilicoplasty might be considered, but care must be taken to create what is cosmetically consistent with a normal umbilicus. — Meera Kotagal (opinion) [Ep 2 · 5:11](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=311) - The differential diagnosis for a 6-month-old infant with umbilical bulge includes umbilical hernia (most common), urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, hernia of the cord, and omphalitis if significant erythema is present. — Meera Kotagal (clinical) [Ep 3 · 0:37](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=37) - Urine draining from the umbilicus is associated with a patent urachus, whereas succus drainage suggests a patent omphalomesenteric duct. — Meera Kotagal (clinical) [Ep 3 · 1:09](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=69) - Umbilical granulomas can cause intermittent serosanguinous drainage. — Meera Kotagal (clinical) [Ep 3 · 1:27](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=87) - For patent urachus or patent omphalomesenteric duct identified on ultrasound, the next step is usually operative exploration. — Meera Kotagal (clinical) [Ep 3 · 1:41](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=101) - Ligation and division of a urachus can be performed through an umbilical incision using a curvilinear fashion in the infraumbilical space. — Meera Kotagal (clinical) [Ep 3 · 1:47](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=107) - For urachal remnant repair, the urachus should be tracked all the way down to the bladder and the bladder is usually repaired at that level in two layers. — Meera Kotagal (clinical) [Ep 3 · 2:09](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=129) - For patent omphalomesenteric duct or remnant, it should be tracked down to the intestine and resected at the level of the intestine, but small bowel resection is not needed. — Meera Kotagal (clinical) [Ep 3 · 2:17](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=137) - An umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that can be excised by tying it off and ligating it in clinic, either dividing it or letting it fall off over time. — Meera Kotagal (clinical) [Ep 3 · 2:35](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=155) - An umbilical granuloma is granulation tissue or pink tissue at the base of the umbilicus, often seen in very small infants shortly after umbilical cord separation, and is treated with silver nitrate. — Meera Kotagal (clinical) [Ep 3 · 2:50](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=170) - To differentiate umbilical granuloma from polyp on physical exam, use a Q-tip to spread open the umbilicus and look at the base: a polyp has a stalk and moves more freely, whereas granulomatous tissue is more adherent at the base. — Meera Kotagal (clinical) [Ep 3 · 3:15](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=195) - The primary risk factor for umbilical hernias is prematurity. — Meera Kotagal (epidemiological) [Ep 3 · 3:38](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=218) - African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians. — Meera Kotagal (epidemiological) [Ep 3 · 3:42](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=222) - For umbilical hernias, repair is generally delayed until the patient is at least 4 years of age, though some recommendations suggest 2 years as the lower age limit. — Meera Kotagal (guideline) [Ep 3 · 3:57](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=237) - 85% of infant umbilical hernias will close on their own. — Meera Kotagal (epidemiological) [Ep 3 · 4:09](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=249) - Small umbilical hernia defects are more likely to close spontaneously compared to larger defects over 1 to 1.5 cm. — Meera Kotagal (clinical) [Ep 3 · 4:14](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=254) - Really large umbilical hernias may be closed earlier if children are symptomatic or if they are so large they are unlikely to close spontaneously. — Meera Kotagal (opinion) [Ep 3 · 4:21](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=261) - If umbilical hernia repair is delayed to closer to 4 years of age, families should be counseled about signs of incarceration or strangulation including abdominal pain, vomiting, skin changes, or a bulge that is not reducible. — Meera Kotagal (clinical) [Ep 3 · 4:33](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=273) - Routine pediatric umbilical hernia repair is an outpatient procedure involving an infraumbilical curvilinear incision, though some surgeons prefer a vertical incision through the umbilicus. — Meera Kotagal (clinical) [Ep 3 · 4:50](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=290) - In pediatric umbilical hernia repair, the umbilical stalk is encircled and divided, the hernia sac is separated from skin and fascia to identify fascial edges, and the defect is closed primarily. — Meera Kotagal (clinical) [Ep 3 · 5:02](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=302) - Unlike in adults, mesh is generally not used for pediatric umbilical hernia repair. — Meera Kotagal (clinical) [Ep 3 · 5:18](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=318) - When closing a pediatric umbilical hernia, it is important to get all the way back to normal fascia and not close hernia sac to hernia sac. — Meera Kotagal (clinical) [Ep 3 · 5:18](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=318) - Even with a prominent proboscis and extra skin at an umbilical hernia site, skin resection or formal umbilicoplasty is generally not needed; tacking down the skin at the center of the repair is sufficient and redundant skin improves over time. — Meera Kotagal (clinical) [Ep 3 · 5:36](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=336) - In instances with significant excess skin, umbilicoplasty might be considered, but care must be taken to create a cosmetically normal-appearing umbilicus. — Meera Kotagal (opinion) [Ep 3 · 5:57](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=357) - The differential diagnosis for an umbilical bulge in a young child includes umbilical hernia (most common), urachal cyst, patent umbilical duct, umbilical granuloma, umbilical polyp, hernia of the cord, and omphalitis if significant erythema is present. — Meera Kotagal (clinical) [Ep 4 · 0:37](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=37) - Urine draining from the umbilicus is associated with a patent uracus, while succus drainage suggests a patent umbilical duct. — Meera Kotagal (clinical) [Ep 4 · 1:04](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=64) - Umbilical drainage is often not clearly urine or succus, and granulomas can also cause intermittent serous drainage. — Meera Kotagal (clinical) [Ep 4 · 1:18](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=78) - If ultrasound shows a patent uracus or patent umbilical duct, the next step is usually operative exploration. — Meera Kotagal (clinical) [Ep 4 · 1:40](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=100) - A patent uracus can often be ligated and divided through an umbilical incision using a curvilinear infraumbilical approach similar to umbilical hernia repair. — Meera Kotagal (clinical) [Ep 4 · 1:46](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=106) - For a urachal remnant, the surgeon should track it all the way down to the bladder and repair the bladder in two layers. — Meera Kotagal (clinical) [Ep 4 · 2:10](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=130) - For a patent umbilical duct or umbilical remnant, the surgeon should track it down to the intestine and resect it at the level of the intestine, but small bowel resection is not needed. — Meera Kotagal (clinical) [Ep 4 · 2:18](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=138) - An umbilical polyp is a small remnant of the umbilical duct extending from the umbilicus that can be excised by tying it off and ligating it in clinic, either dividing it immediately or letting it fall off over time. — Meera Kotagal (clinical) [Ep 4 · 2:35](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=155) - An umbilical granuloma is granulation tissue or asymptomatic pink tissue at the base of the umbilicus, often seen in very small infants shortly after umbilical cord separation, and is treated with silver nitrate. — Meera Kotagal (clinical) [Ep 4 · 2:50](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=170) - To differentiate between an umbilical granuloma and polyp on physical exam, use a Q-tip to spread open the umbilicus and look at the base: a polyp has a stalk and moves more freely, while granulomatous tissue is more stuck at the base. — Meera Kotagal (clinical) [Ep 4 · 3:08](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=188) - The primary risk factor for umbilical hernias is prematurity. — Meera Kotagal (epidemiological) [Ep 4 · 3:38](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=218) - African-American infants are eight times more likely to have an umbilical hernia compared to Caucasians. — Meera Kotagal (epidemiological) [Ep 4 · 3:42](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=222) - For umbilical hernias, repair is generally delayed until the patient is at least four years of age, though some recommendations suggest two years as the lower age limit. — Meera Kotagal (guideline) [Ep 4 · 3:57](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=237) - 85% of infant umbilical hernias will close on their own. — Meera Kotagal (epidemiological) [Ep 4 · 4:09](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=249) - Small umbilical hernia defects are more likely to close spontaneously compared to larger defects (those over 1 to 1.5 cm). — Meera Kotagal (clinical) [Ep 4 · 4:14](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=254) - Really large umbilical hernias may be closed earlier if children are symptomatic or if they are so large that spontaneous closure is unlikely. — Meera Kotagal (clinical) [Ep 4 · 4:21](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=261) - If umbilical hernia repair is delayed until age four, families should be counseled about signs of incarceration or strangulation including abdominal pain, vomiting, skin changes, or a non-reducible bulge. — Meera Kotagal (clinical) [Ep 4 · 4:33](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=273) - Routine pediatric umbilical hernia repair is an outpatient procedure involving an infraumbilical curvilinear incision (though some surgeons go vertically through the umbilicus). — Meera Kotagal (clinical) [Ep 4 · 4:50](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=290) - In pediatric umbilical hernia repair, the surgeon encircles and divides the umbilical stalk, separates the hernia sac from skin and fascia, identifies fascial edges, and closes the defect primarily. — Meera Kotagal (clinical) [Ep 4 · 5:02](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=302) - Unlike in adults, mesh is generally not used for pediatric umbilical hernia repair. — Meera Kotagal (clinical) [Ep 4 · 5:19](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=319) - During pediatric umbilical hernia repair, it is important to close normal fascia to normal fascia and not hernia sac to hernia sac. — Meera Kotagal (clinical) [Ep 4 · 5:19](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=319) - Even with a prominent proboscis and excess skin at an umbilical hernia, skin resection or formal umbilicoplasty is generally not needed; tacking down the skin at the center of the repair is sufficient and redundant skin improves over time. — Meera Kotagal (clinical) [Ep 4 · 5:36](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=336) - In instances with significant excess skin at an umbilical hernia, umbilicoplasty might be considered, but care must be taken to create a cosmetically normal-appearing umbilicus. — Meera Kotagal (clinical) [Ep 4 · 5:57](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=357) - Indirect hernias are a defect above the inguinal ligament and lateral to the epigastric vessels. — Rae Hanke (clinical) [Ep 6 · 1:01](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=61) - A direct hernia is a defect above the inguinal ligament and medial to the epigastric vessels. — Rae Hanke (clinical) [Ep 6 · 1:07](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=67) - A femoral hernia is a defect below the inguinal ligament. — Rae Hanke (clinical) [Ep 6 · 1:07](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=67) - The incidence of inguinal hernias overall ranges from about 1 to 5% in full-term newborns. — Meera Kotagal (epidemiological) [Ep 6 · 1:27](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=87) - The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age. — Meera Kotagal (epidemiological) [Ep 6 · 1:34](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=94) - Over 90% of inguinal hernias in children are indirect. — Meera Kotagal (epidemiological) [Ep 6 · 1:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=100) - Direct hernias are pretty rare in children and are much more commonly found in adolescents. — Meera Kotagal (epidemiological) [Ep 6 · 1:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=105) - Femoral hernias are very rare in children, and as in adults are more common in females. — Meera Kotagal (epidemiological) [Ep 6 · 1:45](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=105) - Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth. — Meera Kotagal (clinical) [Ep 6 · 1:59](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=119) - Inguinal hernias occur as a result of the failure of the processus vaginalis to fuse. — Meera Kotagal (clinical) [Ep 6 · 2:06](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=126) - In utero during gestation, the processus vaginalis should fuse to become the tunica vaginalis. — Meera Kotagal (clinical) [Ep 6 · 2:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=131) - The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias. — Meera Kotagal (clinical) [Ep 6 · 2:17](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=137) - If the processus vaginalis narrows but doesn't totally close, you can get a communicating hydrocele where fluid can move from the peritoneal cavity through the inguinal canal and into the scrotum. — Meera Kotagal (clinical) [Ep 6 · 2:28](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=148) - If the proximal part closes and the distal part isn't obliterated, then you get a non-communicating hydrocele where some fluid is trapped. (clinical) [Ep 6 · 2:35](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=155) - The number one risk factor for inguinal hernias in children is prematurity. — Meera Kotagal (epidemiological) [Ep 6 · 2:47](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=167) - Risk factors for inguinal hernias in children include male sex, family history of inguinal hernias, a history of an undescended testicle or hydrocele, and a connective tissue disorder. — Meera Kotagal (epidemiological) [Ep 6 · 2:57](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=177) - The differential diagnosis for a groin mass in a child includes an inguinal hernia (most likely indirect, although rarely direct), hydrocele, or lymphadenopathy. — Meera Kotagal (clinical) [Ep 6 · 3:35](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=215) - If a groin mass is associated with significant pain, the differential diagnosis should also include testicular torsion, epididymitis, orchitis, or torsion of the appendix testis. — Meera Kotagal (clinical) [Ep 6 · 3:47](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=227) - A retractile testicle or undescended testicle in the groin can be mistaken for a hernia; always make sure both testicles are in the scrotum when you see a bulge in the groin. — Todd (clinical) [Ep 6 · 4:03](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=243) - Timing for decisions about repairs of inguinal hernias has to balance the risks of anesthesia with the risks of incarceration associated with the hernia. — Meera Kotagal (clinical) [Ep 6 · 4:31](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=271) - Inguinal hernia repair is in general considered an elective operation and does not need to be urgently performed. — Meera Kotagal (guideline) [Ep 6 · 4:40](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=280) - Younger children have a higher rate of incarceration. — Meera Kotagal (epidemiological) [Ep 6 · 4:43](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=283) - Children with an incarcerated hernia may present most commonly with pain, particularly groin pain. — Meera Kotagal (clinical) [Ep 6 · 5:24](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=324) - Children with incarcerated hernias may have abdominal distension or emesis if obstruction is present due to bowel being in the incarcerated hernia. — Meera Kotagal (clinical) [Ep 6 · 5:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=330) - Prolonged incarceration can result in strangulation, particularly of bowel contents. — Meera Kotagal (clinical) [Ep 6 · 5:37](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=337) - Patients with a strangulated hernia may present with fever, tachycardia, leukocytosis, severe pain, or overlying erythema in the skin. — Meera Kotagal (clinical) [Ep 6 · 5:37](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=337) - One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm. — Meera Kotagal (clinical) [Ep 6 · 5:59](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=359) - To reduce an incarcerated hernia, place the patient supine in Trendelenburg position with their head down, and use two hands: one to guide the contents through the inguinal ring, and the other to apply gentle steady pressure. — Meera Kotagal (clinical) [Ep 6 · 6:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=371) - You have to keep applying pressure in a slow, gentle fashion, and not just come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia. — Meera Kotagal (clinical) [Ep 6 · 6:28](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=388) - When reducing an incarcerated hernia in the emergency room, you have to be patient because it doesn't usually reduce right away; you have to squeeze the incarcerated bowel so that the edema gets pushed out, which allows it to be reduced. This can take several minutes. — Todd (clinical) [Ep 6 · 6:41](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=401) - Todd recommends not just reducing the bowel after the patient is asleep, but putting a laparoscope in so you can watch the bowel being reduced to make sure it's viable. — Todd (opinion) [Ep 6 · 7:17](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=437) - If you can reduce an incarcerated hernia, you want to go to the OR within the first 24 to 72 hours after the reduction. — Meera Kotagal (guideline) [Ep 6 · 7:34](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=454) - Todd challenges the traditional teaching that you should wait till the next day after reducing an incarcerated hernia; with laparoscopy, you don't necessarily need to wait because it's not that much more difficult if there's swelling, and the edema can actually help lift the peritoneum off. — Todd (opinion) [Ep 6 · 7:50](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=470) - Todd suggests that if it's in the middle of the day and you have time availability and a patient has an incarcerated hernia, you could not even try to reduce it in the emergency room and just go straight to the operating room under laparoscopy, watch it get reduced under visualization, and then do the laparoscopic repair, which is not that difficult even after an incarceration. — Todd (opinion) [Ep 6 · 8:19](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=499) - You can approach the repair of a pediatric inguinal hernia either laparoscopically or in an open fashion. — Meera Kotagal (clinical) [Ep 6 · 8:57](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=537) - The most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open. — Meera Kotagal (clinical) [Ep 6 · 9:03](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=543) - You should consider evaluation of the contralateral side depending on the age of the child. — Meera Kotagal (guideline) [Ep 6 · 9:11](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=551) - Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia. — Meera Kotagal (clinical) [Ep 6 · 9:15](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=555) - The most important thing is that you do the operation that you're comfortable with. — Meera Kotagal (opinion) [Ep 6 · 9:25](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=565) - The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic. — Meera Kotagal (clinical) [Ep 6 · 9:31](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=571) - If a child needs an orchiopexy in addition to their hernia repair, most would approach that hernia in an open fashion. — Meera Kotagal (guideline) [Ep 6 · 9:44](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=584) - Todd does orchiopexies for undescended testicles laparoscopically through the scope, and can deal with the hernia at the time. — Todd (opinion) [Ep 6 · 10:01](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=601) - When people do orchiopexies, they don't necessarily stitch the hole closed, and from that we learned that you may not ever actually need to stitch, that scar alone may be enough. — Todd (clinical) [Ep 6 · 10:15](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=615) - There are surgeons who just cut the sac but don't actually ligate anything, based on learning that patients usually do not get a hernia after an orchiopexy is done and the hole is not ever ligated shut. — Todd (clinical) [Ep 6 · 10:32](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=632) - A floor repair should be considered in children who have long-standing or very large hernias, where you note that the floor might be blown out or unsupported, in order to buttress the repair. — Meera Kotagal (clinical) [Ep 6 · 10:54](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=654) - Complications are fairly rare after an inguinal hernia repair in children. — Meera Kotagal (epidemiological) [Ep 6 · 11:10](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=670) - The most common complications are superficial site infection, which occur in less than 1% of kids, and some risk of recurrence. — Meera Kotagal (epidemiological) [Ep 6 · 11:14](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=674) - The rates of recurrence vary from 1 to 5%, depending on which studies you look at. — Meera Kotagal (epidemiological) [Ep 6 · 11:21](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=681) - A more common complication is the presence of a seroma after a hernia repair; it's important to explain to parents that they might see fluid or something that looks like a bulge again after the repair, and that seroma will resolve with time. — Meera Kotagal (clinical) [Ep 6 · 11:34](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=694) - Todd has not seen a seroma very often, but in laparoscopic repair you can get a postoperative hydrocele; all the ones he's seen (2 or maybe 3 in 15 years) have resolved on their own. — Todd (opinion) [Ep 6 · 11:48](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=708) - In general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within 1 to 2 days. — Meera Kotagal (guideline) [Ep 6 · 12:21](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=741) - The most concerning thing when you have an incarcerated hernia that you're unable to reduce, particularly if you see overlying skin changes or signs of strangulation, is bowel ischemia and necrosis. — Meera Kotagal (clinical) [Ep 6 · 12:51](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=771) - If you identify necrotic bowel, you can approach resecting it either through a groin incision or through a small midline incision. — Meera Kotagal (clinical) [Ep 6 · 13:03](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=783) - You can approach laparoscopically and run the bowel to evaluate for ischemia, and then turn to fix the hernia either laparoscopically or open. — Meera Kotagal (clinical) [Ep 6 · 13:17](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=797) - A lot of times, once the patient is put under anesthesia, an incarcerated hernia that you noted and were unable to reduce in the emergency department may actually spontaneously reduce with the patient's relaxation. — Meera Kotagal (clinical) [Ep 6 · 13:29](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=809) - It's important to do a thorough exam and make sure you understand whether or not patients have undescended testes at the time of your pre-op evaluation. — Meera Kotagal (guideline) [Ep 6 · 13:50](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=830) - If a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair. — Meera Kotagal (guideline) [Ep 6 · 14:01](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=841) - Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period. — Meera Kotagal (guideline) [Ep 6 · 14:18](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=858) - If patients are having significant testicular pain after a hernia repair, the most concerning thing is testicular ischemia. — Meera Kotagal (clinical) [Ep 6 · 14:36](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=876) - The best way to evaluate testicular ischemia is to get an ultrasound looking for Doppler flow. — Meera Kotagal (clinical) [Ep 6 · 14:42](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=882) - In general, patients with testicular ischemia after hernia repair are monitored and observed with pain control, and we only frankly remove a necrotic testicle, and not necessarily one that is partially ischemic. — Meera Kotagal (clinical) [Ep 6 · 14:46](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=886) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - When ultrasound shows patent urachus or patent omphalomesenteric duct, the next step is usually operative exploration. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 1 · 1:25](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=85) - On physical exam, an umbilical polyp has a stalk and can be moved around more freely, whereas granulomatous tissue is more stuck on at the base of the belly button. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 1 · 2:16](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=136) - For umbilical hernias, clinicians generally wait until the patient is at least 4 years of age before surgical repair. — Rod Gerardo summarizes what Dr. Mira Kotigal said [Ep 1 · 2:56](https://library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=176) - The Dalton et al. framework from Kansas City predicts the number of fluid boluses needed based on the original chloride level, so labs do not need to be rechecked between each bolus in children likely to require two or three saline boluses. — Meera Kotagal summarizing a resource [Ep 5 · 1:00](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=60) - Randomized controlled trials by Markel et al. and Adebe et al. found that ad lib feeding compared to protocolized feeding is associated with equivalent or shorter hospital stays. — Meera Kotagal summarizing a resource [Ep 5 · 3:30](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=210) - Ad lib feeding may result in more emesis but there were no complications associated with that emesis in the Markel and Adebe trials. — Meera Kotagal summarizing a resource [Ep 5 · 3:30](https://library.globalcastmd.com/watch/pyloric-stenosis-guideline-recap-5786?t=210) - When ultrasound shows a urachal remnant or omphalomesenteric duct but cannot distinguish between them, the next step is operative exploration. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 2 · 1:37](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=97) - For urachal remnant excision, the remnant must be tracked all the way down to the bladder, and the bladder is repaired in two layers. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 2 · 2:00](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=120) - For umbilical hernias, repair is usually deferred until the patient is at least 4 years of age. — Rod Gerardo summarizes what Dr. Mira Kotigal said [Ep 2 · 3:23](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=203) - Families should be counseled about signs of umbilical hernia incarceration or strangulation including abdominal pain, vomiting, overlying skin changes, or a bulge that cannot be reduced. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 2 · 3:50](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=230) - Tacking the skin down at the center of the repair is usually sufficient for recreating the umbilicus. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 2 · 5:03](https://library.globalcastmd.com/watch/differential-diagnosis-and-management-of-pediatric-umbilical-pathologies-16593?t=303) - A good history and physical examination is important to differentiate varied umbilical pathologies. — The host summarizing the discussion [Ep 3 · 6:13](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=373) - Most umbilical hernias spontaneously close by 4 years, so repair can be performed at that point if closure does not occur. — The host summarizing the discussion [Ep 3 · 6:21](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=381) - Umbilical polyps are common and can often be managed non-operatively in the clinic. — The host summarizing the discussion [Ep 3 · 6:28](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=388) - For other umbilical pathologies, ultrasound can help identify the pathology and direct surgical intervention. — The host summarizing the discussion [Ep 3 · 6:33](https://library.globalcastmd.com/watch/diagnosis-and-management-of-pediatric-umbilical-pathologies-16595?t=393) - Umbilical hernias, polyps, and granulomas are some of the most common consults a pediatric surgeon will receive. — The host summarizes what Dr. Mira Kotogal said [Ep 4 · 0:04](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=4) - A good history and physical exam is important to differentiate varied umbilical pathologies. — The host summarizes what Dr. Mira Kotogal said [Ep 4 · 6:13](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=373) - Most umbilical hernias spontaneously close by four years, so repair can be performed at that point if closure does not occur. — The host summarizes what Dr. Mira Kotogal said [Ep 4 · 6:21](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=381) - Umbilical polyps are common and can often be managed non-operatively in the clinic. — The host summarizes what Dr. Mira Kotogal said [Ep 4 · 6:28](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=388) - For umbilical pathologies other than hernias and polyps, ultrasound can help identify the pathology and direct surgical intervention. — The host summarizes what Dr. Mira Kotogal said [Ep 4 · 6:33](https://library.globalcastmd.com/watch/umbilical-pathology-diagnosis-and-management-in-pediatric-surgery-16613?t=393) - Inguinal hernia repair is the 2nd most common surgery that pediatric surgeons perform. — Rod summarizing the discussion [Ep 6 · 0:30](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=30) - Patients with increased intraabdominal pressure (cystic fibrosis, chronic ventilation, chronic constipation, VP shunts, peritoneal dialysis) present more symptomatically with hernias. — Rod summarizing the discussion [Ep 6 · 3:09](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=189) - More than 50% of incarcerations are in patients that are less than 6 months, and 2/3 of incarcerations are in patients who are less than 1 year. — Rod summarizing the discussion [Ep 6 · 4:51](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=291) - If a premature infant's corrected gestational age is less than 60 weeks, they have a high risk for premature apnea post-operatively, so you have to admit them after surgery to monitor. — Rod summarizing the discussion [Ep 6 · 5:02](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=302) - Pain control and sedation help with hernia reduction because if the child is crying, reduction will be difficult. — Rod summarizing the discussion [Ep 6 · 6:05](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=365) - Rare complications include testicular atrophy or damage to the vas deferens. — Rod summarizing the discussion [Ep 6 · 11:26](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=686) - You can resect bowel through a groin incision. — Rod summarizing the discussion [Ep 6 · 13:12](https://library.globalcastmd.com/watch/pediatric-inguinal-hernia-diagnosis-management-and-complications-16594?t=792) --- Educational content from recorded physician discussions — not medical advice. 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