# Umbilical Hernia — GCMD Library living collection Updated: n/a · 4 episodes · 101 cited statements ## Episodes ### Resources - [Umbilical Cord Defects with Dr. Kenneth Azarow](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298) — podcast · 30:16 · [machine version](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298.md) - [Sutureless Closure of Gastroschisis - APSA Practice Gaps 2019](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302) — video · 21:04 · [machine version](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302.md) - [Gastroschisis and sutureless abdominal wall closure](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557) — podcast · 12:17 · [machine version](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557.md) - [Umbilical Cord Defects with Dr. Kenneth Azarow](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958) — podcast · 30:16 · [machine version](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=0) Introduction and podcast overview (Ep 1) - [1:02](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=62) Timing of umbilical hernia repair in young children (Ep 1) - [5:13](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=313) Incarcerated umbilical hernias and emergency presentations (Ep 1) - [7:19](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=439) Technical aspects of umbilical hernia repair (Ep 1) - [11:51](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=711) Umbilical hernias associated with gastroschisis and omphalocele (Ep 1) - [16:31](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=991) Umbilical drainage and granulomas in infants (Ep 1) - [20:04](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1204) Surgical technique for urachal remnants (Ep 1) - [23:56](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1436) Infected urachal cysts and abscess management (Ep 1) - [26:12](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1572) Patent omphalomesenteric duct with stool drainage (Ep 1) - [27:52](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1672) Epigastric hernias (epiploceles) and closing remarks (Ep 1) - [0:00](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=0) Introduction and umbilical hernia timing (Ep 4) - [2:28](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=148) Factors affecting umbilical hernia repair timing and incarceration (Ep 4) - [7:01](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=421) Umbilical hernia surgical technique (Ep 4) - [12:30](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=750) Umbilical hernias with gastroschisis and omphalocele (Ep 4) - [16:39](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=999) Mesh use in large umbilical hernias (Ep 4) - [18:48](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1128) Umbilical drainage and urachal remnants (Ep 4) - [23:56](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1436) Preoperative workup and infected urachal cysts (Ep 4) - [26:11](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1571) Patent omphalomesenteric duct and epigastric hernias (Ep 4) - [28:59](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1739) Conclusion and practice patterns (Ep 4) - [0:00](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=0) Case presentation and audience polling on gastroschisis closure techniques (Ep 2) - [2:27](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=147) Origin and evidence for sutureless gastroschisis repair (Ep 2) - [6:19](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=379) Practice variation, feeding protocols, and patient selection bias (Ep 2) - [10:40](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=640) Anesthesia considerations and the minimally invasive surgery concept (Ep 2) - [15:06](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=906) Standardized protocols, complicated gastroschisis, and role of bowel peel (Ep 2) - [0:00](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=0) Introduction and Historical Context of Sutureless Closure (Ep 3) - [2:45](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=165) Evolution to Consortium Study (Ep 3) - [5:29](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=329) Study Design and Primary Outcomes (Ep 3) - [7:59](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=479) Interpretation of Findings and Future Directions (Ep 3) - [10:19](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=619) Clinical Implications and Closing Thoughts (Ep 3) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - The sutureless gastroschisis closure technique originated when Tony Sandler at Iowa covered a large defect with umbilical cord and tachyderm, intending to return later, but found the wound had closed spontaneously. — Salim (clinical) [Ep 2 · 2:27](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=147) - Sandler's first series of sutureless closures included about 10 patients and reported that they did not need to go to the OR and closed on their own. — Salim (clinical) [Ep 2 · 4:30](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=270) - The old adage that you must close the fascia for all gastroschisis babies is probably not true; some version of skin closure is adequate. — Salim (opinion) [Ep 2 · 6:00](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=360) - Data over five years shows that about 13% of sutureless repair patients will need an umbilical hernia repair, which is higher than babies who got fascial repair. — Salim (clinical) [Ep 2 · 6:00](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=360) - Fear of feeding after sutureless closure—hesitation to feed because of concern about distension and evisceration—may be driving longer length of stay. — Todd (opinion) [Ep 2 · 7:20](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=440) - A feeding protocol was instituted at the speaker's NICU: if residual output is less than 20 per kilo, it comes out; if tolerating, advance by 20 per kilo each day. — Todd (clinical) [Ep 2 · 7:30](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=450) - In prospective trials, natural selection bias may occur if easier cases are chosen for sutureless closure, leading to better outcomes independent of technique. — Salim (opinion) [Ep 2 · 7:58](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=478) - The heterogeneity of the gastroschisis population—some cases are easy (one or two loops, little Tylenol) while others are complicated (need silo, OR)—makes a huge difference in results and biases non-randomized trials. — Mac (opinion) [Ep 2 · 12:54](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=774) - Some surgeons put a silo on, reduce with the silo, and then apply tape, so inability to immediately reduce does not preclude sutureless closure. — Salim (clinical) [Ep 2 · 15:30](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=930) - At UCLA's UC fetal consortium, all gastroschisis cases are attempted without general anesthesia, without intubation, and with minimal narcotics, using standardized antibiotic and feeding protocols. (clinical) [Ep 2 · 16:02](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=962) - The UCLA consortium found that length of stay did not decrease with the standardized protocol, but use of antibiotics, intubation days, and opioid use significantly decreased. (clinical) [Ep 2 · 16:40](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1000) - At UCLA, one surgeon was able to open the defect, reduce everything, and still do a skin or sutureless closure with great outcomes. (clinical) [Ep 2 · 16:40](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1000) - Complicated gastroschisis cases (atresia, perforation) are excluded from the UCLA sutureless closure pathway. (clinical) [Ep 2 · 16:51](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1011) - The gastroschisis prognostic score (GPS), which assigned a score based on degree of peel, bowel distension, and matting, did not prove useful in predicting outcomes. — Salim (clinical) [Ep 2 · 17:33](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1053) - If a gastroschisis case has a very thick peel, very distended bowel, and lots of bowel loops out, immediate closure should not be considered; a silo should be used for reduction. — Salim (opinion) [Ep 2 · 18:40](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1120) - At the end of silo reduction, a sutureless repair can be performed; immediate closure is not required. — Salim (clinical) [Ep 2 · 19:20](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1160) - There is no real big need for fascial closure, no matter the size of the gastroschisis defect; skin closure alone is probably adequate. — Salim (opinion) [Ep 2 · 20:00](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1200) - Matted bowel does not play into the decision for sutureless closure; if it cannot be immediately reduced, a silo is used, and sutureless repair can be done after reduction. — Todd (clinical) [Ep 2 · 20:31](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1231) - Due to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster. — Jason Frischer (opinion) [Ep 3 · 7:20](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=440) - Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions. — Jason Frischer (opinion) [Ep 3 · 7:20](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=440) - In sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection. — Jason Frischer (clinical) [Ep 3 · 8:05](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=485) - The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation. — Jason Frischer (opinion) [Ep 3 · 8:05](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=485) - The next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates. — Jason Frischer (clinical) [Ep 3 · 8:50](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530) - The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up. — Jason Frischer (clinical) [Ep 3 · 8:50](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530) - Most umbilical hernias will close spontaneously in the first year and some in the second year. — Kenneth Azarow (clinical) [Ep 1 · 2:58](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=178) - 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). — Kenneth Azarow (opinion) [Ep 1 · 3:05](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=185) - A long proboscis does not affect the decision to operate early on an umbilical hernia. — Kenneth Azarow (opinion) [Ep 1 · 3:47](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=227) - Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery. — Kenneth Azarow (clinical) [Ep 1 · 4:12](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=252) - Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair. — Kenneth Azarow (opinion) [Ep 1 · 4:40](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=280) - True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed). — Kenneth Azarow (clinical) [Ep 1 · 5:38](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=338) - Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel. — Kenneth Azarow (clinical) [Ep 1 · 5:49](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=349) - Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics. — Kenneth Azarow (clinical) [Ep 1 · 6:09](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=369) - Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia. — Kenneth Azarow (opinion) [Ep 1 · 6:19](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=379) - LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent. — Kenneth Azarow (clinical) [Ep 1 · 7:47](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=467) - 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). — Kenneth Azarow (clinical) [Ep 1 · 8:26](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=506) - Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice. — Kenneth Azarow (opinion) [Ep 1 · 8:51](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=531) - Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result. — Kenneth Azarow (opinion) [Ep 1 · 10:19](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=619) - Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision. — Kenneth Azarow (clinical) [Ep 1 · 10:37](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=637) - Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis. — Kenneth Azarow (clinical) [Ep 1 · 11:42](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=702) - A pressure dressing should remain in place for 3 days after umbilical hernia repair. — Kenneth Azarow (clinical) [Ep 1 · 12:22](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=742) - 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). — Kenneth Azarow (clinical) [Ep 1 · 12:37](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=757) - Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years. — Kenneth Azarow (clinical) [Ep 1 · 13:24](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=804) - Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously. — Kenneth Azarow (clinical) [Ep 1 · 14:13](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=853) - Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake. — Kenneth Azarow (opinion) [Ep 1 · 15:00](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=900) - 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. — Kenneth Azarow (clinical) [Ep 1 · 15:34](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=934) - If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time. — Kenneth Azarow (opinion) [Ep 1 · 15:13](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=913) - For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely. — Kenneth Azarow (clinical) [Ep 1 · 16:48](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1008) - A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort. — Kenneth Azarow (clinical) [Ep 1 · 17:23](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1043) - Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms. — Kenneth Azarow (opinion) [Ep 1 · 17:17](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1037) - A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months. — Kenneth Azarow (epidemiological) [Ep 1 · 19:17](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1157) - Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery. — Kenneth Azarow (opinion) [Ep 1 · 19:08](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1148) - Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas. — Kenneth Azarow (opinion) [Ep 1 · 19:29](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1169) - Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery. — Kenneth Azarow (clinical) [Ep 1 · 20:59](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1259) - Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily. — Kenneth Azarow (opinion) [Ep 1 · 21:11](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1271) - A prospective trial at Dr. Ponsky's institution found triamcinolone (Kenalog) cream superior to silver nitrate for umbilical granulomas, with such a drastic difference the study was stopped early. — Todd Ponsky (epidemiological) [Ep 1 · 21:33](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1293) - Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas. — Kenneth Azarow (clinical) [Ep 1 · 21:49](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1309) - 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. — Kenneth Azarow (clinical) [Ep 1 · 22:10](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1330) - The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus. — Kenneth Azarow (clinical) [Ep 1 · 22:32](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1352) - A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging. — Kenneth Azarow (epidemiological) [Ep 1 · 24:05](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1445) - Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology. — Kenneth Azarow (clinical) [Ep 1 · 24:52](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1492) - After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess. — Kenneth Azarow (clinical) [Ep 1 · 25:01](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1501) - Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome. — Kenneth Azarow (clinical) [Ep 1 · 25:31](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1531) - Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge. — Kenneth Azarow (clinical) [Ep 1 · 26:23](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1583) - Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract. — Kenneth Azarow (clinical) [Ep 1 · 26:36](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1596) - Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract. — Kenneth Azarow (clinical) [Ep 1 · 26:56](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1616) - 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. — Kenneth Azarow (clinical) [Ep 1 · 28:06](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1686) - The fascial defect in epigastric hernias is typically only 1 millimeter in diameter. — Kenneth Azarow (clinical) [Ep 1 · 28:46](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1726) - Analysis of PHIS (Pediatric Health Information System) data showed the mean age for umbilical hernia repair across U.S. children's hospitals is 4 years. — Todd Ponsky (epidemiological) [Ep 1 · 29:22](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1762) - Most umbilical hernias close spontaneously in the first year, with some closing in the second year. — Kenneth Azarow (clinical) [Ep 4 · 2:28](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=148) - Age 2 is the earliest acceptable time to repair an umbilical hernia with a 2 cm proboscis and 1 cm fascial defect, after extensive counseling; optimal timing is before school entry (age 4–5). — Kenneth Azarow (opinion) [Ep 4 · 3:03](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=183) - Large proboscis size does not affect the decision to operate early on umbilical hernias. — Kenneth Azarow (opinion) [Ep 4 · 3:35](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=215) - Even defects greater than 1 cm (approaching 1.5–2 cm) in infants and young toddlers can still close spontaneously, though less likely; defect size does not affect the decision to operate early. — Kenneth Azarow (clinical) [Ep 4 · 4:12](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=252) - Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair. — Kenneth Azarow (opinion) [Ep 4 · 4:43](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=283) - True incarcerated umbilical hernia with intestine requires bowel obstruction symptoms (vomiting, inability to feed); a red lump at the umbilicus without GI symptoms is typically incarcerated omentum, preperitoneal fat, or infected urachal cyst, not an emergency. — Kenneth Azarow (clinical) [Ep 4 · 5:19](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=319) - Incarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery. — Kenneth Azarow (clinical) [Ep 4 · 6:02](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=362) - For umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery. — Kenneth Azarow (clinical) [Ep 4 · 7:01](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=421) - Paralysis (general anesthesia with muscle relaxation) makes umbilical hernia repair technically easier than LMA; adequate abdominal wall relaxation is essential to prevent omentum and intestine from pushing out during fascial closure. — Kenneth Azarow (clinical) [Ep 4 · 7:38](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=458) - PDS or Maxon suture (non-braided, absorbable, lasts twice as long as Vicryl) is preferred for umbilical hernia fascial closure due to the semi-contaminated field around the umbilicus. — Kenneth Azarow (opinion) [Ep 4 · 8:24](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=504) - Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair; Dr. Ponsky does not, citing lack of literature support and no recalled infections in his practice. — Kenneth Azarow (opinion) [Ep 4 · 8:49](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=529) - Umbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence. — Kenneth Azarow (opinion) [Ep 4 · 10:08](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=608) - Umbilicoplasty technique for large proboscis: create a pedicled skin flap (blood supply from above and below, cannot do circumferential incision), position off to one side in a 'lollipop' fashion, and curl the skin; the result will not look perfect but should be flat. — Kenneth Azarow (clinical) [Ep 4 · 10:32](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=632) - Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence. — Kenneth Azarow (clinical) [Ep 4 · 11:42](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=702) - A pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome. — Kenneth Azarow (clinical) [Ep 4 · 12:22](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=742) - Gastroschisis is an umbilical ring defect (not a separate abdominal wall defect) because the natural history is spontaneous closure, which only occurs at the umbilical ring. — Kenneth Azarow (clinical) [Ep 4 · 12:37](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=757) - Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention. — Kenneth Azarow (clinical) [Ep 4 · 13:25](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=805) - Omphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered. — Kenneth Azarow (opinion) [Ep 4 · 14:38](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=878) - Timing for omphalocele repair: wait until the child lying flat shows flanks bulging outward, indicating abdominal girth expansion and potential for primary closure; no specific timeframe (9–18 months or longer). — Kenneth Azarow (clinical) [Ep 4 · 15:26](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=926) - For large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option. — Kenneth Azarow (clinical) [Ep 4 · 17:00](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1020) - A 5 mm umbilical hernia in a 4-year-old is not an absolute indication for surgery; intestinal incarceration is rare, but fat can become trapped causing discomfort. — Kenneth Azarow (clinical) [Ep 4 · 17:17](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1037) - Small umbilical hernias are easier to repair in childhood than adulthood (adult surgeons typically use mesh; pediatric surgeons use simple suture closure). — Todd Ponsky (opinion) [Ep 4 · 17:52](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1072) - For umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed. — Kenneth Azarow (opinion) [Ep 4 · 18:48](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1128) - Operating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously. — Kenneth Azarow (clinical) [Ep 4 · 19:23](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1163) - A Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary. — Kenneth Azarow (epidemiological) [Ep 4 · 24:05](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1445) - Umbilical granulomas respond better to triamcinolone (Kenalog) cream than silver nitrate, similar to gastrostomy site granulation tissue. — Todd Ponsky (clinical) [Ep 4 · 21:31](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1291) - Surgical technique for persistent urachal remnant: umbilical exploration identical to hernia repair, divide fascia inferiorly to visualize track, bluntly dissect track from preperitoneal space to bladder dome, ligate at bladder, excise distal epithelialized portion from umbilical skin. — Kenneth Azarow (clinical) [Ep 4 · 22:10](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1330) - Infected urachal cyst/abscess: treat with antibiotics ± IR percutaneous drainage if true abscess; perform elective laparoscopic excision of entire urachal remnant after cooling down to prevent recurrence. — Kenneth Azarow (clinical) [Ep 4 · 24:40](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1480) - Laparoscopic urachal remnant excision technique: super-umbilical first port, second port (right or left, upsized to 12 mm) for stapler, staple urachus at bladder dome, extract remnant through umbilicus. — Kenneth Azarow (clinical) [Ep 4 · 25:51](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1551) - Patent omphalomesenteric duct (stool from umbilicus) will not close spontaneously and requires surgery before hospital discharge due to risk of small bowel volvulus around the fistula. — Kenneth Azarow (clinical) [Ep 4 · 26:23](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1583) - Patent omphalomesenteric duct repair: umbilical exploration, bring ileum out through umbilicus, perform elliptical resection (large Meckel's diverticulectomy); laparoscopic assistance may be needed if bowel is wrapped around the duct to reduce volvulus before umbilical approach. — Kenneth Azarow (clinical) [Ep 4 · 26:48](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1608) - Epigastric hernias (epiploceles) are purely elective; they contain only preperitoneal fat through a 1 mm pinhole defect and will not cause intestinal obstruction; repair only if symptomatic. — Kenneth Azarow (clinical) [Ep 4 · 28:06](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1686) - PHIS hospital data shows the mean age for umbilical hernia repair nationally is 4 years. — Todd Ponsky (epidemiological) [Ep 4 · 29:14](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1754) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - Multiple retrospective studies reported that sutureless repair patients eat quicker, go home faster, and are probably cheaper to manage. — Salim summarizing the discussion [Ep 2 · 4:50](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=290) - A randomized study by Brisoni et al. published in the Journal of the American College of Surgeons found that sutureless repair patients took longer to eat and had longer hospital length of stay. — Salim summarizing the discussion [Ep 2 · 5:10](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=310) - A subsequent 98-patient study from UCSF showed a benefit for sutureless repair in terms of time to feeding and length of stay, conflicting with the Brisoni randomized trial. — Salim summarizing the discussion [Ep 2 · 5:40](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=340) - Robert Baird's paper from McGill showed everything was better about tape closure, including a lower umbilical hernia rate, which was surprising. — Todd summarizing the discussion [Ep 2 · 6:19](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=379) - The UCSF study with 98 patients published in JAMA Surgery found a 13% rate of umbilical hernia repair over five years of follow-up in sutureless closure patients. — Salim summarizing the discussion [Ep 2 · 9:45](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=585) - Studies have shown that when fascial closure is attempted without a silo (immediate repair), those patients tend to have a higher incidence of umbilical or ventral hernias requiring repair. — Salim summarizing the discussion [Ep 2 · 10:20](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=620) - Every single general anesthetic agent in every class (volatile gas, IV, ketamine, NMDA receptor blockers) has been shown in rat, mice, and sheep studies to cause increased apoptosis and pervasive developmental issues. — Salim summarizing the discussion [Ep 2 · 11:47](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=707) - The GAS trial and PANDA study in humans showed no difference in neurodevelopmental outcome at five years in babies randomized to spinal versus general anesthesia. — Salim summarizing the discussion [Ep 2 · 12:30](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=750) - Tony Sandler no longer uses the umbilical cord for sutureless closure; it is not as important as once thought and just sits there. — Salim summarizing the discussion [Ep 2 · 15:06](https://library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=906) - In 2004, Tony Sandler published the first manuscript about sutureless closures utilizing the natural umbilical properties to close the gastroschisis defect by itself. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 1:44](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=104) - The Midwest Pediatric Surgery Consortium study was a retrospective cohort of infants born with gastroschisis between 2013 and 2016, with a total of 315 patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - The study divided patients into sutured versus sutureless abdominal wall closures and required subgroup analysis because some babies received silos and some did not. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - Patients who underwent sutureless abdominal wall closure had no difference in days on TPN, time to goal feeds, time to initial feeds, or length of stay compared to sutured closure. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - Sutureless closure patients had less antibiotic use compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - Sutureless closure patients had fewer surgical site and deep space infections compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - Sutureless closure patients had fewer episodes of general anesthetics compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - Sutureless closure patients had less ventilator use compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - The positive outcomes for sutureless repair were observed even when considering patients who required silo use. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 6:01](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361) - Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate. — Jason Frischer summarizes what Dr. Jason Fraser said [Ep 3 · 8:50](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530) - Gastroschisis is an abdominal wall defect that used to necessitate a trip to the OR and is now more like a safe bedside procedure. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 3 · 11:22](https://library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=682) - Emerging anesthesia data suggesting risks of operating before age 2–3 provides additional support for delaying umbilical hernia repair. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 1 · 4:54](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=294) - A Canadian study by Dr. Baird's group showed that gastroschisis patients closed with sutures had higher rates of subsequent umbilical hernia repair compared to sutureless closure. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 1 · 13:45](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=825) - A study by Dr. Phil Gazzetta (approximately 60 years ago, in African American babies) showed larger umbilical defects closed less often than smaller defects. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 4 · 3:50](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=230) - Recent anesthesia data suggesting avoidance of surgery before age 2–3 years provides additional support for delaying umbilical hernia repair. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 4 · 4:43](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=283) - A Canadian study by Dr. Baird's group showed more umbilical hernia repairs were required after sutured gastroschisis closure compared to sutureless (Sandler) technique, likely because sutures make the umbilical ring edge ischemic and destroy ring integrity. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 4 · 13:45](https://library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=825) --- Educational content from recorded physician discussions — not medical advice. 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