Umbilical Cord Defects with Dr. Kenneth Azarow

OK, I have a riddle. A captain and his crew were exploring in an icy region. One of the men called over and said, Captain, I think I've just discovered Adam and Eve. How did he know? Did he not have a belly button? Exactly. So see, the belly button was important even way back then. Actually, Todd, it sounds like belly buttons were not important back then. Good point. So today's podcast is about umbilical disorders, and our expert is Doctor Kenneth Azaro. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Ian Glenn, and Sophia Abdulhai and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to Stay Current in Pediatric Surgery. Today we're going to be talking about a very common problem, not so complicated, but very common, and that's umbilical cord defects. This is something that a lot of us see pretty often as one of the most often things we probably see in our outpatient clinic, and some of these things can be confusing or challenging and definitely controversial. So today we're going to talk to Dr. Kenneth Azrow, who is the Helen B. Tracy Professor of Pediatric Surgery at the Oregon Health and Science University, he is surgeon in chief at Dornbecker Children's Hospital. Dr. Azrow, thanks for joining us. My pleasure as always, Todd. So Ken, you've clearly been an expert in a lot of things. A lot of it's mostly trauma that I've known you for, but we noticed that you wrote a chapter about this. So I assume you must be the expert in umbilical cord defects. I wouldn't say that I'm the expert, but many pediatric surgeons have amassed quite a bit of experience and knowledge, and it's been something that's been of particular interest the last couple of years. OK, perfect. Well, let's jump right into this. So let's start off with a 2-year-old that comes to your office with an umbilical hernia. The pediatrician sent it to you with a question about should we be getting this fixed. The child is asymptomatic, has maybe about a 2 centimeter proboscis from the defect. What do you tell the mom? What's your timing for surgery for this? It's very interesting that you put that as the first question. That's probably one of the most interesting discussions a pediatric surgeon has in the office because no matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day. Parents come in there, they've been looking at it, and they've had it staring right back at them long enough, and they want it fixed. Now, having said that, most umbilical hernias will close on their own, but they'll close on their own in the 1st year and then some in the 2nd year. So once you're at the 2nd year and beyond with a 2 centimeter proboscis and say at least 1 centimeter opening to the abdominal wall, that's the earliest I would ever do this, and that's after a long conversation. To tell the parents we should probably wait another year or two. Typically before they enter school is the optimal time to do this, but after age 2, if there's a big proboscis sticking out, I can be persuaded by the parents, one of the few times. OK, I'm going to give you a bunch of quick scenarios. You tell me how you would do it. Let's take a, let's take a one year old that comes, and the reason the pediatrician sent it to you is because it's a very long proboscis. Would you ever go early because of a long proboscis? No, OK. There was an interesting study that Dr. Phil Gazzetta showed me that was done about, I think, 60 years ago, I think it was in African American babies that showed that the larger defects did not close as often as the smaller defects. Does a larger defect affect your decision? No, and the reason for that is I don't dispute the study. I just don't think it's absolute. I think, you know, even if you have a greater than 1 centimeter, you know, approaching 1.5 to 2 centimeter defect in a baby or a very young toddler. There's still a chance, and I've seen that close many times. While it's less likely to close, that would not affect my decision. I would not operate on early for that. So just to repeat, a large proboscis doesn't affect it. The size of the defect doesn't affect your decision. What about the race or ethnicity of the child? Again, no, it would not affect it. And now another question for you now that we have some of this anesthesia data that may be, you know, operating before 2 or 3 years of age. I mean it sounds like even before that data came out you would have waited anyways, but you know I think for those who like to go early that's just one more argument in favor of waiting. Couldn't agree with you more. Couldn't agree with you more. And that's why I mean I wouldn't even consider it before the age of 2, and I would do and I would do everything I could to talk the family out of it for at least another year or two after that. OK, before I move on from this, is there any other factors you want to talk about relating to? Well, the classic phone call you'll get is that. You have a child in a pediatrician's office who's got a lump at the umbilicus and it's red, and they tell you it's an incarcerated umbilical hernia, and I would say we get one of those a month, and it's never an incarcerated umbilical hernia in the manner that we're thinking of. So intestine incarcerated in the umbilical defect. You need to have a bowel obstruction as you're presenting symptoms for that if the child's eating OK despite everything else going on. It's not an incarcerated umbilical hernia that needs an emergent operation. It's either going to be incarcerated omentum or preperineal fat, or it's going to be an infected urachal cyst. Either way, it's not an emergent indication for surgery. You can have the child come into the office and take a look at the child and kind of go from there. And usually incarcerated fat you can treat with a nonsteroidal and a urachal infection you treat with antibiotics. And you almost never have to operate on those. As a matter of fact, I can't remember the time where I operated on an emergent incarcerated umbilical hernia. I'm sure it happens. I just can't remember ever doing it. So Ken, let me tell you something. So I have had 22 that were presented as an incarcerated hernia, both at our county hospital. Both were truly incarcerated. Did they have GI symptoms or not? No? This is what I was going to say. This is what I was going to say. So both went to the operating room. Both were very tough to reduce. And now that you're saying this, I will tell you in retrospect, both presented with a bowel obstruction. So that is a great that's the rate limiting factor. They present with bowel obstructions. Done deal. Different category. That's not the group that I'm talking about here. And that's what I tell, you know, all the residents and fellows. First thing, even for the groin hernias, you know, you get these, you know, hydroceles or quote unquote incarcerated inguinal hernias. First thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem. That's a great pearl. I love that because you're right, that's how both of mine presented. So let's say you have your 4 year old uncomplicated umbilical hernia. You schedule them for surgery. Talk to me about a few things. First of all, do you do this with LMA, or will you, do you do this with a general anesthesia? Another great question. So type of anesthesia, if the child is paralyzed, it makes it technically easier to do. There is absolutely no question about it. Having said that, I think an LMA is very useful, and if you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you. So you need to have a talk with your anesthesia provider just to make sure they understand that if they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole. Yeah, in my experience I've not had great success with LMA, so I usually do general, but you're right, if they can get them relaxed, it should be done. What type of suture do you use? I'm a big PDS fan. It's either PDS or Maxon, depending upon your company, tends to last about twice as long. Vicryl does, and it's not braided, so I don't think you need a permanent suture. And no matter how much you clean the umbilicus, there's always a question of, you know, operating around the belly button that's semi dirty, so I prefer a non-braided suture. Do you give antibiotics? I do. OK, so I don't give antibiotics. I don't believe that there's literature to support it, so I don't use you give antibiotics for your inguinal hernias? Nope. Good for you. Excellent. I have not had an infection following an umbilical hernia repair that I can remember. Not saying it hasn't happened, but I can't remember any. I have had suture granulomas. Now remember, can I do mine laparoscopically? So I have had two patients that had a suture granuloma spit their knot. That's a totally different issue. I have not had an inguinal infection or an umbilical infection from an from an umbilical hernia repair. I have had them from. Appendectomies and other laparoscopic procedures. Maybe I just haven't had practice long enough. Well, I would say 0 is an impossible number to achieve in our business, but I applaud you for your results. Yeah, I, I haven't had one come back to me. How about that? And that's fine. Most of our infections are like that. As a matter of fact, most of our infections. Soap and water corner of the wound opens up. You don't even have to treat it. It's just done, right. But either way, I have no problem antibiotic or no antibiotic. I typically will use it for umbilicals. I typically do not use it for inguinal incisions, but you're correct, that is anecdotal in my opinion. OK, now, so you do your umbilical repair and you have a bunch of excess skin. Do you do an umbilical plasty? I do. Um, I think that if you don't, you're going to have extremely unhappy parents. I think the skin will stick down, but I think your, your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning. Can you talk to me about how you do your umbilical plasty? Well, it's a little different. It depends if there's a really large proboscis, you literally have to map it out almost as if you're doing, you know, a plastic surgeon. We're doing a breast reconstruction type of a thing. It depends where your incision is. Obviously blood supply comes in from above and below, so you can't do a completely circumferential incision. So you leave a pedicle above, and then it's essentially a pedicleized skin flap that you create. You can put it off to one side, then you can curl the skin around a little bit. So pedicleized, kind of a lollipop fashion, but a little skewed to one side and then just curl it. I think probably no matter what you do it's going to look ugly. So, well, the key is to try and get it flat. If you can get it flat with a scar there, that's better than if you have excess skin hanging out, and I agree with you it's never going to look perfect, but you don't want excess skin hanging out if you can avoid it, right? And I apologize to you now, Ken, that I gave you this topic because like appendicitis, this is one topic that everyone has an opinion on, and I know absolutely. There's no, there's no right, wrong, there's no difference. There's just nothing like that. The one thing I do do is regardless of how you do the skin, I'll tack the under surface of the skin down to the fascia, OK, and that I, and that I will use a braided suture for. I'll use some Vicryl for that just because I want an inflammatory response there. OK. All right, and I think that's a good point, and I will say even within my group, I think we're split 50/50. I also do them. Local plasties. My partners don't like it. They think it flattens over time, but I agree with you. I think you get a better result with it. So, and I wouldn't argue that over time it flattens. I would argue that if it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks. OK, valid point. Do you put a pressure dressing on there or just a regular dress? I do. OK. Pressure dressing stays on for 3 days. OK. All right, I do the same. All right, let's talk about an umbilical hernia that's associated with gastroschisis or halocele. Talk to me about that. So as you know, I think the sutureless gastroschisis closure that our friend Tony Sandler has popularized, I Has changed the way we look at these defects, you know, when, when we went to medical school and residency and even by fellowship, you're, you're taught that an phallocele is an umbilical defect and a gastroschisis is not because it's to the right of an intact umbilical cord. But I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring, so a hernia for gastroschisis. is treated just like an umbilical hernia. In other words, if I have a gastroschisis, it goes closed. I use a sutureless technique for all mine, whether they have a silo or not. Over half of them will have large umbilical hernias, and I don't touch them for several years, and I've only had to fix one umbilical hernia when the child was 5 years of age. The other one's all closed, and those actually took 2 to 3 years to close. They didn't all close in the first year, so I treat them the same way. So it's interesting we recently through our state current Facebook group and also the Journal of Pediatric Surgery Facebook group, we posted a review of a great article from Canada, Dr. Baird's group, that actually showed the opposite of what I thought, that there are actually more umbilical repairs for those that were closed with suture. Versus Dr. Sandler's technique, which shocked me. Almost all of the patients that had Dr. Sandler's repair had the defect initially, but most of them closed. So right, well, that doesn't surprise me because when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring, even though you're closing the defect at the time. So the fact that some of them go on to develop hernias that won't close again, that actually is what I would expect from that study. So it doesn't surprise me. Now phallos, different deal. That's not just the hernia that you can just pop. A few sutures and close, and it's usually not a hernia that'll just close on its own because it's so large. So what you really want to do and the principle is while you've got a covering to the intestine and then however you're going to take care of it, we'll talk about the giant ones. If you're going to do paint and weight, you'll develop a pseudo skin. It's a purely elective situation. Children will grow. They will develop, they will thrive. You just do not want to operate early. I think even to the point of if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough. So I never give the parents a timeframe. If they want to know 9 months, a year, 18 months, I tell them there is no time frame. And what I tell them to look for is let the child grow and develop. And when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together in that situation. So you really just don't want to go too early. Having said that, living with an omphalocele, while it's not dangerous, is definitely lifestyle limiting, so you're going to want to fix it at some point in time. So then you come up with a variety of different choices, and just like our prior situation, I'm sure everybody has their own way of attacking this and doing it. Whether you're going to use component separation or a permanent mesh or a biologic mesh or just try and get it together primarily with a variety of techniques, everybody has their own way of doing this, but the principle is you don't want to operate too early. That's a mistake. Fortunately, Dr. Langer is going to be doing an entire podcast on abdominal wall defects and I have a feeling that's going to be a major part of the discussion, but let me ask you about the use of mesh for a larger umbilical hernia, let's say, in an older patient. Do you use mesh ever in an older teenager? It has to be a fairly large umbilical hernia, and if I'm deciding that ahead of time that I don't think I can get it. Together primarily, then I actually will do it laparoscopically and I'll use mesh, but that's a very rare event in my practice. OK. All right, Dr. Razo, you have a mom that comes to your office with her 4-year-old child who has a pretty small umbilical hernia, asymptomatic. You can feel maybe a 5 millimeter defect. You tell the mom that it's an umbilical hernia, and she says, Do you really need to fix this? What do you say to them? So what I say to them is the presence of that umbilical hernia is not an absolute indication for surgery. Very rarely will the intestine ever be an issue through a 5 millimeter defect. In fact, almost never. On the other hand, little pieces of fat can get caught there, and it might cause some uncomfortableness. If the child has never complained a day in their life and Mom wants to watch this, I'm happy watching it. If the child's kind of having intermittent pain and is tender when you press the lump there, the child probably will benefit from having that little piece of fat excised and that tiny pinhole closed. So I tell them it's not absolute, it's their choice, right? I believe, and I don't know this for a fact, but I believe that it's probably a lot easier for us to fix these in childhood than adults. I'm not aware of the literature that's followed these non-operative umbilicals into adulthood to see if they grow, but the only argument I give to the parents is that it might be a whole lot easier for us to fix this now, but I tell them the same as you, that we don't have to fix it. Yeah, and in fact I had an attending when I trained who used to say the best thing that could happen is a little momentum, get incarcerated, then it necros and it would just scar in there. I don't know if that's true or not, but that's what he used to say. So you know, but you talk to the adult surgeons and most of their umbilicals they do with mesh, whereas we just put a few stitches in. So all right, let's take a different patient. This is a 4 week old that comes to your office and The pediatrician sent this patient to you because she has noticed that she's got some drainage from the umbilicus. How do you evaluate that patient? So physical examination, I mean, really, my and my practice has changed in the last 5 years with this particular patient. I did not do this 20 years ago and 15 years ago. I don't think the patient needs an ultrasound. I don't think the patient needs a VCUG. I don't think the patient needs anything other than a physical examination. And in fact, if there is a tiny drop of clear drainage or even whitish drainage, this patient's just a few months old, I would watch this patient. I participated and we published a study in Nebraska prior to my coming to Oregon. And we showed that if you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve. I've pretty much stopped operating in the 1st 6 months for just tiny little, you know, drops of fluid or little material seen at the umbilicus. Now that's different than a, you know, a full fistula, obviously, and the child's, you know, got urine pouring out of the umbilicus. So that's a completely different deal. But if we're just talking about a tiny drop of fluid or a drop of little decimated skin, sebum that kind of comes out periodically, those can be watched for a while. I've already learned something from what you just said. I used to wait 2 months, and if it was still persistent. It operate, but I like what you're saying, and I agree there's no emergency, so maybe I'll wait longer. Yeah, and even with the whole anesthesia literature that's coming out, some people, I can tell you that people are going to be waiting 12 and 18 months on these kids now because the usual complaint is the mom doesn't even see the fluid. They see a spot on the kid's clothing, and there's just a spot on the kid's clothing, you know, and it comes there every few days, and that's why they do it. And just to state the obvious, Ken, you're Assuming that this child either has a urachal sinus or possibly a granuloma, right? Correct, correct, absolutely correct, which is what most of these remnants will be. They won't really be fistulas. They'll be just sinus tracts that are epithelialized, and you're getting a little bit of fluid or a little bit of semen from that, or you'll have a granuloma there. Tell me what you do if you look and you see a big bright red granuloma there. So big bright red granuloma, if you're seeing that in the first few weeks, I'll give a shot at silver nitrate with that to see if that makes it go away, and a lot of them will just go away with that. I'm not a big fan of ligating those in the office unless there's a very, very, very narrow stalk. Sometimes they're not that narrow and they don't fall off as easy as you think. So silver nitrate, I'm a big fan of, and then I'll watch them. And again, if that persists, take them out 6 months probably. I don't operate in the 1st 3 months at all anymore on those. I love that. So I have a. Comment and then a question. We started a prospective trial here comparing the use of silver nitrate to triamcinolone cream or Kenalog cream, and we're actually going to stop the study early because there's such a drastic difference that the triamcinolone cream improved the granuloma so much better. Yeah, yeah, and you'd expect that because that's the same thing for a gastrostomy. Sites. So if you have granulation tissue at gastrostomy sites, your steroid cream works better than silver nitrate. So I think that's very reasonable. So that's great. So let's say that it's now 6 months or even a year later and it's still draining. Talk to me about what you do in that procedure. Then I'll treat it just like a urachal remnant. I'll do an umbilical exploration. There's usually a fibrosis track that you can follow down to do a bladder ligated, so that's really not a big deal. It's all done through a tiny umbilical incision. And then the real issue with this is inverting the umbilical skin and dealing with the distal part of the remnant. Once you do your umbilical hernia portion, you divide that remnant in half, and then the distal part of the remnant is usually what's losing. It's epithelium and or what's weeping from the granuloma part, then you have to excise that out of the umbilical skin. You do not want to devascularize the umbilicus, so but you can take a little wedge or ellipse out of the center of the umbilicus as long as you've got a good pedicle coming down superiorly for an inferior incision and you're leaving good margins through the umbilicus. And for those graduating fellows who may have spent their entire Fellowship seeking out the big complicated TEF cases and may have missed some of these. When you do your umbilical exploration, you do it like an umbilical hernia repair and then look at the inferior portion to find the track. So identical to an umbilical hernia repair. OK, when you have your little hole, the inferior portion of that, you just have to divide the fascia just a little bit to see the track real well. And then once you do that and you can put a snap on the track. You can just use a tiny little kittner and it just bluntly dissects away from the preperitoneal space and you can literally pull the dome of the bladder all the way up to the like if you need to. That's a great explanation. Sometimes I can just pull up on the peritoneum. On the sack, and as you pull up harder on the sack, you start seeing the urachal remnant. Correct. I find making a tiny little nick in the fascia is not a big deal because that's getting closed anyway with a figure of 8 when you do your umbilical or hernia closed, and it just makes it easier to see the track. I like that. OK, now talk to me about these patients that you think have a urachal anomaly. What kind of preoperative workup do you do for them? So that was, that was the other thing that our paper in Nebraska showed is that we looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did, so I don't, I don't work them up at all. I don't do any preoperative evaluation for them. That's great, so. Now let me take another urachal patient, but presenting quite differently. You get called to the emergency department for, let's say a 3 year old who has abdominal discomfort. They get an ultrasound and they see what looks like a urachal cyst in the midline there. So yes, very different patient. OK, so the first thing is, does the patient have an abscess and is the patient really sick, or does this just look like some cellulitis over the lower abdomen or the umbilicus? You have to determine that because usually antibiotics alone can take care of this and then you can deal with an elective situation. But if you have a true, true, true urachal abscess. And I've seen probably less than 6 dozen of these in my career. Then you have to antibiotics, drain the abscess, and I still would recommend dealing with the whole congenital remnant in an elective situation after you've cooled everything down, because if you don't, you'll wind up with a recurrent abscess. How do you treat this electively now? So if it's a big abscess in the preperitoneal space, I'll have IR do percutaneous drainage and use antibiotics. So when you go back to the OR, what do you do? So now you're doing your elective operation in the OR. So this is also one case that you do have imaging ahead of time, and you really want to know exactly where this is. Most of the time I'll put a scope in. And I'll do this laparoscopically, and you can staple off the urachus right at the dome of the bladder laparoscopically. It's not that difficult to do, and then you can just pull that remnant out through the umbilicus. Where do you put your first port? So the first port, I do a super umbilical, and then my second port will be either right or left side, depends where, and I'll make the Right or left one up to a 12 because you need to get a stapler in to come across that and you want to go kind of a straight shot across the dome of the bladder so you just pick your side as to which side you want to go. OK, so let me ask you about a patient. This is someone that actually I had about a month ago. Babies born in the NICU. They're actually sending the baby home and they noticed there's stool coming from the umbilicus. What do we do with this? So that will not close on its own. So now you're talking about an ocutaneous fistula, so a patently phallo mesenteric duct, and even more dangerous than that is there's a loop of intestine right underneath. And if the fistula has any length to it, that could be a source for a volvulus for small bowel wrapping around that to even complicate things even worse. So that's an operation before you go home from the hospital, OK. And that, hey, you know, we've also changed our practice too. That's a laparoscopic procedure now with a little umbilical approach as well. So that one I would probably approach with an umbilical exploration. And if when I got down to the umbilicus, if I felt that I needed a little extra assistance in freeing up the bowel from the umbilicus, then I'll put a scope in and attack it kind of from the sides just for an assist. Otherwise I'll just do it through an umbilical approach, and I'll bring the ileum straight out the umbilicus and do what I need to, just a little ellipse and then close the bowel back up again. But Sometimes you have to put a scope in to see what's going on. I agree that you can do all this most of the time through a pretty small umbilical incision, sort of get around it and do basically a large Meckel's diverticulectomy. So the problem is if you have bowel already wrapped around it, then that's going to be really hard to reduce through that incision. So then I found that if you put a scope in, typically you can, you can. Twist the bowel from around that and then you don't have to do a giant laparotomy because then once you untwist the bowel, then it comes relatively easy and you just go back to your umbilical approach again. That's a great tip. One last question, I know this is not umbilical, but similar to the umbilical hernia question, if you have a 3 or 4 year old that comes to you and the mom noticed a bump in the epigastrum, what do you tell the mom about fixing those? Again, purely elective, those typically will not go away unless the fat twists and necrosis, and sometimes that can be a little ischemic, and it's preperitoneal fat, and that can cause some discomfort. So what I tell the parents, if it's causing the child discomfort, we'll fix it. If not, there's really no need to. It's purely elective. It's not going to cause an intestinal obstruction. It's always preperitoneal fat, and I tell the residents, don't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole, and then it is literally, as you know, a pinhole. If you do a cut down right over top of it and take the fat, it is a 1 millimeter. Tiny little hole that you're amazed anything could ever get through in a million years, but that's what they're always like, and I always give the choice to the parents. Perfect. Can I give the same choice and inevitably more than half of them come back and say, Yeah, they're having symptoms now. So yeah, I know, but I just don't have it in me to tell them that we just need to fix this. I agree because there are some of them that we don't fix and they do perfectly fine. I agree. Well, that was a fantastic review of something that's probably the most common thing that we deal with, and we did look at the PIS hospitals around the country. We wanted to know when most people repair these the umbilical hernias. It was 4 years of age was the mean. That makes me feel much better. That's great. So people are doing that. But I think the interesting thing will be to look at fizz and see when people are fixing these urachal things. And I think that's going to be a moving target in the next couple of years. No, I think that's great you guys are looking into that at your institution, so. Ken, always a pleasure talking to you. I really appreciate you taking the time to, uh, do this with us today, and we'll be talking to you soon. All right, I'm sure I'll see you in October somewhere. Yes sir, I'm sure. All right, thanks. Bye bye. Bye bye. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. 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