Hey everyone, here is your snack sized bonus episode. My name is Rod Gerardo and I'm Ellen Ancisco, a research fellows at Cincinnati Children's. And today, Doctor Mira Kotigal, pediatric surgeon from Cincinnati Children's Hospital Medical Center, is joining us to give you brief information about umbilical pathologies. So let's dive right in. Doctor Kotigal, we know there are many possible pathologies that come to mind when we see an infant with an umbilical bulge. So what should be on our differential diagnosis? The History and physical are really important in the evaluation of a young child with an umbilical bulge. Your differential diagnosis includes an umbilical hernia, which is obviously the most common, a ureachal cyst, a patent phallo mesenteric duct, umbilical granuloma, or an umbilical polyp, or in some instances, If there's significant erythema, you might consider umphalitis. All right, gotcha. So, is there any sign or symptom that we could use to distinguish them? The presence of umbilical drainage may help you distinguish whether or not it's one of these things. For example, urine draining from the umbilicus would be associated with a patent urachus, whereas if you see succus, you might consider it a patent lymphalamassenteric duct. OK, so we do the ultrasound, we see something. But we can't decide if it's a patent urachus or a patent oomphalomesenteric duct. So what is our next step? Good question, Rod. As far as I know, if the ultrasound shows one of those things, the next step is usually operative exploration. Let's hear more from Doctor Kotokal about the technique. So we make a similar incision that we would make to an umbilical hernia repair in a curvilinear fashion in the infra umbilical space and dissect down. You can then identify the attachments from the um. Like us to the bladder or to the intestine and track those down in order to divide them. OK, I have another question this time. It's for Doctor Kotigal. What's the difference between an umbilical granuloma and an umbilical polyp? An umbilical polyp is a small remnant of the phallo mesenteric duct, which happens to extend from the umbilicus. Usually this is something that we can excise. An umbilical granuloma, granulation tissue or asymptomatic pink tissue that usually is at the base of the umbilicus. We often see that. Very small infants shortly after the umbilical cord has separated, and the treatment for that is silver nitrate. Also, Rod, an important point is differentiating them on physical exam. We usually use a Q-tip or a similar tool to spread open the belly button and look down the base of it. If it's a polyp, you should see a little bit of a stalk and be able to move that tissue around a little bit more freely, whereas granulomatous tissue may be more stuck on, kind of at the base of the belly button. OK, so what about risk factors for umbilical hernia? what increases the chances for these kids? The primary risk factor for umbilical hernias is prematurity. African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians. OK, now I have a question for you, Rod. Let's say you have a 1 year old patient diagnosed with umbilical hernia. When would you try to fix it? OK, so now Ellen is pimping me, but OK, so for umbilical hernias, we generally wait until the patient is at least 4 years of age. Before we fix it. How do we do that? Doctor Kigal, she's gonna explain it. And that's due to the fact that 85% of infant umbilical hernias will close on their own. Small defects are more likely to close spontaneously compared to larger defects, those that are over 1 centimeter or 1 centimeter and a half. OK, I think in this scenario, we need to go with surgery. How do we do a routine umbilical hernia repair? Here's Doctor Koigal. So routine pediatric umbilical hernias are an outpatient procedure. They usually involve an infra umbilical curvilinear incision. Once you've gotten down to the fascia, people will encircle the stalk, umbilical stalk, and then divide it. Once you've done that, then you want to separate the hernia sac from the skin and fascia in that fashion. It allows you to identify the fascial edges and then to close the defect primarily. And unlike in adults, we don't use mesh when we're repairing a child's umbilical hernia. But it is really important to make sure when you do that repair that you get all the way back to normal fashion. And that you're not closing hernia sac to hernia sac. All right, so there you have it. Our quick summary on umbilical pathologies with Doctor Koigal. If you like these little short soundbite podcasts, let us know in the comments. Give us a review, follow us on social media. If you want the full episode, download theta Current pediatric Surgery app. We have full length podcast there waiting for you. But until then, I'm Rod and I'm Ellen. And remember, knowledge should be free.
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