Umbilical Cord Defects with Dr. Kenneth Azarow
With Dr. Kenneth Azarow · hosted by Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Most umbilical hernias close spontaneously in the first year, with some closing in the second year.
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).
Large proboscis size does not affect the decision to operate early on umbilical hernias.
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.
Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.
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.
Incarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery.
For umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery.
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.
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.
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.
Umbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence.
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.
Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence.
A pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome.
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.
Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention.
Omphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered.
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).
For large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option.
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.
Small umbilical hernias are easier to repair in childhood than adulthood (adult surgeons typically use mesh; pediatric surgeons use simple suture closure).
For umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed.
Operating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously.
Umbilical granulomas respond better to triamcinolone (Kenalog) cream than silver nitrate, similar to gastrostomy site granulation tissue.
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.
A Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary.
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.
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.
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.
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.
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.
PHIS hospital data shows the mean age for umbilical hernia repair nationally is 4 years.
A study by Dr. Phil Gazzetta (approximately 60 years ago, in African American babies) showed larger umbilical defects closed less often than smaller defects.
Recent anesthesia data suggesting avoidance of surgery before age 2–3 years provides additional support for delaying umbilical hernia repair.
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.