Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Umbilical Cord Defects with Dr. Kenneth Azarow
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This podcast discusses the work up and management of umbilical cord defects. Dr. Todd A. Ponsky is an associate professor of surgery and pediatrics and pediatric surgeon at Akron Children's Hospital. Dr. Kenneth S. Azarow is surgeon-in-chie
podcast30:16 · Dec 2020
Sutureless Closure of Gastroschisis - APSA Practice Gaps 2019
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At the 7th Annual Pediatric Surgery Update Course, Dr. Saleem Islam discusses sutureless closure of gastroschisis, one of the 2019 practice gaps identified by the American Pediatric Surgical Association’s Professional Development Committee.
video21:04 · Mar 2020
Gastroschisis and sutureless abdominal wall closure
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Dr. Rod Gerardo and Dr. Todd Ponsky talk to Dr. Jason Fraser about the paradigm shift in gastroschisis management that is still in flux. Plus a deep dive into Dr. Fraser's recent publication: "Sutureless vs sutured abdominal wall closure fo
podcast12:17 · Jan 2021
Umbilical Cord Defects with Dr. Kenneth Azarow
Listen →
This podcast discusses the work up and management of umbilical cord defects. Dr. Todd A. Ponsky is an associate professor of surgery and pediatrics and pediatric surgeon at Akron Children's Hospital. Dr. Kenneth S. Azarow is surgeon-in-chie
podcast30:16 · Jan 2019
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Spontaneous closure remains the dominant natural history: most umbilical hernias close in the first year, with additional closures in year two. Even defects exceeding 1 cm may close spontaneously, though less reliably than smaller defects. Optimal repair timing is age 4–5 (before school entry); age 2 is the earliest acceptable threshold after extensive counseling, supported by emerging anesthesia safety data favoring delay until age 2–3. National PHIS data confirm mean repair age of 4 years. Neither proboscis size nor patient race/ethnicity alters timing decisions.
True incarceration is exceedingly rare and requires bowel obstruction symptoms (vomiting, feeding intolerance); red umbilical lumps without GI symptoms represent incarcerated omentum, preperitoneal fat, or infected urachal cysts—not surgical emergencies. Conservative management with NSAIDs or antibiotics suffices. Technical repair principles include PDS/Maxon suture (non-braided, prolonged absorption) for fascial closure, umbilicoplasty with pedicled flap technique to achieve flat contour, fascial tacking with braided suture to promote skin adherence, and 3-day pressure dressing. Adequate muscle relaxation is essential. Gastroschisis-related hernias merit special consideration: sutureless closure produces >50% hernia rate but most close spontaneously over 2–3 years; sutured closure damages ring integrity and paradoxically increases repair need.
- Delay repair until age 4–5; age 2 is earliest acceptable threshold. Defect size, proboscis length, and race do not justify early operation.[e298-c2][e298-c3][e298-c4][e298-c5][e958-c2]
- Red umbilical lump without vomiting/feeding intolerance is not incarcerated bowel—treat omentum/fat with NSAIDs, infected urachal cyst with antibiotics.[e298-c7][e298-c8][e298-c9][e958-c8][e958-c9]
- Use PDS/Maxon for fascial closure (prolonged absorption, non-braided), perform umbilicoplasty with pedicled flap, tack skin to fascia with Vicryl, apply 3-day pressure dressing.[e298-c12][e298-c14][e298-c15][e298-c16][e298-c17]
- Gastroschisis is an umbilical ring defect; sutureless closure causes >50% hernia rate but most close spontaneously. Sutured closure damages ring, increasing repair need.[e298-c18][e298-c19][e298-c20][e298-c21]
- Delay omphalocele repair until flanks bulge when supine (abdominal domain expansion). Wait longer if mesh seems inevitable—many achieve primary closure with time.[e298-c22][e298-c23][e298-c24]
For patients & families
Umbilical hernias are common in babies and young children, appearing as a soft bulge at the belly button. The good news is that most of these hernias close on their own during the first year or two of life. Even larger openings—over 1 centimeter—can still close naturally, though they may take longer. Doctors typically wait until a child is at least 2 years old before considering surgery, and many prefer to wait until closer to school age (around 4–5 years) to give the hernia more time to close and to avoid anesthesia risks in very young children. National data shows that the average age for umbilical hernia repair is 4 years. Parents sometimes worry when they see a red, tender lump at the belly button, but doctors explain this is usually trapped fat or an infection—not trapped intestine—and can be treated with anti-inflammatory medicine or antibiotics rather than emergency surgery. True emergencies, where bowel is trapped and blocked, cause vomiting and feeding problems. When surgery is needed, doctors repair the opening in the muscle layer and reshape the belly button for a flat, natural appearance. A pressure bandage stays on for three days to help healing.
Umbilical hernias are common in babies and young children, appearing as a soft bulge at the belly button. The good news is that most of these hernias close on their own during the first year or two of life. Even larger openings—over 1 centimeter—can still close naturally, though they may take longer. Doctors typically wait until a child is at least 2 years old before considering surgery, and many prefer to wait until closer to school age (around 4–5 years) to give the hernia more time to close and to avoid anesthesia risks in very young children. National data shows that the average age for umbilical hernia repair is 4 years. Parents sometimes worry when they see a red, tender lump at the belly button, but doctors explain this is usually trapped fat or an infection—not trapped intestine—and can be treated with anti-inflammatory medicine or antibiotics rather than emergency surgery. True emergencies, where bowel is trapped and blocked, cause vomiting and feeding problems. When surgery is needed, doctors repair the opening in the muscle layer and reshape the belly button for a flat, natural appearance. A pressure bandage stays on for three days to help healing.
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Sutureless Closure of Gastroschisis - APSA Practice Gaps 2019
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.
clinicalSalim2:27 ↗
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.
clinicalSalim4:30 ↗
Multiple retrospective studies reported that sutureless repair patients eat quicker, go home faster, and are probably cheaper to manage.
Host summarySalim summarizing the discussion — not the host's own clinical position4:50 ↗
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.
Host summarySalim summarizing the discussion — not the host's own clinical position5:10 ↗
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.
Host summarySalim summarizing the discussion — not the host's own clinical position5:40 ↗
The old adage that you must close the fascia for all gastroschisis babies is probably not true; some version of skin closure is adequate.
opinionSalim6:00 ↗
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.
clinicalSalim6:00 ↗
Robert Baird's paper from McGill showed everything was better about tape closure, including a lower umbilical hernia rate, which was surprising.
Host summaryTodd summarizing the discussion — not the host's own clinical position6:19 ↗
Fear of feeding after sutureless closure—hesitation to feed because of concern about distension and evisceration—may be driving longer length of stay.
opinionTodd7:20 ↗
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.
clinicalTodd7:30 ↗
In prospective trials, natural selection bias may occur if easier cases are chosen for sutureless closure, leading to better outcomes independent of technique.
opinionSalim7:58 ↗
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.
Host summarySalim summarizing the discussion — not the host's own clinical position9:45 ↗
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.
Host summarySalim summarizing the discussion — not the host's own clinical position10:20 ↗
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.
Host summarySalim summarizing the discussion — not the host's own clinical position11:47 ↗
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.
Host summarySalim summarizing the discussion — not the host's own clinical position12:30 ↗
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.
opinionMac12:54 ↗
Tony Sandler no longer uses the umbilical cord for sutureless closure; it is not as important as once thought and just sits there.
Host summarySalim summarizing the discussion — not the host's own clinical position15:06 ↗
Some surgeons put a silo on, reduce with the silo, and then apply tape, so inability to immediately reduce does not preclude sutureless closure.
clinicalSalim15:30 ↗
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.
clinical16:02 ↗
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.
clinical16:40 ↗
At UCLA, one surgeon was able to open the defect, reduce everything, and still do a skin or sutureless closure with great outcomes.
clinical16:40 ↗
Complicated gastroschisis cases (atresia, perforation) are excluded from the UCLA sutureless closure pathway.
clinical16:51 ↗
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.
clinicalSalim17:33 ↗
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.
opinionSalim18:40 ↗
At the end of silo reduction, a sutureless repair can be performed; immediate closure is not required.
clinicalSalim19:20 ↗
There is no real big need for fascial closure, no matter the size of the gastroschisis defect; skin closure alone is probably adequate.
opinionSalim20:00 ↗
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.
clinicalTodd20:31 ↗
Gastroschisis and sutureless abdominal wall closure
In 2004, Tony Sandler published the first manuscript about sutureless closures utilizing the natural umbilical properties to close the gastroschisis defect by itself.
Host summaryRod Gerardo summarizes what Dr. Jason Fraser said — not the host's own clinical position1:44 ↗
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.
Host summaryRod Gerardo summarizes what Dr. Jason Fraser said — not the host's own clinical position6:01 ↗
The study divided patients into sutured versus sutureless abdominal wall closures and required subgroup analysis because some babies received silos and some did not.
Host summaryRod Gerardo summarizes what Dr. Jason Fraser said — not the host's own clinical position6:01 ↗
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