Diagnosis and Management of Pediatric Umbilical Pathologies

The differential diagnosis for a 6-month-old infant with umbilical bulge includes umbilical hernia (most common), urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, hernia of the cord, and omphalitis if significant erythema is present.

Urine draining from the umbilicus is associated with a patent urachus, whereas succus drainage suggests a patent omphalomesenteric duct.

Umbilical granulomas can cause intermittent serosanguinous drainage.

For patent urachus or patent omphalomesenteric duct identified on ultrasound, the next step is usually operative exploration.

Ligation and division of a urachus can be performed through an umbilical incision using a curvilinear fashion in the infraumbilical space.

For urachal remnant repair, the urachus should be tracked all the way down to the bladder and the bladder is usually repaired at that level in two layers.

For patent omphalomesenteric duct or remnant, it should be tracked down to the intestine and resected at the level of the intestine, but small bowel resection is not needed.

An umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that can be excised by tying it off and ligating it in clinic, either dividing it or letting it fall off over time.

An umbilical granuloma is granulation tissue or pink tissue at the base of the umbilicus, often seen in very small infants shortly after umbilical cord separation, and is treated with silver nitrate.

To differentiate umbilical granuloma from polyp on physical exam, use a Q-tip to spread open the umbilicus and look at the base: a polyp has a stalk and moves more freely, whereas granulomatous tissue is more adherent at the base.

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.

For umbilical hernias, repair is generally delayed until the patient is at least 4 years of age, though some recommendations suggest 2 years as the lower age limit.

85% of infant umbilical hernias will close on their own.

Small umbilical hernia defects are more likely to close spontaneously compared to larger defects over 1 to 1.5 cm.

Really large umbilical hernias may be closed earlier if children are symptomatic or if they are so large they are unlikely to close spontaneously.

If umbilical hernia repair is delayed to closer to 4 years of age, families should be counseled about signs of incarceration or strangulation including abdominal pain, vomiting, skin changes, or a bulge that is not reducible.

Routine pediatric umbilical hernia repair is an outpatient procedure involving an infraumbilical curvilinear incision, though some surgeons prefer a vertical incision through the umbilicus.

In pediatric umbilical hernia repair, the umbilical stalk is encircled and divided, the hernia sac is separated from skin and fascia to identify fascial edges, and the defect is closed primarily.

Unlike in adults, mesh is generally not used for pediatric umbilical hernia repair.

When closing a pediatric umbilical hernia, it is important to get all the way back to normal fascia and not close hernia sac to hernia sac.

Even with a prominent proboscis and extra skin at an umbilical hernia site, skin resection or formal umbilicoplasty is generally not needed; tacking down the skin at the center of the repair is sufficient and redundant skin improves over time.

In instances with significant excess skin, umbilicoplasty might be considered, but care must be taken to create a cosmetically normal-appearing umbilicus.