Differential diagnosis and management of pediatric umbilical pathologies

The differential diagnosis for a pediatric umbilical bulge includes umbilical hernia (most common), urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, and omphalitis if significant erythema is present.

Urine draining from the umbilicus is associated with a patent urachus.

Succus draining from the umbilicus suggests a patent omphalomesenteric duct.

For excision of urachal or omphalomesenteric remnants, a curvilinear infra-umbilical incision is made, attachments from umbilicus to bladder or intestine are identified and tracked down, then divided.

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, then dividing it or letting it fall off over time.

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

On physical exam, an umbilical polyp has a stalk and can be moved around more freely, whereas granulomatous tissue is more stuck on at the base of the belly button.

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.

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

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

Really large umbilical hernias may be closed earlier if children are symptomatic or if they are so large that spontaneous closure is unlikely.

Pediatric umbilical hernia repair is an outpatient procedure involving an infra-umbilical curvilinear incision.

In 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 not typically used to repair an umbilical hernia in a child.

During umbilical hernia repair, it is important to ensure closure extends back to normal fascia and not hernia sac to hernia sac.

Even with a prominent umbilical proboscis and excess skin, skin resection or formal umbilicoplasty is generally not needed.

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