Umbilical Pathology: Diagnosis and Management in Pediatric Surgery

The differential diagnosis for an umbilical bulge in a young child includes umbilical hernia (most common), urachal cyst, patent umbilical 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 uracus, while succus drainage suggests a patent umbilical duct.

Umbilical drainage is often not clearly urine or succus, and granulomas can also cause intermittent serous drainage.

If ultrasound shows a patent uracus or patent umbilical duct, the next step is usually operative exploration.

A patent uracus can often be ligated and divided through an umbilical incision using a curvilinear infraumbilical approach similar to umbilical hernia repair.

For a urachal remnant, the surgeon should track it all the way down to the bladder and repair the bladder in two layers.

For a patent umbilical duct or umbilical remnant, the surgeon should track it down to the intestine and resect it at the level of the intestine, but small bowel resection is not needed.

An umbilical polyp is a small remnant of the umbilical duct extending from the umbilicus that can be excised by tying it off and ligating it in clinic, either dividing it immediately 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 umbilical cord separation, and is treated with silver nitrate.

To differentiate between an umbilical granuloma and 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, while granulomatous tissue is more stuck at the base.

The primary risk factor for umbilical hernias is prematurity.

African-American infants are eight times more likely to have an umbilical hernia compared to Caucasians.

For umbilical hernias, repair is generally delayed until the patient is at least four years of age, though some recommendations suggest two 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 (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.

If umbilical hernia repair is delayed until age four, families should be counseled about signs of incarceration or strangulation including abdominal pain, vomiting, skin changes, or a non-reducible bulge.

Routine pediatric umbilical hernia repair is an outpatient procedure involving an infraumbilical curvilinear incision (though some surgeons go vertically through the umbilicus).

In pediatric umbilical hernia repair, the surgeon encircles and divides the umbilical stalk, separates the hernia sac from skin and fascia, identifies fascial edges, and closes the defect primarily.

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

During pediatric umbilical hernia repair, it is important to close normal fascia to normal fascia and not hernia sac to hernia sac.

Even with a prominent proboscis and excess skin at an umbilical hernia, 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 at an umbilical hernia, umbilicoplasty might be considered, but care must be taken to create a cosmetically normal-appearing umbilicus.