Umbilical Cord Defects Podcast.mp3

Pediatric Surgery
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-chief for Doernbecher Children’s Hospital and Helen B. Tracy professor of pediatric surgery at Oregan Health and Science University.

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UMBILICAL CORD DEFECTS

Umbilical Hernia

  • Timing of surgery:
    • Most umbilical hernias close spontaneously in the 1st year, while some close in 2nd year.
      • Larger defects (>1-2 cm) are less likely to close1.
    • Size of proboscis or defect should not affect timing of surgery.
    • Race/ethnicity should also not affect the decision.
    • Presence of a hernia is no an absolute indication for surgery. If the patient is asymptomatic, it is reasonable to watch; however, it may be easier to fix the defect in childhood than adulthood.
  • Anesthesia:
    • Laryngeal mask airway (LMA) vs General anesthesia (GA)
      • LMA is a useful alternative but only if the anesthesia provider is able to provide enough abdominal wall relaxation.
      • GA has the advantage of paralytics
  • Suture:
    • This closure usually does not require permanent suture
    • Dr. Azarow's preference is PDS or Maxon.
      • This lasts twice as long as Vicryl and is not braided, thus avoiding an inflammatory response.
  • Pre-operative antibiotics:
    • This is based on surgeon preference and its use is anecdotal.
    • There is currently no data that supports antibiotic use in elective umbilical hernia repairs2.
  • Mesh:
    • May need to be considered in adolescents with symptomatic umbilical hernias that are unable to be closed primarily.
  • Umbilicoplasty:
    • Consider performing for cosmesis, especially in patients with a long proboscis.
      • The excess skin after the hernia repair may stick down with time, but patient and family satisfaction may be affected.
      • Technique:
        • If there is a large proboscis, recommend mapping out the resection area before creating the incision, making sure to leave adequate blood supply (blood supply comes from above and below).
        • There are multiple umbilicoplasty techniques described in the literature.
          • Dr. Azarow describes creating a pedicle from the superior flap of skin in a lollipop fashion.
          • The key is to get the umbilicus flat.
        • Tack the undersurface of the umbilicus to the fascia using a braided suture, to create an inflammatory response.
        • Place a pressure dressing and leave it in place for 2-3 days post-operatively.
  • Management of an incarcerated umbilical hernia:
    • If incarcerated bowel,
      • May present with an erythematous umbilicus
      • History must include bowel obstruction symptoms.
      • Will need emergent operative intervention. 
    • If incarcerated omentum or preperitoneal fat,
      • Treat with NSAIDs
      • The defect may be repaired electively. 
Gastroschisis
  • Treat it like an umbilical hernia.
    • Suture-less closure technique was described by Sandler et al. and he found that most of these will close spontaneously3.
  • Primary closure of the defect may have a higher incidence of hernia recurrence compared to the suture-less closure4.
    • It is hypothesized that the suture may make the fascial rim ischemic and destroy its integrity thus resulting in a higher incidence of hernia recurrence. 
Omphalocele
  • These rarely close spontaneously because of the larger defect.
  • The key is to not operate too early.
    • While the intestine is still covered with peritoneum, it can dressed with pseudoskin.
    • If you wait for the child to grow, many will be able to be closed primarily.
    • If unable to close primarily, other options are component separation and mesh (biologic or permanent).
Urachal Anomalies
  • Urachal sinus:
    • This is from an epithelialized sinus tract.
    • It presents as a small amount of white or clear drainage, often seen as a spot on clothing as opposed to active drainage.
    • These may be safely observed. But if drainage persists for more than 6 months to 1 year, then consider surgical removal.
  • Granuloma:
    • These drain serosanguineous fluid if they are very large.
    • First manage them medically using silver nitrate or a steroid cream.
    • If drainage persists for more than 6 months to 1 year, then consider surgical removal.
      • Suture ligation may be considered if there is a narrow stalk.  
  • Urachal cyst:
    • A true urachal abscess is rare.
      • May treat with antibiotics and percutaneous drainage, and then deal with the congenital defect electively.
    • Preoperative imaging is helpful in identifying the exact location of the cyst.
  • Operative management:
    • Consider for persistently draining umbilicus (granuloma or urachal sinus) for greater than 6 months to 1 year.
      • Stopak et al. described possible increase in complications if patients are operated on prior to 6 months of age5.
    • Technique:
      • Perform an umbilical exploration.
        • You will usually find a fibrosed tract.
        • Place a hemostat on the tract, and then bluntly dissect away the surrounding tissue using a blunt instrument, such as a Kittner.
        • If you are having difficulty seeing the tract, consider creating a small incision in the fascia.
        • Dissect until you reaching the dome of the bladder. Ligate the tract off of this.
        • To remove the distal end, you will need to invert the umbilical skin and ligate it. A part of the umbilical skin may also need to be removed in an ellipse fashion, taking care to leave good margins and no devascularize it.
      • If unable to visualize appropriately, may consider laparoscopic exploration.
        • Place a supraumbilical port for your camera, and an additional port on either the right or left side.
        • Use the stapler to ligate the urachal remnant off the dome of the bladder.
        • The remnant may then be pulled out of the umbilicus. The the rest of the procedure as described above. 
Patent Omphalomesenteric duct/enterocutaneous fistula
  • Usually present with stool from the umbilicus.
  • Operative timing:
    • If the fistula is long, it can be a source of volvulus, so these should be managed prior to discharge from the hospital
  • Operative technique:
    • Perform an umbilical exploration. Dissect down the tract until reaching the bowel.
    • May pull ileum out through umbilicus, ellipse out a piece of bowel and then close primarily.
    • If unable to adequately visualize the bowel, then consider laparoscopy-assisted exploration.
      • Laparoscopy will allow you to adequately visualize the bowel, and assist in freeing up the bowel from the umbilicus.
Epigastric hernia (or epiplocele)
  • If it is asymptomatic, this is purely elective and does not require surgical intervention. It is the choice of the parent.
  • If it is symptomatic, it is usually because of necrosis of the preperitoneal fat.
    • These do not close spontaneously and may require surgical management for the symptoms.
    • The procedure is performed by cutting down over the defect and then closing it primarily. The defect is usually small (1 mm).

     

REFERENCES 

  1. Walker SH. The natural history of umbilical hernia. A six-year follow up of 314 Negro children with this defect. Clin Pediatr (Phila). 1967;6(1):29-32.
  2. Horwitz JR, Chwals WJ, Doski JJ, Suescun EA, Cheu HW, Lally KP. Pediatric wound infections: a prospective multicenter study. Ann Surg. 1998;227(4):553-558.
  3. Sandler A, Lawrence J, Meehan J, Phearman L, Soper R. A "Plastic” sutureless abdominal wall closure in gastroschisis. J Pediatr Surg. 2004;39(5):738-741. doi:10.1016/j.jpedsurg.2004.01.040.
  4. Youssef F, Gorgy A, Arbash G, Puligandla PS, Baird RJ. Flap versus fascial closure for gastroschisis: a systematic review and meta-analysis. J Pediatr Surg. 2016;51(5):718-725. doi:10.1016/j.jpedsurg.2016.02.010.
  5. Stopak JK, Azarow KS, Abdessalam SF, Raynor SC, Perry DA, Cusick RA. Trends in surgical management of urachal anomalies. J Pediatr Surg. 2015;50(8):1334-1337. doi:10.1016/j.jpedsurg.2015.04.020.

 

     

     

     

     

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