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Disorders of the Umbilicus Treatment & Management

  • Author: Robert K Minkes, MD, PhD; Chief Editor: Eugene S Kim, MD, FACS, FAAP  more...
 
Updated: Nov 02, 2015
 

Approach Considerations

Small umbilical granulomas usually respond to silver nitrate application. Large umbilical granulomas or those that persist after silver nitrate treatment require surgical excision.

Omphalomesenteric remnants and urachal remnants require surgical excision. The precise diagnosis is often not confirmed until surgery is performed and the anatomy of the umbilicus is established.

The diameter of the umbilical ring defect is predictive of spontaneous closure. The length of the protruding skin is not prognostically significant. Umbilical hernias with ring diameters less than 1 cm are more likely to spontaneously close than those with ring diameters more than 1.5 cm. Surgery is indicated for all symptomatic umbilical hernias. Incarceration, strangulation, skin erosion, and bowel perforation are indications for immediate surgery. Similarly, patients presenting with pain should be repaired on an elective basis.

Asymptomatic umbilical hernias can be safely monitored until the child is aged 4-5 years to allow spontaneous closure, especially if the ring defect is small. Because umbilical hernias with larger defects (ie, >1.5 cm) are unlikely to close spontaneously, surgery can be performed at an earlier age.

Similarly, closing umbilical hernias with large ring defects is reasonable in younger children if the child is having a general anesthetic for another procedure, such as an inguinal hernia repair. It is also reasonable to consider surgery in younger children who have a large protrusion of the umbilical skin that is causing distress to the parents.

For necrotizing fasciitis and gangrene of the umbilical skin, emergency surgical debridement is required and can be life-saving.

No specific contraindications to surgery for umbilical disorders are known, and timing of surgery depends on the general medical condition of the infant or child.

There remains some controversy regarding the optimal timing for umbilical hernia repair, and the true instance of complications related to umbilical hernias in adults is not known.

Most surgeons agree that in the majority of cases, small hernias can be monitored safely. Although spontaneous closure does occur, large hernias with large fascial defects are less likely to close on their own, and continued stretching of the umbilical skin may make closure more difficult. Therefore, many surgeons advocate earlier repair in these children. Others argue that umbilical hernias should be monitored until children reach the age of 5 years.

The umbilicus is a common site for port entry for laparoscopic surgery and is being used for single-incision laparoscopic surgery.

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Medical Therapy

Medical therapy is indicated only when infection is present. For omphalitis or necrotizing fasciitis, broad-spectrum antibiotics are needed. Antibiotics are also administered for acute infection of omphalomesenteric and urachal remnants. Surgical drainage is often needed.

Many umbilical hernias spontaneously close; currently, no medical therapy to hasten this process is recognized.

Silver nitrate application to umbilical granulomas is usually successful. One or more applications may be needed. Care must be taken to avoid contact with the skin. Silver nitrate can cause painful burns. Small umbilical granulomas with a narrow base may be safely excised in the office setting. Large granulomas and those growing in response to an umbilical fistula or sinus do not resolve with silver nitrate and must be surgically excised in the operating room setting.

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Surgical Therapy

Surgical therapy is the mainstay of treatment for the following umbilical conditions: 

  • Large persistent umbilical granulomas
  • Umbilical polyps
  • Omphalomesenteric remnants
  • Urachal remnants
  • Umbilical gangrene and necrotizing fasciitis
  • Umbilical hernias that are symptomatic or do not spontaneously close

Often, surgery on the umbilicus is performed for a mass or drainage without a specific preoperative diagnosis. Surgical principles include identification of all structures of the umbilicus, excision of urachal or omphalomesenteric remnants, closure of the umbilical ring, and preservation of the natural appearance of the umbilicus.

Laparoscopy is a valuable adjunct to open umbilical exploration. It allows identification of both normal and abnormal structures. The laparoscopic approach can be used to remove urachal remnants, as well as omphalomesenteric abnormalities (see the images below).

Laparoscopic view of urachal fistula, which extend Laparoscopic view of urachal fistula, which extends from umbilicus above to bladder below. Image courtesy of Eugene S Kim, MD.
Laparoscopic view of remnant fibrous band of ompha Laparoscopic view of remnant fibrous band of omphalomesenteric duct, which extends from umbilicus to terminal ileum below. Image courtesy of Eugene S Kim, MD.

If acute infection with an abscess is present, surgical drainage is carried out in the operating room or by means of interventional radiology. In most cases, definitive surgical resection of the underlying lesion is needed several weeks following the initial infection.

Wide surgical debridement of the umbilicus and abdominal wall can be life-saving in patients with necrotizing umbilical infections.

Procedural details

Most umbilical procedures can be performed on an elective basis, and surgery should be scheduled when the child is in his or her usual state of health. The exceptions are infants with necrotizing infections and those with stool draining from the umbilicus, indicative of an enteric-umbilical fistula.

Mechanical bowel preparation is not needed. Perioperative antibiotics are used for sinuses and fistulas. Antibiotics are not needed for umbilical hernia repairs.

General anesthesia is used. The child is placed supine. The abdomen should be widely prepared with antiseptic solution and draped in standard fashion. Omphalomesenteric and urachal remnants can be approached directly through the umbilicus or through an incision in the infraumbilical or supraumbilical crease. Larger children may need additional or larger incisions. Laparoscopy can be performed through the umbilical incision.

During exploration of the umbilicus, an attempt is made to identify all anatomic structures (see the image below). A history of infection and resultant inflammation or scar tissue can complicate identification of normal and abnormal structures. Dissection of the umbilicus off the fascia is often useful and can provide access for a small port to perform laparoscopy. The umbilical vein (round ligament), the umbilical arteries (medial umbilical ligaments), and the urachus (median umbilical ligament) can often be identified.

Umbilical region viewed from the posterior surface Umbilical region viewed from the posterior surface of the abdominal wall of an infant with the umbilical cord attached. UA: Umbilical artery; UV: Umbilical vein; RL: Round ligament (obliterated umbilical vein); UR: Umbilical ring; UL: Umbilical ligament; medial (obliterated umbilical arteries); median (obliterated urachus). Note fascial covering of surface and umbilical ring.
Anatomic relationship between the umbilicus and it Anatomic relationship between the umbilicus and its embryologic attachments.

A patent vitelline duct must be traced to its origin and divided. If a Meckel diverticulum is present (see the image below), it is excised. Similarly, the urachus should be traced to its origin and divided. Broad-based connections of the urachus and bladder are closed in two layers.

Omphalomesenteric duct remnants. (A) Meckel divert Omphalomesenteric duct remnants. (A) Meckel diverticulum. Note feeding vessel. (B) Meckel diverticulum attached to posterior surface of anterior abdominal wall by a fibrous cord. (C) Fibrous cord attaching ileum to abdominal wall. (D) Intestinal-umbilical fistula. Intestinal mucosa extends to skin surface. (E) Omphalomesenteric cyst arising in a fibrous cord. The cyst may contain intestinal or gastric mucosa. (F) Umbilical sinus ending in a fibrous cord attaching to the ileum. (G, H) Omphalomesenteric cyst and sinus without intestinal attachments.

Laparoscopy is a useful adjunct, especially when there is a confirmed preoperative diagnosis or when no anomaly is found during the exploration (see the images below).[6] Additional ports can be placed to remove identified urachal or omphalomesenteric structures. Removed structures are sent to pathology for histologic examination.

Laparoscopic removal of urachal cyst (U). L indica Laparoscopic removal of urachal cyst (U). L indicates the left medial umbilical ligament. R indicates the right medial umbilical remnant. B indicates the bladder. The distal attachment to the bladder is being grasped.
Laparoscopic removal of urachal cyst. View is from Laparoscopic removal of urachal cyst. View is from left lower abdomen port. The umbilicus is on the right and the bladder on the left. The attachments or the urachal cyst to the bladder and the umbilicus have been clipped (not shown) and divided. Note the convergence of the right and left medial umbilical ligaments as they approach the umbilical ring on the right.
Photograph of laparoscopically removed urachal cys Photograph of laparoscopically removed urachal cyst and its attachments.

The umbilical fascia is closed with interrupted or running suture. The umbilical skin is then closed. Attempts should be made to create a natural-appearing umbilicus. Antibiotic ointment and a light dressing can be applied to the incision. If an abscess is identified preoperatively or found intraoperatively, an incision-and-drainage procedure is indicated. Definitive resection should be delayed.

Umbilical hernias are approached through an incision in the infraumbilical or supraumbilical crease. Dissection is carried down to the level of the fascia. The hernia sac is identified at its base and encircled. Contents from the hernia sac should be reduced. The sac is then disconnected from its attachment with the umbilicus.

Care is taken to avoid injury to contents within the hernia sac and to the umbilical skin. Opening the anterior surface of the sac may help to avoid injury to the bowel. The sac is resected down to the level of the fascia. The umbilical fascia is closed with interrupted or running absorbable suture. For large or recurrent hernias, nonabsorbable suture is used by many surgeons. The wound should be inspected and meticulous hemostasis achieved.

The umbilicus is tacked down to the fascia with an interrupted suture. The subcutaneous tissue is reapproximated with a few interrupted sutures, and the skin is closed with a subcuticular stitch. Bupivacaine can be injected for postoperative analgesia. The skin is cleaned, and Steri-Strips are applied. A pressure dressing may be used for large hernias to prevent a postoperative hematoma or seroma.

Routine umbilicoplasty (see the image below), the removal of excessive umbilical skin, is generally not needed. In most cases, a redundant umbilicus appears more natural than a neoumbilicus. Several techniques can be used for extremely protuberant umbilical hernias. A simple technique is to invert the umbilicus over a finger so that the undersurface is exposed. The skin is then incised circumferentially so that a 1-cm to 2-cm rim of umbilicus remains. The umbilical skin defect is reapproximated from within the umbilicus and tacked down to the fascia.

Neoumbilicus following umbilicoplasty. Neoumbilicus following umbilicoplasty.

For necrotizing fasciitis, wide surgical debridement of the umbilicus and preperitoneal structures, skin, fat, muscle, and fascia back to healthy bleeding tissue is required.[7] A silo or fascial patch may be needed.

Postoperative care

Most umbilical hernia repairs and excision of umbilical remnants can be performed as outpatient procedures. For incisions within the umbilicus not covered by adhesive bandages (eg, Steri-Strips), antibiotic ointment should be applied twice a day for 3-4 days. Pressure dressings may be removed in 24-48 hours.

Feedings can be initiated when the child recovers from the anesthetic. Incisions are generally kept dry for 3 days. No activity restrictions are indicated for infants and small children. Older children should avoid heavy activity for 1 week.

Most children need only acetaminophen for pain relief, especially when bupivacaine has been used. Older children may require narcotic analgesia.

Follow-up

Children undergoing umbilical surgery must be seen in the surgery clinic 2-6 weeks after the surgical procedure, or sooner if problems occur.

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Complications

Complications of any surgical procedure include intraoperative or postoperative bleeding. Bleeding problems are rare during umbilical surgery. A postoperative hematoma may occur when a large cavity is left after umbilical hernia repair.

Infection of the incision is also rare; however, if infection is present, treatment with antibiotics is indicated. Opening of the incision to drain an abscess may also be needed. Drainage following umbilical exploration and excision may indicate infection or retained embryologic tissue.

Recurrent umbilical hernias are very rare. Small children with larger umbilical hernias often have more pain and can develop a postoperative ileus. Silver nitrate can cause painful burns to the umbilical skin.

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Contributor Information and Disclosures
Author

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Mark V Mazziotti, MD Associate Professor of Surgery and Pediatrics, Baylor College of Medicine, Texas Children's Hospital

Mark V Mazziotti, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Medical Association, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Li Ern Chen, MD Medical Director of Surgical Services, Baylor Health Care System; Director of Surgical Outcomes Research, Department of Surgery, Baylor University Medical Center

Li Ern Chen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Eugene S Kim, MD, FACS, FAAP Associate Professor of Surgery, Division of Pediatric Surgery, Keck School of Medicine of the University of Southern California; Attending Pediatric Surgeon, Children's Hospital Los Angeles

Eugene S Kim, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, Society of University Surgeons, Texas Medical Association, Children's Oncology Group

Disclosure: Nothing to disclose.

Stephen M Megison, MD Professor of Surgery, University of Texas Southwestern Medical Center; Medical Director, Trauma Service, Children's Medical Center, Dallas

Stephen M Megison, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Pediatric Surgical Association, American Trauma Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Deborah F Billmire, MD Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Eugene S Kim, MD, FACS, FAAP Associate Professor of Surgery, Division of Pediatric Surgery, Keck School of Medicine of the University of Southern California; Attending Pediatric Surgeon, Children's Hospital Los Angeles

Eugene S Kim, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, Society of University Surgeons, Texas Medical Association, Children's Oncology Group

Disclosure: Nothing to disclose.

Additional Contributors

Robert Kelly, MD 

Robert Kelly, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Abdominal Surgeons, Medical Society of Virginia, Norfolk Academy of Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Robert S Bloss, MD Clinical Associate Professor of Surgery and Pediatrics, University of Texas Medical School; Clinical Assistant Professor, Department of Surgery, Baylor College of Medicine; Consulting Staff, Houston Pediatric Surgeons

Robert S Bloss, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Southwestern Surgical Congress, and Texas Pediatric Society

Disclosure: Nothing to disclose.

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Cartoon illustrating the developing umbilical cord. (A) Embryonic disk: At this stage, the ventral surface of the fetus is in contact with the yolk sac. (B) The yolk sac narrows as the fetus grows and folds. The intracoelomic yolk sac forms the intestine and communicates with the extracoelomic yolk sac through the vitelline duct. The vitelline duct is also referred to as the omphalomesenteric duct and the yolk stalk. The allantois has begun to grow into the body stalk. (C) The yolk and body stalks fuse to become the umbilical cord.
Umbilical region viewed from the posterior surface of the abdominal wall of an infant with the umbilical cord attached. UA: Umbilical artery; UV: Umbilical vein; RL: Round ligament (obliterated umbilical vein); UR: Umbilical ring; UL: Umbilical ligament; medial (obliterated umbilical arteries); median (obliterated urachus). Note fascial covering of surface and umbilical ring.
Variations in the umbilical ring structure. (A) Usual configuration of the round ligament and urachus. (B) Less common configuration that can result in weakness at the umbilical ring.
Animation demonstrating variability in the covering of the umbilical ring by the umbilical fascia. (A) Complete cover of the umbilical ring (36%). (B) Umbilical fascia is present but does not cover the umbilical ring (4%), or fascia is absent (16%). (C) Umbilical fascia covers the superior portion of the umbilical ring only (38%). (D) Umbilical fascia covers the inferior portion only (6%). Incomplete coverage of the umbilical ring may predispose individuals to formation of umbilical hernias.
Preoperative photograph demonstrating umbilical hernia with redundant skin.
Omphalomesenteric duct remnants. (A) Meckel diverticulum. Note feeding vessel. (B) Meckel diverticulum attached to posterior surface of anterior abdominal wall by a fibrous cord. (C) Fibrous cord attaching ileum to abdominal wall. (D) Intestinal-umbilical fistula. Intestinal mucosa extends to skin surface. (E) Omphalomesenteric cyst arising in a fibrous cord. The cyst may contain intestinal or gastric mucosa. (F) Umbilical sinus ending in a fibrous cord attaching to the ileum. (G, H) Omphalomesenteric cyst and sinus without intestinal attachments.
Photograph of newborn with intestinal prolapse through a patent omphalomesenteric duct. Both the proximal and distal limbs of the intestine have prolapsed. The umbilicus was explored, the bowel was easily reduced, and the patent duct was excised. The child was discharged from the hospital 2 days later.
Anatomic relationship between the umbilicus and its embryologic attachments.
Laparoscopic removal of urachal cyst (U). L indicates the left medial umbilical ligament. R indicates the right medial umbilical remnant. B indicates the bladder. The distal attachment to the bladder is being grasped.
Laparoscopic removal of urachal cyst. View is from left lower abdomen port. The umbilicus is on the right and the bladder on the left. The attachments or the urachal cyst to the bladder and the umbilicus have been clipped (not shown) and divided. Note the convergence of the right and left medial umbilical ligaments as they approach the umbilical ring on the right.
Photograph of laparoscopically removed urachal cyst and its attachments.
Urachal sinus with purulent drainage in midline below the umbilicus (black arrow). A laparoscope was placed in the supraumbilical crease (red arrow) for mobilization of the internal portion of the urachal remnant as depicted in the next image.
Urachal cyst mobilized by the laparoscopic approach. Arrow demonstrates sinus communication through abdominal wall and skin 3 cm inferior to the umbilicus. See next image.
External mobilization of urachal sinus through abdominal wall incision 3 cm inferior to umbilicus. Patient presented with recurrent drainage and infection from sinus. The internal portion was mobilized laparoscopically. See previous image.
Neoumbilicus following umbilicoplasty.
Upper gastrointestinal contrast study showing incidental umbilical hernia in an infant. Red line outlines the umbilical hernia. The arrow shows contrast flowing into the intestine within the umbilical hernia. The umbilical hernia was easily reducible and no intervention based on this study was performed.
Laparoscopic view of urachal fistula, which extends from umbilicus above to bladder below. Image courtesy of Eugene S Kim, MD.
Laparoscopic view of remnant fibrous band of omphalomesenteric duct, which extends from umbilicus to terminal ileum below. Image courtesy of Eugene S Kim, MD.
 
 
 
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