eMedicine Specialties > Pediatrics: Surgery > General Surgery
Disorders of the Umbilicus: Treatment
Updated: Oct 27, 2008
Treatment
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. Large granulomas and those growing in response to an umbilical fistula or sinus do not resolve with silver nitrate and must be surgically excised.
Surgical Therapy
Surgical therapy is the mainstay of treatment for large umbilical granulomas, omphalomesenteric remnants, urachal remnants, umbilical gangrene and necrotizing fasciitis, and 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.
If acute infection with an abscess is present, surgical drainage is required in the operating room or by 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.
Preoperative 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.
A mechanical bowel preparation is not needed. Perioperative antibiotics are used for sinuses and fistulas. Antibiotics are not needed for umbilical hernia repairs.
Intraoperative Details
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 usually be approached through the umbilicus without the need for additional incisions. Alternatively, an infraumbilical incision may be used. An infraumbilical incision is used for umbilical hernias.
During exploration of the umbilicus, all structures must be identified (see Media file 2, Media file 8). The umbilical vein (round ligament), the umbilical arteries (medial umbilical ligaments), and the urachus (median umbilical ligament) must be identified (see Media file 2). A patent vitelline duct must be traced to its origin and divided (see Media file 6). If a Meckel diverticulum is present, 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 2 layers. 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 Media file 9), 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.
For necrotizing fasciitis, wide surgical debridement of the umbilicus and preperitoneal structures, skin, fat, muscle, and fascia back to healthy bleeding tissue is required.5 A silo or fascial patch may be needed.
Postoperative Details
Most umbilical hernia repairs and excision of umbilical remnants can be performed as outpatient procedures. For incisions within the umbilicus not covered by 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 one week.
Most children need only acetaminophen for pain, 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 following surgery or sooner if problems occur.
Complications
Complications of any surgery include intraoperative or postoperative bleeding. Bleeding problems are rare during umbilical surgery. A postoperative hematoma may occur when a large cavity is left following 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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Further Reading
Keywords
umbilical disorders, umbilical granuloma, umbilical infection, omphalitis, omphalomesenteric remnant, umbilical hernia, gastroschisis, omphalocele, delayed separation of the umbilical cord, urachal remnants, abdominal wall defects, umbilical polyps, omphalocele, gastroschisis, dermoid cysts, hemangiomas, inclusion cysts, necrotizing fasciitis, sepsis, Down syndrome, trisomy 13, trisomy 18, Beckwith-Wiedemann syndrome, Staphylococcus aureus, Streptococcus pyogens, bowel obstruction, abdominal distention, tachycardia, purpura, leukocytosis
