Pediatric emergency medicine trisk 3795 3795

Umbilical Hernias
Umbilical hernias are common in small infants, particularly in AfricanAmericans. Fortunately, most of the hernias tend to close spontaneously, and only
rarely does incarceration occur. Umbilical hernias can be large and unsightly, and
families need reassurance that watchful waiting is the best course. However, if the
umbilical hernia fails to close by the age of 5 to 6 years, surgical repair is
indicated. Umbilical hernias may be repaired earlier if there is a large ring that
shows no signs of diminishing in size over 1 to 2 years, if there is a thinning of
the umbilical skin, or if an incarceration has occurred. Hernias that have a
supraumbilical component tend not to close spontaneously and may be operated
on at an earlier time of life.

Other Umbilical Defects
Omphalomesenteric duct remnants may persist in either of two forms. When the
duct is patent from the ileum to the umbilicus, there is a release of small bowel
contents via an opening in the umbilicus. A second form involves a remnant of
the omphalomesenteric duct that contains a secreting mucosal patch that is
attached to an opening in the center of the umbilicus. Passage of a sterile blunt
probe or instillation of contrast dye under fluoroscopy via the umbilical opening
will usually confirm either of these conditions. Once identified, these remnants
must be excised surgically. In contrast, some infants present with umbilical
granuloma in which an excessive amount of granulation tissue has built up after
separation of the umbilical cord. In these patients, no opening in the granulation
tissue can be seen or felt by means of a probe. These granulomas are usually best
treated by application of silver nitrate to the granulation tissue. After each
treatment, the area should be rinsed thoroughly to prevent burning of adjacent
skin. If the granuloma is allowed to persist, it will eventually epithelialize and
become an umbilical papilloma ( Fig. 116.26 ).