Most new attending pediatric surgeons are astounded by the number and variety of umbilical disorders that present almost daily in outpatient practice. Umbilical granulomas can usually be treated with silver nitrate, but the pediatrician will have tried two or three times already. Pedunculated granulomas can be ligated after application of alcohol or Betadine using a 000 braided absorbable suture, though almost any sterile suture will do. The granuloma nearly always falls off within 2 weeks. Those that are not amenable to ligation can be treated more aggressively with silver nitrate: apply Vaseline to the surrounding skin, apply the silver nitrate with firm pressure, and repeat the application (or have the parents apply it) on 3 consecutive days. Surgical excision should rarely be necessary and raises the suspicion of a duct remnant.
Parents are often disappointed when the surgeon refuses to repair their child’s umbilical hernia before the age of 2 or 3. Usually, gentle reassurance is enough to dissuade them. It is probably true that infants and young children are at greater risk, have inferior long-term cosmetic results, and are more prone to recurrence than children who are repaired after age 2, but none of these statements has been proven. Most pediatric surgeons are taught to excise the sac, close the fascia transversely and use absorbable suture, but there are many experienced surgeons who simply invert the hernia sac into the abdominal cavity after separating it from the skin, close the fascia in the midline, or use permanent sutures (or even running suture) and have excellent results. It is better to decide whether the child will need an umbilicoplasty before you begin the operation, so that the proper incision can be made. There are several different ways to perform an umbilicoplasty, but regardless, it is important to leave some excess skin to prevent effacement of the umbilicus as the child grows. A simple purse-string closure (after amputating the tip of the proboscis) is usually adequate in most cases, though excising three inverted triangles of skin from the edge usually allows better dermal apposition and improved cosmesis. Meticulous hemostasis is crucial, but pressure dressings should never be necessary.
Urachal and omphalomesenteric duct remnants are interesting but relatively straightforward anomalies to repair. A peri-umbilical incision should be used in most cases as it provides the necessary exposure and is more cosmetically acceptable than a midline or large laparotomy incision. A minimal access technique can be used but in most cases is probably more invasive than a simple peri-umbilical incision. It is almost always a mistake to attempt resection of a urachal cyst that is actively infected, as this turns a simple procedure into a complicated and potentially dangerous operation.
Omphalitis can be life-threatening and usually warrants aggressive treatment with hospital admission, intravenous antibiotics, and meticulous surveillance for a necrotizing process. Necrotizing fasciitis is a devastating complication that requires aggressive surgical debridement of the abdominal wall and advanced surgical techniques for delayed reconstruction.