# Umbilical Hernia — GCMD Library living collection

Everything in the library about umbilical hernia — built automatically from dossiers that name it.

Updated: n/a · 9 episodes · 189 cited statements

## Episodes
### Fundamentals
- [Umbilical Pathologies Bonus Episode](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331) — podcast · 4:25 · [machine version](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331.md)

### Acute Management
- [Opioid Use in Pediatric Surgery](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297) — video · [machine version](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297.md)

### Surgical Management
- [Umbilical Cord Defects with Dr. Kenneth Azarow](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958) — podcast · 30:16 · [machine version](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958.md)

### Evidence & Research
- [Sutureless Closure of Gastroschisis - APSA Practice Gaps 2019](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302) — video · 21:04 · [machine version](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302.md)
- [What is the ideal timing of umbilical hernia repair in children?](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311) — video · [machine version](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311.md)
- [Gastroschisis and sutureless abdominal wall closure](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557) — podcast · 12:17 · [machine version](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557.md)
- [Best of the Best Gen Surg - Pilot Randomized Control Trial Evaluating the Use of a Shared Decision Making Aid for Older Ventral Hernia Patients - Dr. Kushner](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863) — video · 13:33 · [machine version](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863.md)

### In-Depth Reviews
- [Umbilical Cord Defects with Dr. Kenneth Azarow](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298) — podcast · 30:16 · [machine version](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298.md)
- [22. HerniaTalk LIVE Q&A: Pediatric Hernias](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362) — video · 59:08 · [machine version](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362.md)

## Chapters
- [0:00](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=0) Introduction and podcast overview (Ep 5)
- [1:02](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=62) Timing of umbilical hernia repair in young children (Ep 5)
- [5:13](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=313) Incarcerated umbilical hernias and emergency presentations (Ep 5)
- [7:19](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=439) Technical aspects of umbilical hernia repair (Ep 5)
- [11:51](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=711) Umbilical hernias associated with gastroschisis and omphalocele (Ep 5)
- [16:31](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=991) Umbilical drainage and granulomas in infants (Ep 5)
- [20:04](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1204) Surgical technique for urachal remnants (Ep 5)
- [23:56](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1436) Infected urachal cysts and abscess management (Ep 5)
- [26:12](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1572) Patent omphalomesenteric duct with stool drainage (Ep 5)
- [27:52](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1672) Epigastric hernias (epiploceles) and closing remarks (Ep 5)
- [0:00](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=0) Introduction and umbilical hernia timing (Ep 1)
- [2:28](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=148) Factors affecting umbilical hernia repair timing and incarceration (Ep 1)
- [7:01](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=421) Umbilical hernia surgical technique (Ep 1)
- [12:30](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=750) Umbilical hernias with gastroschisis and omphalocele (Ep 1)
- [16:39](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=999) Mesh use in large umbilical hernias (Ep 1)
- [18:48](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1128) Umbilical drainage and urachal remnants (Ep 1)
- [23:56](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1436) Preoperative workup and infected urachal cysts (Ep 1)
- [26:11](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1571) Patent omphalomesenteric duct and epigastric hernias (Ep 1)
- [28:59](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1739) Conclusion and practice patterns (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=0) Current opioid prescribing practices for common pediatric procedures (Ep 2)
- [3:17](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=197) Epidemiology of pediatric opioid deaths and prescribing patterns (Ep 2)
- [7:18](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=438) Buffalo intervention study results (Ep 2)
- [8:14](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=494) Gabapentin use in pediatric surgery (Ep 2)
- [10:55](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=655) TAP blocks and IV acetaminophen (Ep 2)
- [0:00](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=0) Case presentation and audience polling on gastroschisis closure techniques (Ep 3)
- [2:27](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=147) Origin and evidence for sutureless gastroschisis repair (Ep 3)
- [6:19](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=379) Practice variation, feeding protocols, and patient selection bias (Ep 3)
- [10:40](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=640) Anesthesia considerations and the minimally invasive surgery concept (Ep 3)
- [15:06](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=906) Standardized protocols, complicated gastroschisis, and role of bowel peel (Ep 3)
- [0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0) Timing of umbilical hernia repair in children (Ep 4)
- [0:00](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=0) Introduction and Historical Context of Sutureless Closure (Ep 6)
- [2:45](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=165) Evolution to Consortium Study (Ep 6)
- [5:29](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=329) Study Design and Primary Outcomes (Ep 6)
- [7:59](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=479) Interpretation of Findings and Future Directions (Ep 6)
- [10:19](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=619) Clinical Implications and Closing Thoughts (Ep 6)
- [0:02](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=2) Differential diagnosis of umbilical bulge in infants (Ep 7)
- [1:00](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=60) Distinguishing features and surgical approach to patent urachus and omphalomesenteric duct (Ep 7)
- [1:49](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=109) Umbilical granuloma versus umbilical polyp (Ep 7)
- [2:34](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=154) Risk factors and natural history of umbilical hernias (Ep 7)
- [3:27](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=207) Surgical technique for pediatric umbilical hernia repair (Ep 7)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The sutureless gastroschisis closure technique originated when Tony Sandler at Iowa covered a large defect with umbilical cord and tachyderm, intending to return later, but found the wound had closed spontaneously. — Salim (clinical) [Ep 3 · 2:27](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=147)
- Sandler's first series of sutureless closures included about 10 patients and reported that they did not need to go to the OR and closed on their own. — Salim (clinical) [Ep 3 · 4:30](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=270)
- The old adage that you must close the fascia for all gastroschisis babies is probably not true; some version of skin closure is adequate. — Salim (opinion) [Ep 3 · 6:00](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=360)
- Data over five years shows that about 13% of sutureless repair patients will need an umbilical hernia repair, which is higher than babies who got fascial repair. — Salim (clinical) [Ep 3 · 6:00](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=360)
- Fear of feeding after sutureless closure—hesitation to feed because of concern about distension and evisceration—may be driving longer length of stay. — Todd (opinion) [Ep 3 · 7:20](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=440)
- A feeding protocol was instituted at the speaker's NICU: if residual output is less than 20 per kilo, it comes out; if tolerating, advance by 20 per kilo each day. — Todd (clinical) [Ep 3 · 7:30](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=450)
- In prospective trials, natural selection bias may occur if easier cases are chosen for sutureless closure, leading to better outcomes independent of technique. — Salim (opinion) [Ep 3 · 7:58](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=478)
- The heterogeneity of the gastroschisis population—some cases are easy (one or two loops, little Tylenol) while others are complicated (need silo, OR)—makes a huge difference in results and biases non-randomized trials. — Mac (opinion) [Ep 3 · 12:54](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=774)
- Some surgeons put a silo on, reduce with the silo, and then apply tape, so inability to immediately reduce does not preclude sutureless closure. — Salim (clinical) [Ep 3 · 15:30](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=930)
- At UCLA's UC fetal consortium, all gastroschisis cases are attempted without general anesthesia, without intubation, and with minimal narcotics, using standardized antibiotic and feeding protocols. (clinical) [Ep 3 · 16:02](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=962)
- The UCLA consortium found that length of stay did not decrease with the standardized protocol, but use of antibiotics, intubation days, and opioid use significantly decreased. (clinical) [Ep 3 · 16:40](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1000)
- At UCLA, one surgeon was able to open the defect, reduce everything, and still do a skin or sutureless closure with great outcomes. (clinical) [Ep 3 · 16:40](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1000)
- Complicated gastroschisis cases (atresia, perforation) are excluded from the UCLA sutureless closure pathway. (clinical) [Ep 3 · 16:51](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1011)
- The gastroschisis prognostic score (GPS), which assigned a score based on degree of peel, bowel distension, and matting, did not prove useful in predicting outcomes. — Salim (clinical) [Ep 3 · 17:33](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1053)
- If a gastroschisis case has a very thick peel, very distended bowel, and lots of bowel loops out, immediate closure should not be considered; a silo should be used for reduction. — Salim (opinion) [Ep 3 · 18:40](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1120)
- At the end of silo reduction, a sutureless repair can be performed; immediate closure is not required. — Salim (clinical) [Ep 3 · 19:20](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1160)
- There is no real big need for fascial closure, no matter the size of the gastroschisis defect; skin closure alone is probably adequate. — Salim (opinion) [Ep 3 · 20:00](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1200)
- Matted bowel does not play into the decision for sutureless closure; if it cannot be immediately reduced, a silo is used, and sutureless repair can be done after reduction. — Todd (clinical) [Ep 3 · 20:31](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1231)
- Due to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster. — Jason Frischer (opinion) [Ep 6 · 7:20](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=440)
- Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions. — Jason Frischer (opinion) [Ep 6 · 7:20](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=440)
- In sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection. — Jason Frischer (clinical) [Ep 6 · 8:05](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=485)
- The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation. — Jason Frischer (opinion) [Ep 6 · 8:05](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=485)
- The next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates. — Jason Frischer (clinical) [Ep 6 · 8:50](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530)
- The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up. — Jason Frischer (clinical) [Ep 6 · 8:50](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530)
- Most umbilical hernias will close spontaneously in the first year and some in the second year. — Kenneth Azarow (clinical) [Ep 5 · 2:58](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=178)
- Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5). — Kenneth Azarow (opinion) [Ep 5 · 3:05](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=185)
- A long proboscis does not affect the decision to operate early on an umbilical hernia. — Kenneth Azarow (opinion) [Ep 5 · 3:47](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=227)
- Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery. — Kenneth Azarow (clinical) [Ep 5 · 4:12](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=252)
- Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair. — Kenneth Azarow (opinion) [Ep 5 · 4:40](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=280)
- True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed). — Kenneth Azarow (clinical) [Ep 5 · 5:38](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=338)
- Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel. — Kenneth Azarow (clinical) [Ep 5 · 5:49](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=349)
- Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics. — Kenneth Azarow (clinical) [Ep 5 · 6:09](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=369)
- Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia. — Kenneth Azarow (opinion) [Ep 5 · 6:19](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=379)
- LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent. — Kenneth Azarow (clinical) [Ep 5 · 7:47](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=467)
- PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field). — Kenneth Azarow (clinical) [Ep 5 · 8:26](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=506)
- Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice. — Kenneth Azarow (opinion) [Ep 5 · 8:51](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=531)
- Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result. — Kenneth Azarow (opinion) [Ep 5 · 10:19](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=619)
- Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision. — Kenneth Azarow (clinical) [Ep 5 · 10:37](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=637)
- Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis. — Kenneth Azarow (clinical) [Ep 5 · 11:42](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=702)
- A pressure dressing should remain in place for 3 days after umbilical hernia repair. — Kenneth Azarow (clinical) [Ep 5 · 12:22](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=742)
- Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring). — Kenneth Azarow (clinical) [Ep 5 · 12:37](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=757)
- Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years. — Kenneth Azarow (clinical) [Ep 5 · 13:24](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=804)
- Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously. — Kenneth Azarow (clinical) [Ep 5 · 14:13](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=853)
- Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake. — Kenneth Azarow (opinion) [Ep 5 · 15:00](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=900)
- Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable. — Kenneth Azarow (clinical) [Ep 5 · 15:34](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=934)
- If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time. — Kenneth Azarow (opinion) [Ep 5 · 15:13](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=913)
- For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely. — Kenneth Azarow (clinical) [Ep 5 · 16:48](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1008)
- A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort. — Kenneth Azarow (clinical) [Ep 5 · 17:23](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1043)
- Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms. — Kenneth Azarow (opinion) [Ep 5 · 17:17](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1037)
- A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months. — Kenneth Azarow (epidemiological) [Ep 5 · 19:17](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1157)
- Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery. — Kenneth Azarow (opinion) [Ep 5 · 19:08](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1148)
- Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas. — Kenneth Azarow (opinion) [Ep 5 · 19:29](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1169)
- Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery. — Kenneth Azarow (clinical) [Ep 5 · 20:59](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1259)
- Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily. — Kenneth Azarow (opinion) [Ep 5 · 21:11](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1271)
- A prospective trial at Dr. Ponsky's institution found triamcinolone (Kenalog) cream superior to silver nitrate for umbilical granulomas, with such a drastic difference the study was stopped early. — Todd Ponsky (epidemiological) [Ep 5 · 21:33](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1293)
- Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas. — Kenneth Azarow (clinical) [Ep 5 · 21:49](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1309)
- For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome. — Kenneth Azarow (clinical) [Ep 5 · 22:10](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1330)
- The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus. — Kenneth Azarow (clinical) [Ep 5 · 22:32](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1352)
- A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging. — Kenneth Azarow (epidemiological) [Ep 5 · 24:05](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1445)
- Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology. — Kenneth Azarow (clinical) [Ep 5 · 24:52](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1492)
- After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess. — Kenneth Azarow (clinical) [Ep 5 · 25:01](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1501)
- Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome. — Kenneth Azarow (clinical) [Ep 5 · 25:31](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1531)
- Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge. — Kenneth Azarow (clinical) [Ep 5 · 26:23](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1583)
- Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract. — Kenneth Azarow (clinical) [Ep 5 · 26:36](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1596)
- Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract. — Kenneth Azarow (clinical) [Ep 5 · 26:56](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1616)
- Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias. — Kenneth Azarow (clinical) [Ep 5 · 28:06](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1686)
- The fascial defect in epigastric hernias is typically only 1 millimeter in diameter. — Kenneth Azarow (clinical) [Ep 5 · 28:46](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1726)
- Analysis of PHIS (Pediatric Health Information System) data showed the mean age for umbilical hernia repair across U.S. children's hospitals is 4 years. — Todd Ponsky (epidemiological) [Ep 5 · 29:22](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1762)
- Most umbilical hernias close spontaneously in the first year, with some closing in the second year. — Kenneth Azarow (clinical) [Ep 1 · 2:28](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=148)
- Age 2 is the earliest acceptable time to repair an umbilical hernia with a 2 cm proboscis and 1 cm fascial defect, after extensive counseling; optimal timing is before school entry (age 4–5). — Kenneth Azarow (opinion) [Ep 1 · 3:03](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=183)
- Large proboscis size does not affect the decision to operate early on umbilical hernias. — Kenneth Azarow (opinion) [Ep 1 · 3:35](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=215)
- Even defects greater than 1 cm (approaching 1.5–2 cm) in infants and young toddlers can still close spontaneously, though less likely; defect size does not affect the decision to operate early. — Kenneth Azarow (clinical) [Ep 1 · 4:12](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=252)
- Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair. — Kenneth Azarow (opinion) [Ep 1 · 4:43](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=283)
- True incarcerated umbilical hernia with intestine requires bowel obstruction symptoms (vomiting, inability to feed); a red lump at the umbilicus without GI symptoms is typically incarcerated omentum, preperitoneal fat, or infected urachal cyst, not an emergency. — Kenneth Azarow (clinical) [Ep 1 · 5:19](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=319)
- Incarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery. — Kenneth Azarow (clinical) [Ep 1 · 6:02](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=362)
- For umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery. — Kenneth Azarow (clinical) [Ep 1 · 7:01](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=421)
- Paralysis (general anesthesia with muscle relaxation) makes umbilical hernia repair technically easier than LMA; adequate abdominal wall relaxation is essential to prevent omentum and intestine from pushing out during fascial closure. — Kenneth Azarow (clinical) [Ep 1 · 7:38](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=458)
- PDS or Maxon suture (non-braided, absorbable, lasts twice as long as Vicryl) is preferred for umbilical hernia fascial closure due to the semi-contaminated field around the umbilicus. — Kenneth Azarow (opinion) [Ep 1 · 8:24](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=504)
- Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair; Dr. Ponsky does not, citing lack of literature support and no recalled infections in his practice. — Kenneth Azarow (opinion) [Ep 1 · 8:49](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=529)
- Umbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence. — Kenneth Azarow (opinion) [Ep 1 · 10:08](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=608)
- Umbilicoplasty technique for large proboscis: create a pedicled skin flap (blood supply from above and below, cannot do circumferential incision), position off to one side in a 'lollipop' fashion, and curl the skin; the result will not look perfect but should be flat. — Kenneth Azarow (clinical) [Ep 1 · 10:32](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=632)
- Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence. — Kenneth Azarow (clinical) [Ep 1 · 11:42](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=702)
- A pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome. — Kenneth Azarow (clinical) [Ep 1 · 12:22](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=742)
- Gastroschisis is an umbilical ring defect (not a separate abdominal wall defect) because the natural history is spontaneous closure, which only occurs at the umbilical ring. — Kenneth Azarow (clinical) [Ep 1 · 12:37](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=757)
- Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention. — Kenneth Azarow (clinical) [Ep 1 · 13:25](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=805)
- Omphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered. — Kenneth Azarow (opinion) [Ep 1 · 14:38](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=878)
- Timing for omphalocele repair: wait until the child lying flat shows flanks bulging outward, indicating abdominal girth expansion and potential for primary closure; no specific timeframe (9–18 months or longer). — Kenneth Azarow (clinical) [Ep 1 · 15:26](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=926)
- For large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option. — Kenneth Azarow (clinical) [Ep 1 · 17:00](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1020)
- A 5 mm umbilical hernia in a 4-year-old is not an absolute indication for surgery; intestinal incarceration is rare, but fat can become trapped causing discomfort. — Kenneth Azarow (clinical) [Ep 1 · 17:17](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1037)
- Small umbilical hernias are easier to repair in childhood than adulthood (adult surgeons typically use mesh; pediatric surgeons use simple suture closure). — Todd Ponsky (opinion) [Ep 1 · 17:52](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1072)
- For umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed. — Kenneth Azarow (opinion) [Ep 1 · 18:48](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1128)
- Operating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously. — Kenneth Azarow (clinical) [Ep 1 · 19:23](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1163)
- A Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary. — Kenneth Azarow (epidemiological) [Ep 1 · 24:05](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1445)
- Umbilical granulomas respond better to triamcinolone (Kenalog) cream than silver nitrate, similar to gastrostomy site granulation tissue. — Todd Ponsky (clinical) [Ep 1 · 21:31](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1291)
- Surgical technique for persistent urachal remnant: umbilical exploration identical to hernia repair, divide fascia inferiorly to visualize track, bluntly dissect track from preperitoneal space to bladder dome, ligate at bladder, excise distal epithelialized portion from umbilical skin. — Kenneth Azarow (clinical) [Ep 1 · 22:10](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1330)
- Infected urachal cyst/abscess: treat with antibiotics ± IR percutaneous drainage if true abscess; perform elective laparoscopic excision of entire urachal remnant after cooling down to prevent recurrence. — Kenneth Azarow (clinical) [Ep 1 · 24:40](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1480)
- Laparoscopic urachal remnant excision technique: super-umbilical first port, second port (right or left, upsized to 12 mm) for stapler, staple urachus at bladder dome, extract remnant through umbilicus. — Kenneth Azarow (clinical) [Ep 1 · 25:51](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1551)
- Patent omphalomesenteric duct (stool from umbilicus) will not close spontaneously and requires surgery before hospital discharge due to risk of small bowel volvulus around the fistula. — Kenneth Azarow (clinical) [Ep 1 · 26:23](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1583)
- Patent omphalomesenteric duct repair: umbilical exploration, bring ileum out through umbilicus, perform elliptical resection (large Meckel's diverticulectomy); laparoscopic assistance may be needed if bowel is wrapped around the duct to reduce volvulus before umbilical approach. — Kenneth Azarow (clinical) [Ep 1 · 26:48](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1608)
- Epigastric hernias (epiploceles) are purely elective; they contain only preperitoneal fat through a 1 mm pinhole defect and will not cause intestinal obstruction; repair only if symptomatic. — Kenneth Azarow (clinical) [Ep 1 · 28:06](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1686)
- PHIS hospital data shows the mean age for umbilical hernia repair nationally is 4 years. — Todd Ponsky (epidemiological) [Ep 1 · 29:14](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=1754)
- Umbilical hernia is the most common cause of umbilical bulge in infants. — Meera Kotagal (clinical) [Ep 7 · 0:34](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=34)
- The differential diagnosis of umbilical bulge includes umbilical hernia, urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, and omphalitis (when significant erythema is present). — Meera Kotagal (clinical) [Ep 7 · 0:34](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=34)
- Urine draining from the umbilicus is associated with a patent urachus. — Meera Kotagal (clinical) [Ep 7 · 1:00](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=60)
- Succus draining from the umbilicus suggests a patent omphalomesenteric duct. — Meera Kotagal (clinical) [Ep 7 · 1:00](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=60)
- An umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that can be excised. — Meera Kotagal (clinical) [Ep 7 · 1:56](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=116)
- An umbilical granuloma is granulation tissue or asymptomatic pink tissue at the base of the umbilicus, often seen in very small infants shortly after umbilical cord separation, treated with silver nitrate. — Meera Kotagal (clinical) [Ep 7 · 1:56](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=116)
- The primary risk factor for umbilical hernias is prematurity. — Meera Kotagal (epidemiological) [Ep 7 · 2:42](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=162)
- African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians. — Meera Kotagal (epidemiological) [Ep 7 · 2:42](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=162)
- 85% of infant umbilical hernias will close on their own. — Meera Kotagal (epidemiological) [Ep 7 · 3:09](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=189)
- Small umbilical hernia defects are more likely to close spontaneously compared to larger defects (those over 1 to 1.5 centimeters). — Meera Kotagal (clinical) [Ep 7 · 3:09](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=189)
- Routine pediatric umbilical hernias are repaired as an outpatient procedure. — Meera Kotagal (clinical) [Ep 7 · 3:28](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=208)
- Pediatric umbilical hernia repair does not use mesh, unlike adult repairs. — Meera Kotagal (clinical) [Ep 7 · 3:28](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=208)
- During pediatric umbilical hernia repair, it is important to close normal fascia to normal fascia, not hernia sac to hernia sac. — Meera Kotagal (clinical) [Ep 7 · 3:28](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=208)
- Shared decision making is defined as care that is evidence informed, respectful, and responsive to an individual patient's preferences — Bradley S. Kushner (guideline) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- By the year 2050, the number of adults 60 years of age or older will at least double — Bradley S. Kushner (epidemiological) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- Age-related risk factors and morbidities have been shown to predict mortality and morbidity following eventual hernia repair — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- In phase 1 of the GRAMPS program, age-related risk factors in the elective hernia population were demonstrated to be both common and present a real challenge to the hernia surgeon — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- The novel shared decision making tool was designed based on the Agency for Healthcare Research and Quality suggested framework for incorporating shared decision making into practice and included 5 key parts — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- The tool was designed to be completed in real time during the patient consultation and to act as a living document that patients could reference and bring to their surgery date or subsequent appointments — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- Patients were excluded if they were deemed to be a non-operative candidate despite potential future prehabilitation options or who had a documented history of cognitive impairment — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- During the 4 month trial enrollment period, 18 patients were consented and randomized, half to each of the experimental and control groups, with overall recruitment percentage greater than 95% — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- The median time of consultation was 9 minutes longer in the experimental group — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- There was higher retention of key hernia knowledge in the experimental group when patients were given a follow-up hernia quiz one week after the initial consultation — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- 75% of patients in the experimental group perceived their visit as shared decision making as compared to only 50% in the control group when using the collaborate scale — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- There was a meaningful clinical decrease in the decisional conflict of patients in the experimental group, with a difference of 6 points on the decisional conflict scale — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- Previous groups have found that for every point decrease on the decisional conflict scale, there was an associated 19% less likelihood to blame doctors for poorer outcomes — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- The two most important treatment goals identified by patients in the experimental group were improving quality of life and preventing hernia recurrence — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- Only 1 patient previously had discussed their code status with their doctor, and only 33% had a documented power of attorney — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- 100% of patients in the experimental group both enjoyed the shared decision making aid and found it to be a useful exercise when asked about it on exit interview — Bradley S. Kushner (clinical) [Ep 8 · 0:29](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=29)
- Patients eligible for the study were identified about a week or two before their first hernia clinic by looking at schedules of the three main hernia surgeons at the institution — Bradley S. Kushner (clinical) [Ep 8 · 6:54](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=414)
- Patients were called and told about the study looking at shared decision-making and that they would be randomized to either a newer tool or the standard shared decision-making visit that surgeons typically do — Bradley S. Kushner (clinical) [Ep 8 · 6:54](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=414)
- The IRB required telling patients after the fact that those in the control group were withheld the actual aid — Bradley S. Kushner (clinical) [Ep 8 · 6:54](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=414)
- For a 60-year-old gentleman with a primary 4 centimeter ventral hernia or primary umbilical hernia, asking 10 hernia surgeons might get 10 different answers on how to repair it — Bradley S. Kushner (opinion) [Ep 8 · 9:47](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=587)
- Different hernia repair approaches have potential for different quality of life for the patient in terms of how big the operation would be, the percentage of hernia recurrence, and potential options for the future — Bradley S. Kushner (clinical) [Ep 8 · 9:47](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=587)
- The next phase is a randomized controlled trial currently running with a condensed form of the shared decision-making aid — Bradley S. Kushner (clinical) [Ep 8 · 12:11](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=731)
- The most important parts of the aid were not actually going through all the decision-making with patients, but having it written down for the patient to take home and discuss with their loved ones — Bradley S. Kushner (clinical) [Ep 8 · 12:11](https://origin-library.globalcastmd.com/watch/best-of-the-best-gen-surg-pilot-randomized-control-trial-evaluating-the-use-of-a-5863?t=731)
- Hernias in children (inguinal and appendicitis) are among the most common operations performed in pediatric surgery. — Todd Ponsky (epidemiological) [Ep 9 · 2:02](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=122)
- There are three types of hernias in children: inguinal hernias in the groin, umbilical hernias in the belly button, and epigastric hernias in the top of the abdomen. — Todd Ponsky (clinical) [Ep 9 · 2:11](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=131)
- 80% of umbilical hernias will close spontaneously by the time the child is 3 to 5 years of age. — Todd Ponsky (clinical) [Ep 9 · 5:24](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=324)
- If umbilical hernia repair is performed under age 3, there is a higher chance of recurrence. — Todd Ponsky (clinical) [Ep 9 · 5:37](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=337)
- Age 4 or 5 is the sweet spot for umbilical hernia repair timing. — Todd Ponsky (opinion) [Ep 9 · 5:51](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=351)
- The incidence of umbilical hernia incarceration (intestines getting stuck) is less than 2%. — Todd Ponsky (epidemiological) [Ep 9 · 7:09](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=429)
- The chance of inguinal hernia incarceration in premature newborns is 30% (1 out of 3). — Todd Ponsky (epidemiological) [Ep 9 · 9:40](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=580)
- Once children reach about 1 year of age, the inguinal hernia incarceration rate drops to the same level as adulthood, which is very low (less than 1%). — Todd Ponsky (epidemiological) [Ep 9 · 10:16](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=616)
- During the third trimester of gestation, testicles or ovaries drop from high in the abdomen down into the pelvis, and testicles continue outside the abdomen through a canal between the muscles. — Todd Ponsky (clinical) [Ep 9 · 11:40](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=700)
- The tunnel created by testicular descent usually closes behind the testicles after they descend; when this fails to close (often due to premature birth), a canal remains through which intestines can follow, creating an inguinal hernia. — Todd Ponsky (clinical) [Ep 9 · 11:59](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=719)
- The laparoscopic hernia repair recurrence rate using the modified Japanese approach is less than 1%, confirmed by multiple studies. — Todd Ponsky (clinical) [Ep 9 · 13:16](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=796)
- The original laparoscopic hernia repair technique had a 3-4% recurrence rate, but newer techniques have reduced this to less than 1%. — Todd Ponsky (clinical) [Ep 9 · 13:29](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=809)
- A baby hernia is fundamentally different from an adult hernia: it is not a problem with the muscle, which is totally normal, but rather a persistent thin layer of peritoneum that went between the muscles and stayed open. — Todd Ponsky (clinical) [Ep 9 · 14:38](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=878)
- For pediatric inguinal hernia repair, all that is needed is to remove the thin peritoneal tissue, and the muscles close again naturally. — Todd Ponsky (clinical) [Ep 9 · 15:00](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=900)
- The chance of a pediatric hernia repair failing twice is extremely low, unless the child has a connective tissue disorder. — Todd Ponsky (clinical) [Ep 9 · 15:29](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=929)
- In adolescents, the laparoscopic non-mesh inguinal hernia repair has less than 2% recurrence rate for all patients. — Todd Ponsky (clinical) [Ep 9 · 18:13](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1093)
- At 5-year follow-up, which covers when most recurrences happen (early after surgery), the pediatric repair shows good durability, though lifetime follow-up data beyond 5 years is limited. — Todd Ponsky (clinical) [Ep 9 · 18:36](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1116)
- Direct inguinal hernias are extremely rare in children; Dr. Ponsky has seen only one in 20 years of practice, and it was likely caused by surgical injury during a prior operation. — Todd Ponsky (epidemiological) [Ep 9 · 20:34](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1234)
- With laparoscopic repair, injury to the thin floor that can cause direct hernias cannot happen because the technique does not involve lifting and manipulating structures; it only places a stitch. — Todd Ponsky (clinical) [Ep 9 · 20:52](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1252)
- For pediatric inguinal hernia repair, the technique is typically high ligation (tying off the peritoneal tissue at its origin and removing excess), not a Marcy repair; a Marcy stitch to reinforce muscle is unusual and only used if there is visible muscle weakness. — Todd Ponsky (clinical) [Ep 9 · 21:38](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1298)
- Braided sutures can cause reactions and infections or abscesses when placed close to the skin in open inguinal hernia repairs, so most surgeons use dissolvable stitches for open repairs. — Todd Ponsky (clinical) [Ep 9 · 22:45](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1365)
- In laparoscopic repairs, braided permanent sutures are inside the abdomen and reactions should not occur, though they are possible. — Todd Ponsky (clinical) [Ep 9 · 23:04](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1384)
- Pediatric surgeons are trained specifically for pediatric anatomy and procedures, and patients also benefit from pediatric anesthesiologists when treated by pediatric surgeons. — Todd Ponsky (opinion) [Ep 9 · 23:30](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1410)
- The incidence of mortality from anesthesia in children is less than the chance of being struck by lightning, and less than the chance of being hit by a car while walking. — Todd Ponsky (epidemiological) [Ep 9 · 24:25](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1465)
- Children can develop incisional hernias, and in tiny babies, midline incisions can have a higher incisional hernia rate than in adults because the muscles are not yet strong and formed. — Todd Ponsky (clinical) [Ep 9 · 27:04](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1624)
- In tiny babies, transverse (across the abdomen) incisions are preferred over midline incisions because they have a lower rate of incisional hernia. — Todd Ponsky (clinical) [Ep 9 · 27:22](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1642)
- Mesh is avoided in children because they are still growing; a piece of mesh placed over an area will become distorted and move off to the side as the child grows, no longer covering the intended area. — Todd Ponsky (clinical) [Ep 9 · 28:52](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1732)
- Mesh is not needed in pediatric groin hernias because the primary tissue repair (high ligation) has a less than 1% recurrence rate, which works very well even up to adolescence. — Todd Ponsky (clinical) [Ep 9 · 29:28](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1768)
- Placing mesh in a child who has not been through their fertile years could theoretically injure the spermatic cord (which carries sperm) through scarring and scaffolding formation, which is a concern for future fertility. — Todd Ponsky (clinical) [Ep 9 · 30:28](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1828)
- In children, 20% of the time when fixing one inguinal hernia, there is also a hernia on the other side. — Todd Ponsky (epidemiological) [Ep 9 · 48:20](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2900)
- A hydrocele is a type of hernia where the canal closed almost all the way after testicular descent but left a microscopic hole allowing fluid (but not intestines) to accumulate; these are not dangerous and are mainly a cosmetic problem. — Todd Ponsky (clinical) [Ep 9 · 48:58](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2938)
- Hydroceles are repaired but surgeons wait until children are older because there is no urgency and most resolve spontaneously. — Todd Ponsky (clinical) [Ep 9 · 49:20](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2960)
- Undescended testicles that remain high by the abdomen can cause infertility and have a slightly increased risk of cancer, so they should be brought down into the scrotum for examination and fertility preservation. — Todd Ponsky (clinical) [Ep 9 · 50:20](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=3020)
- Undescended testicle repair is performed by about 6 months to 1 year of age, but many testicles that appear high at birth will descend spontaneously, so observation is appropriate initially. — Todd Ponsky (clinical) [Ep 9 · 50:52](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=3052)
- A retractile testicle (where strong muscles pull small testicles upward but they can be easily pulled down manually) does not require surgery; the testicles will fall normally as the child grows. — Todd Ponsky (clinical) [Ep 9 · 51:31](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=3091)
- There is absolutely a familial/congenital component to hernias, though it does not follow exact autosomal dominant or recessive genetic patterns. — Todd Ponsky (clinical) [Ep 9 · 53:10](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=3190)
- Hiatal hernias are very common in newborns (who vomit frequently due to large hiatal hernias that improve with time), and surgery is avoided unless the baby cannot feed. — Todd Ponsky (clinical) [Ep 9 · 53:49](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=3229)
- Sports hernias are not true hernias but ligamentous tears from aggressive sports; treatment is 6-8 weeks of physical therapy and rest, not surgery. — Todd Ponsky (clinical) [Ep 9 · 45:44](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2744)
- Epigastric hernias (defects in the top of the abdomen) are controversial; many surgeons now trend toward not fixing them because they are more cosmetic, though some fix them to prevent harder repairs in adulthood. — Todd Ponsky (opinion) [Ep 9 · 47:06](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2826)
- When an asymptomatic inguinal hernia defect is found incidentally during another operation, it is typically not repaired at that time because many people have such holes that never cause problems; families are informed it could become symptomatic and require future repair. — Todd Ponsky (clinical) [Ep 9 · 47:50](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2870)
- Biologic mesh does not work very well in pediatric surgery; when bridging is needed (e.g., diaphragmatic hernias, abdominal wall defects), polypropylene or Gore-Tex mesh is typically used. — Todd Ponsky (clinical) [Ep 9 · 44:22](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=2662)
- For acute appendicitis, the speaker's group does not prescribe opioids at discharge and has not had problems with patients calling back. (clinical) [Ep 2 · 0:53](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=53)
- For umbilical hernia repair, patients are put on scheduled acetaminophen and ibuprofen alternating every four hours when awake. (clinical) [Ep 2 · 1:53](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=113)
- Julie Rios gives fewer narcotics to adult patients, using acetaminophen and ibuprofen, and sends them home with a few oxycodone tablets as breakthrough for one or two days. — Julie Rios (clinical) [Ep 2 · 2:47](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=167)
- Gabapentin is used at 300 milligrams TID in bigger kids. (clinical) [Ep 2 · 8:38](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=518)
- Gabapentin is continued even if patients are NPO, as part of ERAS protocol with very short NPO times. (clinical) [Ep 2 · 9:34](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=574)
- In bariatric patients using gabapentin, postop day one discharge increased from about 20% to 50 plus percent. (clinical) [Ep 2 · 10:31](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=631)
- TAP blocks involve medicine that goes intercostally with a catheter that numbs the abdominal wall, allowing patients to get up, move, and pass gas the same day without narcotic medication. — Julie Rios (clinical) [Ep 2 · 11:47](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=707)
- IV Tylenol is very expensive compared to per rectum Tylenol. (clinical) [Ep 2 · 12:38](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=758)
- IV Tylenol is no more or less efficacious than per rectum Tylenol. (clinical) [Ep 2 · 13:00](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=780)
- IV Tylenol used to be hundreds of dollars a dose and is now maybe 20 or 30 dollars a dose. (clinical) [Ep 2 · 13:33](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=813)
- Per rectum Tylenol works just as well as IV with the same bioavailability, according to pharmacy literature on kinetics. (clinical) [Ep 2 · 13:48](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=828)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Multiple retrospective studies reported that sutureless repair patients eat quicker, go home faster, and are probably cheaper to manage. — Salim summarizing the discussion [Ep 3 · 4:50](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=290)
- A randomized study by Brisoni et al. published in the Journal of the American College of Surgeons found that sutureless repair patients took longer to eat and had longer hospital length of stay. — Salim summarizing the discussion [Ep 3 · 5:10](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=310)
- A subsequent 98-patient study from UCSF showed a benefit for sutureless repair in terms of time to feeding and length of stay, conflicting with the Brisoni randomized trial. — Salim summarizing the discussion [Ep 3 · 5:40](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=340)
- Robert Baird's paper from McGill showed everything was better about tape closure, including a lower umbilical hernia rate, which was surprising. — Todd summarizing the discussion [Ep 3 · 6:19](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=379)
- The UCSF study with 98 patients published in JAMA Surgery found a 13% rate of umbilical hernia repair over five years of follow-up in sutureless closure patients. — Salim summarizing the discussion [Ep 3 · 9:45](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=585)
- Studies have shown that when fascial closure is attempted without a silo (immediate repair), those patients tend to have a higher incidence of umbilical or ventral hernias requiring repair. — Salim summarizing the discussion [Ep 3 · 10:20](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=620)
- Every single general anesthetic agent in every class (volatile gas, IV, ketamine, NMDA receptor blockers) has been shown in rat, mice, and sheep studies to cause increased apoptosis and pervasive developmental issues. — Salim summarizing the discussion [Ep 3 · 11:47](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=707)
- The GAS trial and PANDA study in humans showed no difference in neurodevelopmental outcome at five years in babies randomized to spinal versus general anesthesia. — Salim summarizing the discussion [Ep 3 · 12:30](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=750)
- Tony Sandler no longer uses the umbilical cord for sutureless closure; it is not as important as once thought and just sits there. — Salim summarizing the discussion [Ep 3 · 15:06](https://origin-library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=906)
- In 2004, Tony Sandler published the first manuscript about sutureless closures utilizing the natural umbilical properties to close the gastroschisis defect by itself. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 1:44](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=104)
- The Midwest Pediatric Surgery Consortium study was a retrospective cohort of infants born with gastroschisis between 2013 and 2016, with a total of 315 patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- The study divided patients into sutured versus sutureless abdominal wall closures and required subgroup analysis because some babies received silos and some did not. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- Patients who underwent sutureless abdominal wall closure had no difference in days on TPN, time to goal feeds, time to initial feeds, or length of stay compared to sutured closure. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- Sutureless closure patients had less antibiotic use compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- Sutureless closure patients had fewer surgical site and deep space infections compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- Sutureless closure patients had fewer episodes of general anesthetics compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- Sutureless closure patients had less ventilator use compared to sutured closure patients. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- The positive outcomes for sutureless repair were observed even when considering patients who required silo use. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 6:01](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate. — Jason Frischer summarizes what Dr. Jason Fraser said [Ep 6 · 8:50](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530)
- Gastroschisis is an abdominal wall defect that used to necessitate a trip to the OR and is now more like a safe bedside procedure. — Rod Gerardo summarizes what Dr. Jason Fraser said [Ep 6 · 11:22](https://origin-library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=682)
- Emerging anesthesia data suggesting risks of operating before age 2–3 provides additional support for delaying umbilical hernia repair. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 5 · 4:54](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=294)
- A Canadian study by Dr. Baird's group showed that gastroschisis patients closed with sutures had higher rates of subsequent umbilical hernia repair compared to sutureless closure. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 5 · 13:45](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=825)
- A study by Dr. Phil Gazzetta (approximately 60 years ago, in African American babies) showed larger umbilical defects closed less often than smaller defects. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 1 · 3:50](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=230)
- Recent anesthesia data suggesting avoidance of surgery before age 2–3 years provides additional support for delaying umbilical hernia repair. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 1 · 4:43](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=283)
- A Canadian study by Dr. Baird's group showed more umbilical hernia repairs were required after sutured gastroschisis closure compared to sutureless (Sandler) technique, likely because sutures make the umbilical ring edge ischemic and destroy ring integrity. — Todd Ponsky summarizes what Dr. Kenneth Azarow said [Ep 1 · 13:45](https://origin-library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-958?t=825)
- When ultrasound shows patent urachus or patent omphalomesenteric duct, the next step is usually operative exploration. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 7 · 1:25](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=85)
- On physical exam, an umbilical polyp has a stalk and can be moved around more freely, whereas granulomatous tissue is more stuck on at the base of the belly button. — Ellen Encisco summarizes what Dr. Mira Kotigal said [Ep 7 · 2:16](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=136)
- For umbilical hernias, clinicians generally wait until the patient is at least 4 years of age before surgical repair. — Rod Gerardo summarizes what Dr. Mira Kotigal said [Ep 7 · 2:56](https://origin-library.globalcastmd.com/watch/umbilical-pathologies-bonus-episode-5331?t=176)
- New research suggests there may be long-term deleterious neurodevelopmental effects of anesthesia in babies under age 2. — Todd Ponsky summarizing a resource [Ep 9 · 6:10](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=370)
- Most pediatric surgeons in the United States now avoid elective operations until age 2 or 3 unless urgent, due to anesthesia concerns. — Todd Ponsky summarizing a resource [Ep 9 · 6:31](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=391)
- A Mayo Clinic 50-year follow-up study found that the small number of patients requiring re-operation after pediatric inguinal hernia repair had developed direct hernias, which are adult-type hernias, suggesting these were new hernias rather than true recurrences. — Todd Ponsky summarizing a resource [Ep 9 · 20:17](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1217)
- A New England Journal of Medicine publication raised the theory that multiple anesthetics in babies under 2 years may cause neurodevelopmental effects noticeable in adulthood, though this is unclear and will be refuted soon. — Todd Ponsky summarizing a resource [Ep 9 · 24:54](https://origin-library.globalcastmd.com/watch/22-herniatalk-live-q-a-pediatric-hernias-13362?t=1494)
- Umbilical hernia repair is one of the most common operations performed in children. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- Umbilical hernias have a high chance of spontaneous resolution. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- There are almost zero complications while waiting for spontaneous resolution of umbilical hernias. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- Many children are having umbilical hernia repair at an early age. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- A multi-state retrospective cohort study published in the Journal of Pediatrics in 2019 found that umbilical hernia repair before the age of four has double the recurrence rate compared to repair at age four or later. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- A multi-state retrospective cohort study published in the Journal of Pediatrics in 2019 found that umbilical hernia repair before the age of four has double the readmission rate compared to repair at age four or later. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- Surgeons should probably wait until at least the age of four to operate on umbilical hernias if not already doing so. — The host summarizing a resource [Ep 4 · 0:00](https://origin-library.globalcastmd.com/watch/what-is-the-ideal-timing-of-umbilical-hernia-repair-in-children-2311?t=0)
- Over the past 18 years, 9,000 children and adolescents have died from opioids. — The host summarizing the discussion [Ep 2 · 3:47](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=227)
- Opioid mortality rate in children has increased threefold. — The host summarizing the discussion [Ep 2 · 4:00](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=240)
- In kids zero to four years old, there is a 7% death rate from kids getting opioids. — The host summarizing the discussion [Ep 2 · 4:10](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=250)
- 25% of pediatric opioid deaths have been homicides. — The host summarizing the discussion [Ep 2 · 4:18](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=258)
- 81% of pediatric opioid deaths are adolescent. — The host summarizing the discussion [Ep 2 · 4:23](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=263)
- The heroin death rate has increased 485%. — The host summarizing the discussion [Ep 2 · 4:27](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=267)
- Kurt Heist says the return to system or coming back to the hospital or call backs are the same for those with or without opioids, if the Tylenol motrin dosings are scheduled and given in advance. — The host summarizing the discussion [Ep 2 · 4:45](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=285)
- In a study from 2006 to 2014, 68% of patients were prescribed opioids. — The host summarizing the discussion [Ep 2 · 5:20](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=320)
- Adult general surgeons tended to give more opioids than pediatric surgeons. — The host summarizing the discussion [Ep 2 · 5:28](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=328)
- The opioid group has increased ED visits for constipation. — The host summarizing the discussion [Ep 2 · 5:35](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=335)
- In umbilical hernia data from 2012 to 2015, 52% of 4,000 patients received post-op opioids. — The host summarizing the discussion [Ep 2 · 5:50](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=350)
- Six years old or older patients tended to get more opioids than younger kids. — The host summarizing the discussion [Ep 2 · 6:10](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=370)
- Southern US was more problematic than Northeast in opioid prescribing. — The host summarizing the discussion [Ep 2 · 6:18](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=378)
- Duration of opioid prescribing: less than three days was 50%, four to 10 days was almost 50%, and greater than 10 days was 4%. — The host summarizing the discussion [Ep 2 · 6:25](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=385)
- After the Buffalo intervention, opioid prescribing at discharge for appendectomy dropped from 84% to 7%. — The host summarizing the discussion [Ep 2 · 7:45](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=465)
- After the Buffalo intervention, acetaminophen prescribing at discharge increased from 31% to 94%. — The host summarizing the discussion [Ep 2 · 7:58](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=478)
- After the Buffalo intervention, ibuprofen prescribing at discharge increased from 58% to 86%. — The host summarizing the discussion [Ep 2 · 8:05](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=485)
- After the Buffalo intervention, automatic Miralax at discharge dropped from 77% to 47% as there were fewer problems with constipation. — The host summarizing the discussion [Ep 2 · 8:10](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=490)
- Gabapentin dose for younger kids is 5 milligrams per kilo per dose TID for three to five days, according to Dr. Heist. — The host summarizing the discussion [Ep 2 · 9:08](https://origin-library.globalcastmd.com/watch/opioid-use-in-pediatric-surgery-2297?t=548)

## Changelog
- Sep 24: 3 items added automatically
- Sep 17: 2 items added automatically
- Sep 16: 1 item added automatically
- Sep 7: 3 items added automatically

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