When the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together in that situation.
when the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together
when you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring
if you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring.
I think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 21 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 21 · 3:05
opinionAge 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).↗
▶Ep 21 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 21 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 21 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 21 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 21 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 21 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 21 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 21 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 21 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 21 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 21 · 8:26
clinicalPDS 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).↗
▶Ep 21 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 21 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 21 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 21 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 21 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 21 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 21 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 21 · 12:37
clinicalGastroschisis 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).↗
▶Ep 21 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 21 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 21 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 21 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 21 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 21 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 21 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 21 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 21 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 21 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 21 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 21 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 21 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 21 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 21 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 21 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 21 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 21 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 21 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 21 · 22:10
clinicalFor 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.↗
▶Ep 21 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 21 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 21 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 21 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 21 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 21 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 21 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 21 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 21 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 21 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 21 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 21 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Kenneth's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus)68 statements
quotepart of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.↗
▶Ep 6 · 1:25
quoteThere's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.↗
▶Ep 6 · 3:26
quoteyou really cannot widen the root of the mesentery any further than this.↗
▶Ep 6 · 6:56
clinicalAppendectomy carries a slight long-term complication rate from adhesions.↗
▶Ep 6 · 8:59
quoteit's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.↗
▶Ep 6 · 8:59
clinicalA low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.↗
▶Ep 6 · 15:36
opinionIf a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.↗
▶Ep 6 · 19:08
guidelineCurrent trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.↗
▶Ep 6 · 19:17
clinicalManaging solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.↗
▶Ep 6 · 19:26
quotewe were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.↗
▶Ep 6 · 20:34
clinicalTachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.↗
▶Ep 6 · 20:52
clinicalPatients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.↗
▶Ep 6 · 21:13
clinicalA patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.↗
▶Ep 6 · 23:49
opinionOnce a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.↗
Umbilical Cord Defects with Dr. Kenneth Azarow
▶Ep 29 · 2:30
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 29 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 29 · 3:05
opinionAge 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).↗
▶Ep 29 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 29 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 29 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 29 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 29 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 29 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 29 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 29 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 29 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 29 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 29 · 8:26
clinicalPDS 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).↗
▶Ep 29 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 29 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 29 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 29 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 29 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 29 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 29 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 29 · 12:37
clinicalGastroschisis 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).↗
▶Ep 29 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 29 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 29 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 29 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 29 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 29 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 29 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 29 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 29 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 29 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 29 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 29 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 29 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 29 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 29 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 29 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 29 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 29 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 29 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 29 · 22:10
clinicalFor 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.↗
▶Ep 29 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 29 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 29 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 29 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 29 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 29 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 29 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 29 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 29 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 29 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 29 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 29 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Kenneth's statements about Gastroschisis54 statements
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 11 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 11 · 3:05
opinionAge 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).↗
▶Ep 11 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 11 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 11 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 11 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 11 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 11 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 11 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 11 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 11 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 11 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 11 · 8:26
clinicalPDS 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).↗
▶Ep 11 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 11 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 11 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 11 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 11 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 11 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 11 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 11 · 12:37
clinicalGastroschisis 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).↗
▶Ep 11 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 11 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 11 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 11 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 11 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 11 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 11 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 11 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 11 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 11 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 11 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 11 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 11 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 11 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 11 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 11 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 11 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 11 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 11 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 11 · 22:10
clinicalFor 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.↗
▶Ep 11 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 11 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 11 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 11 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 11 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 11 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 11 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 11 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 11 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 11 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 11 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 11 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Kenneth's statements about Gastroschisis54 statements
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 12 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 12 · 3:05
opinionAge 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).↗
▶Ep 12 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 12 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 12 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 12 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 12 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 12 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 12 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 12 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 12 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 12 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 12 · 8:26
clinicalPDS 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).↗
▶Ep 12 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 12 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 12 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 12 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 12 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 12 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 12 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 12 · 12:37
clinicalGastroschisis 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).↗
▶Ep 12 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 12 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 12 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 12 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 12 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 12 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 12 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 12 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 12 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 12 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 12 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 12 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 12 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 12 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 12 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 12 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 12 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 12 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 12 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 12 · 22:10
clinicalFor 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.↗
▶Ep 12 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 12 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 12 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 12 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 12 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 12 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 12 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 12 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 12 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 12 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 12 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 12 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Kenneth's statements about Intestinal Rehab68 statements
quotepart of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.↗
▶Ep 7 · 1:25
quoteThere's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.↗
▶Ep 7 · 3:26
quoteyou really cannot widen the root of the mesentery any further than this.↗
▶Ep 7 · 6:56
clinicalAppendectomy carries a slight long-term complication rate from adhesions.↗
▶Ep 7 · 8:59
clinicalA low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.↗
▶Ep 7 · 8:59
quoteit's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.↗
▶Ep 7 · 15:36
opinionIf a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.↗
▶Ep 7 · 19:08
guidelineCurrent trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.↗
▶Ep 7 · 19:17
clinicalManaging solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.↗
▶Ep 7 · 19:26
quotewe were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.↗
▶Ep 7 · 20:34
clinicalTachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.↗
▶Ep 7 · 20:52
clinicalPatients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.↗
▶Ep 7 · 21:13
clinicalA patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.↗
▶Ep 7 · 23:49
opinionOnce a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.↗
Umbilical Cord Defects with Dr. Kenneth Azarow
▶Ep 38 · 2:30
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 38 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 38 · 3:05
opinionAge 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).↗
▶Ep 38 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 38 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 38 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 38 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 38 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 38 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 38 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 38 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 38 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 38 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 38 · 8:26
clinicalPDS 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).↗
▶Ep 38 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 38 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 38 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 38 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 38 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 38 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 38 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 38 · 12:37
clinicalGastroschisis 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).↗
▶Ep 38 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 38 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 38 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 38 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 38 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 38 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 38 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 38 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 38 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 38 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 38 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 38 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 38 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 38 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 38 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 38 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 38 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 38 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 38 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 38 · 22:10
clinicalFor 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.↗
▶Ep 38 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 38 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 38 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 38 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 38 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 38 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 38 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 38 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 38 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 38 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 38 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 38 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Kenneth's statements about Malrotation14 statements
quotepart of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.↗
▶Ep 2 · 1:25
quoteThere's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.↗
▶Ep 2 · 3:26
quoteyou really cannot widen the root of the mesentery any further than this.↗
▶Ep 2 · 6:56
clinicalAppendectomy carries a slight long-term complication rate from adhesions.↗
▶Ep 2 · 8:59
clinicalA low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.↗
▶Ep 2 · 8:59
quoteit's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.↗
▶Ep 2 · 15:36
opinionIf a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.↗
▶Ep 2 · 19:08
guidelineCurrent trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.↗
▶Ep 2 · 19:17
clinicalManaging solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.↗
▶Ep 2 · 19:26
quotewe were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.↗
▶Ep 2 · 20:34
clinicalTachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.↗
▶Ep 2 · 20:52
clinicalPatients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.↗
▶Ep 2 · 21:13
clinicalA patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.↗
▶Ep 2 · 23:49
opinionOnce a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.↗
Kenneth's statements about Malrotation14 statements
quotepart of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today.↗
▶Ep 2 · 1:25
quoteThere's really no controversy if someone has a volvulus. I mean you either operate or you get a new job.↗
▶Ep 2 · 3:26
quoteyou really cannot widen the root of the mesentery any further than this.↗
▶Ep 2 · 6:56
clinicalAppendectomy carries a slight long-term complication rate from adhesions.↗
▶Ep 2 · 8:59
quoteit's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation.↗
▶Ep 2 · 8:59
clinicalA low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation.↗
▶Ep 2 · 15:36
opinionIf a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously.↗
▶Ep 2 · 19:08
guidelineCurrent trend in solid organ injury management is to manage based on hemodynamics rather than CT grade.↗
▶Ep 2 · 19:17
clinicalManaging solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols.↗
▶Ep 2 · 19:26
quotewe were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy.↗
▶Ep 2 · 20:34
clinicalTachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability.↗
▶Ep 2 · 20:52
clinicalPatients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours.↗
▶Ep 2 · 21:13
clinicalA patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital.↗
▶Ep 2 · 23:49
opinionOnce a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen.↗
Kenneth's statements about Omphalocele48 statements
quoteMost umbilical hernias will close on their own, but they'll close on their own in the 1st year and then some in the 2nd year.↗
▶Ep 2 · 2:28
clinicalMost umbilical hernias close spontaneously in the first year, with some closing in the second year.↗
▶Ep 2 · 3:03
opinionAge 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).↗
▶Ep 2 · 3:15
quoteTypically before they enter school is the optimal time to do this, but after age 2, if there's a big proboscis sticking out, I can be persuaded by the parents, one of the few times.↗
▶Ep 2 · 3:35
opinionLarge proboscis size does not affect the decision to operate early on umbilical hernias.↗
▶Ep 2 · 4:12
clinicalEven 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.↗
▶Ep 2 · 4:43
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 2 · 5:19
clinicalTrue 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.↗
▶Ep 2 · 5:43
quoteYou need to have a bowel obstruction as you're presenting symptoms for that if the child's eating OK despite everything else going on. It's not an incarcerated umbilical hernia that needs an emergent operation.↗
▶Ep 2 · 6:02
clinicalIncarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery.↗
▶Ep 2 · 7:01
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 2 · 7:01
clinicalFor umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery.↗
▶Ep 2 · 7:38
clinicalParalysis (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.↗
▶Ep 2 · 7:47
quoteIf you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you.↗
▶Ep 2 · 8:24
opinionPDS 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.↗
▶Ep 2 · 8:49
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair; Dr. Ponsky does not, citing lack of literature support and no recalled infections in his practice.↗
▶Ep 2 · 10:08
opinionUmbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence.↗
▶Ep 2 · 10:17
quoteI think your, your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 2 · 10:32
clinicalUmbilicoplasty 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.↗
▶Ep 2 · 11:05
quoteI think probably no matter what you do it's going to look ugly.↗
▶Ep 2 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence.↗
▶Ep 2 · 12:10
quoteIf it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 2 · 12:22
clinicalA pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome.↗
▶Ep 2 · 12:37
clinicalGastroschisis 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.↗
▶Ep 2 · 12:57
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring.↗
▶Ep 2 · 13:25
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention.↗
▶Ep 2 · 14:38
opinionOmphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered.↗
▶Ep 2 · 15:26
clinicalTiming 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).↗
▶Ep 2 · 15:26
quoteWhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together in that situation.↗
▶Ep 2 · 15:50
quoteYou really just don't want to go too early. Having said that, living with an omphalocele, while it's not dangerous, is definitely lifestyle limiting.↗
▶Ep 2 · 17:00
clinicalFor large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option.↗
▶Ep 2 · 17:17
clinicalA 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.↗
▶Ep 2 · 18:48
opinionFor umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed.↗
▶Ep 2 · 18:48
quoteI don't think the patient needs an ultrasound. I don't think the patient needs a VCUG. I don't think the patient needs anything other than a physical examination.↗
▶Ep 2 · 19:23
clinicalOperating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously.↗
▶Ep 2 · 19:23
quoteIf you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up.↗
▶Ep 2 · 20:10
quoteIf we're just talking about a tiny drop of fluid or a drop of little decimated skin, sebum that kind of comes out periodically, those can be watched for a while.↗
▶Ep 2 · 20:18
quoteThe usual complaint is the mom doesn't even see the fluid. They see a spot on the kid's clothing, and there's just a spot on the kid's clothing, you know, and it comes there every few days, and that's why they do it.↗
▶Ep 2 · 22:10
clinicalSurgical 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.↗
▶Ep 2 · 24:05
epidemiologicalA Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary.↗
▶Ep 2 · 24:40
clinicalInfected 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.↗
▶Ep 2 · 25:51
clinicalLaparoscopic 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.↗
▶Ep 2 · 26:23
quoteSo that will not close on its own. So now you're talking about an ocutaneous fistula, so a patently phallo mesenteric duct, and even more dangerous than that is there's a loop of intestine right underneath.↗
▶Ep 2 · 26:23
clinicalPatent 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.↗
▶Ep 2 · 26:40
quoteThat's an operation before you go home from the hospital.↗
▶Ep 2 · 26:48
clinicalPatent 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.↗
▶Ep 2 · 28:06
clinicalEpigastric 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.↗
▶Ep 2 · 28:30
quoteDon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole.↗
Kenneth's statements about Omphalocele48 statements
clinicalMost umbilical hernias close spontaneously in the first year, with some closing in the second year.↗
▶Ep 2 · 2:28
quoteMost umbilical hernias will close on their own, but they'll close on their own in the 1st year and then some in the 2nd year.↗
▶Ep 2 · 3:03
opinionAge 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).↗
▶Ep 2 · 3:15
quoteTypically before they enter school is the optimal time to do this, but after age 2, if there's a big proboscis sticking out, I can be persuaded by the parents, one of the few times.↗
▶Ep 2 · 3:35
opinionLarge proboscis size does not affect the decision to operate early on umbilical hernias.↗
▶Ep 2 · 4:12
clinicalEven 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.↗
▶Ep 2 · 4:43
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 2 · 5:19
clinicalTrue 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.↗
▶Ep 2 · 5:43
quoteYou need to have a bowel obstruction as you're presenting symptoms for that if the child's eating OK despite everything else going on. It's not an incarcerated umbilical hernia that needs an emergent operation.↗
▶Ep 2 · 6:02
clinicalIncarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery.↗
▶Ep 2 · 7:01
clinicalFor umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery.↗
▶Ep 2 · 7:01
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 2 · 7:38
clinicalParalysis (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.↗
▶Ep 2 · 7:47
quoteIf you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you.↗
▶Ep 2 · 8:24
opinionPDS 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.↗
▶Ep 2 · 8:49
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair; Dr. Ponsky does not, citing lack of literature support and no recalled infections in his practice.↗
▶Ep 2 · 10:08
opinionUmbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence.↗
▶Ep 2 · 10:17
quoteI think your, your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 2 · 10:32
clinicalUmbilicoplasty 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.↗
▶Ep 2 · 11:05
quoteI think probably no matter what you do it's going to look ugly.↗
▶Ep 2 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence.↗
▶Ep 2 · 12:10
quoteIf it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 2 · 12:22
clinicalA pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome.↗
▶Ep 2 · 12:37
clinicalGastroschisis 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.↗
▶Ep 2 · 12:57
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring.↗
▶Ep 2 · 13:25
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention.↗
▶Ep 2 · 14:38
opinionOmphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered.↗
▶Ep 2 · 15:26
clinicalTiming 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).↗
▶Ep 2 · 15:26
quoteWhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together in that situation.↗
▶Ep 2 · 15:50
quoteYou really just don't want to go too early. Having said that, living with an omphalocele, while it's not dangerous, is definitely lifestyle limiting.↗
▶Ep 2 · 17:00
clinicalFor large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option.↗
▶Ep 2 · 17:17
clinicalA 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.↗
▶Ep 2 · 18:48
opinionFor umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed.↗
▶Ep 2 · 18:48
quoteI don't think the patient needs an ultrasound. I don't think the patient needs a VCUG. I don't think the patient needs anything other than a physical examination.↗
▶Ep 2 · 19:23
clinicalOperating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously.↗
▶Ep 2 · 19:23
quoteIf you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up.↗
▶Ep 2 · 20:10
quoteIf we're just talking about a tiny drop of fluid or a drop of little decimated skin, sebum that kind of comes out periodically, those can be watched for a while.↗
▶Ep 2 · 20:18
quoteThe usual complaint is the mom doesn't even see the fluid. They see a spot on the kid's clothing, and there's just a spot on the kid's clothing, you know, and it comes there every few days, and that's why they do it.↗
▶Ep 2 · 22:10
clinicalSurgical 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.↗
▶Ep 2 · 24:05
epidemiologicalA Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary.↗
▶Ep 2 · 24:40
clinicalInfected 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.↗
▶Ep 2 · 25:51
clinicalLaparoscopic 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.↗
▶Ep 2 · 26:23
clinicalPatent 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.↗
▶Ep 2 · 26:23
quoteSo that will not close on its own. So now you're talking about an ocutaneous fistula, so a patently phallo mesenteric duct, and even more dangerous than that is there's a loop of intestine right underneath.↗
▶Ep 2 · 26:40
quoteThat's an operation before you go home from the hospital.↗
▶Ep 2 · 26:48
clinicalPatent 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.↗
▶Ep 2 · 28:06
clinicalEpigastric 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.↗
▶Ep 2 · 28:30
quoteDon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole.↗
Kenneth's statements about Umbilical Hernia102 statements
quoteMost umbilical hernias will close on their own, but they'll close on their own in the 1st year and then some in the 2nd year.↗
▶Ep 1 · 2:28
clinicalMost umbilical hernias close spontaneously in the first year, with some closing in the second year.↗
▶Ep 1 · 3:03
opinionAge 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).↗
▶Ep 1 · 3:15
quoteTypically before they enter school is the optimal time to do this, but after age 2, if there's a big proboscis sticking out, I can be persuaded by the parents, one of the few times.↗
▶Ep 1 · 3:35
opinionLarge proboscis size does not affect the decision to operate early on umbilical hernias.↗
▶Ep 1 · 4:12
clinicalEven 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.↗
▶Ep 1 · 4:43
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 1 · 5:19
clinicalTrue 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.↗
▶Ep 1 · 5:43
quoteYou need to have a bowel obstruction as you're presenting symptoms for that if the child's eating OK despite everything else going on. It's not an incarcerated umbilical hernia that needs an emergent operation.↗
▶Ep 1 · 6:02
clinicalIncarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery.↗
▶Ep 1 · 7:01
clinicalFor umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery.↗
▶Ep 1 · 7:01
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 1 · 7:38
clinicalParalysis (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.↗
▶Ep 1 · 7:47
quoteIf you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you.↗
▶Ep 1 · 8:24
opinionPDS 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.↗
▶Ep 1 · 8:49
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair; Dr. Ponsky does not, citing lack of literature support and no recalled infections in his practice.↗
▶Ep 1 · 10:08
opinionUmbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence.↗
▶Ep 1 · 10:17
quoteI think your, your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 1 · 10:32
clinicalUmbilicoplasty 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.↗
▶Ep 1 · 11:05
quoteI think probably no matter what you do it's going to look ugly.↗
▶Ep 1 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence.↗
▶Ep 1 · 12:10
quoteIf it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 1 · 12:22
clinicalA pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome.↗
▶Ep 1 · 12:37
clinicalGastroschisis 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.↗
▶Ep 1 · 12:57
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring.↗
▶Ep 1 · 13:25
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention.↗
▶Ep 1 · 14:38
opinionOmphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered.↗
▶Ep 1 · 15:26
clinicalTiming 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).↗
▶Ep 1 · 15:26
quoteWhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together in that situation.↗
▶Ep 1 · 15:50
quoteYou really just don't want to go too early. Having said that, living with an omphalocele, while it's not dangerous, is definitely lifestyle limiting.↗
▶Ep 1 · 17:00
clinicalFor large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option.↗
▶Ep 1 · 17:17
clinicalA 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.↗
▶Ep 1 · 18:48
opinionFor umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed.↗
▶Ep 1 · 18:48
quoteI don't think the patient needs an ultrasound. I don't think the patient needs a VCUG. I don't think the patient needs anything other than a physical examination.↗
▶Ep 1 · 19:23
quoteIf you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up.↗
▶Ep 1 · 19:23
clinicalOperating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously.↗
▶Ep 1 · 20:10
quoteIf we're just talking about a tiny drop of fluid or a drop of little decimated skin, sebum that kind of comes out periodically, those can be watched for a while.↗
▶Ep 1 · 20:18
quoteThe usual complaint is the mom doesn't even see the fluid. They see a spot on the kid's clothing, and there's just a spot on the kid's clothing, you know, and it comes there every few days, and that's why they do it.↗
▶Ep 1 · 22:10
clinicalSurgical 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.↗
▶Ep 1 · 24:05
epidemiologicalA Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary.↗
▶Ep 1 · 24:40
clinicalInfected 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.↗
▶Ep 1 · 25:51
clinicalLaparoscopic 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.↗
▶Ep 1 · 26:23
quoteSo that will not close on its own. So now you're talking about an ocutaneous fistula, so a patently phallo mesenteric duct, and even more dangerous than that is there's a loop of intestine right underneath.↗
▶Ep 1 · 26:23
clinicalPatent 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.↗
▶Ep 1 · 26:40
quoteThat's an operation before you go home from the hospital.↗
▶Ep 1 · 26:48
clinicalPatent 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.↗
▶Ep 1 · 28:06
clinicalEpigastric 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.↗
▶Ep 1 · 28:30
quoteDon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole.↗
Umbilical Cord Defects with Dr. Kenneth Azarow
▶Ep 3 · 2:30
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 3 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 3 · 3:05
opinionAge 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).↗
▶Ep 3 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 3 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 3 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 3 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 3 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 3 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 3 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 3 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 3 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 3 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 3 · 8:26
clinicalPDS 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).↗
▶Ep 3 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 3 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 3 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 3 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 3 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 3 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 3 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 3 · 12:37
clinicalGastroschisis 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).↗
▶Ep 3 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 3 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 3 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 3 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 3 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 3 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 3 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 3 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 3 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 3 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 3 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 3 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 3 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 3 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 3 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 3 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 3 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 3 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 3 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 3 · 22:10
clinicalFor 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.↗
▶Ep 3 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 3 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 3 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 3 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 3 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 3 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 3 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 3 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 3 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 3 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 3 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 3 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Kenneth's statements about Umbilical Hernia102 statements
quoteMost umbilical hernias will close on their own, but they'll close on their own in the 1st year and then some in the 2nd year.↗
▶Ep 1 · 2:28
clinicalMost umbilical hernias close spontaneously in the first year, with some closing in the second year.↗
▶Ep 1 · 3:03
opinionAge 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).↗
▶Ep 1 · 3:15
quoteTypically before they enter school is the optimal time to do this, but after age 2, if there's a big proboscis sticking out, I can be persuaded by the parents, one of the few times.↗
▶Ep 1 · 3:35
opinionLarge proboscis size does not affect the decision to operate early on umbilical hernias.↗
▶Ep 1 · 4:12
clinicalEven 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.↗
▶Ep 1 · 4:43
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 1 · 5:19
clinicalTrue 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.↗
▶Ep 1 · 5:43
quoteYou need to have a bowel obstruction as you're presenting symptoms for that if the child's eating OK despite everything else going on. It's not an incarcerated umbilical hernia that needs an emergent operation.↗
▶Ep 1 · 6:02
clinicalIncarcerated omentum or preperitoneal fat at the umbilicus can be treated with NSAIDs; infected urachal cyst is treated with antibiotics; neither requires emergent surgery.↗
▶Ep 1 · 7:01
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 1 · 7:01
clinicalFor umbilical or inguinal hernias, if the child is not vomiting and is feeding normally, it is not an emergent incarceration requiring immediate surgery.↗
▶Ep 1 · 7:38
clinicalParalysis (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.↗
▶Ep 1 · 7:47
quoteIf you can get the child deep enough, it easily can be accomplished with an LMA. It really is anesthesiologist or anesthesia provider dependent though that I will tell you.↗
▶Ep 1 · 8:24
opinionPDS 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.↗
▶Ep 1 · 8:49
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair; Dr. Ponsky does not, citing lack of literature support and no recalled infections in his practice.↗
▶Ep 1 · 10:08
opinionUmbilicoplasty (excision of excess skin) is necessary to achieve a flat, cosmetically acceptable result; without it, parents will be unhappy despite eventual skin adherence.↗
▶Ep 1 · 10:17
quoteI think your, your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 1 · 10:32
clinicalUmbilicoplasty 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.↗
▶Ep 1 · 11:05
quoteI think probably no matter what you do it's going to look ugly.↗
▶Ep 1 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory response and better adherence.↗
▶Ep 1 · 12:10
quoteIf it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 1 · 12:22
clinicalA pressure dressing applied for 3 days after umbilical hernia repair improves cosmetic outcome.↗
▶Ep 1 · 12:37
clinicalGastroschisis 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.↗
▶Ep 1 · 12:57
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring.↗
▶Ep 1 · 13:25
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias; most close spontaneously over 2–3 years without intervention.↗
▶Ep 1 · 14:38
opinionOmphaloceles should not be repaired early; they are purely elective and children will grow and thrive with the defect covered.↗
▶Ep 1 · 15:26
clinicalTiming 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).↗
▶Ep 1 · 15:26
quoteWhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together in that situation.↗
▶Ep 1 · 15:50
quoteYou really just don't want to go too early. Having said that, living with an omphalocele, while it's not dangerous, is definitely lifestyle limiting.↗
▶Ep 1 · 17:00
clinicalFor large umbilical hernias in older teenagers where primary closure is not feasible, laparoscopic repair with mesh is an option.↗
▶Ep 1 · 17:17
clinicalA 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.↗
▶Ep 1 · 18:48
opinionFor umbilical drainage in a 4-week-old, physical examination alone is sufficient; ultrasound and VCUG are not needed.↗
▶Ep 1 · 18:48
quoteI don't think the patient needs an ultrasound. I don't think the patient needs a VCUG. I don't think the patient needs anything other than a physical examination.↗
▶Ep 1 · 19:23
clinicalOperating on urachal remnants in the first 3 months increases complication rates; observation for 6 months is recommended as many resolve spontaneously.↗
▶Ep 1 · 19:23
quoteIf you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up.↗
▶Ep 1 · 20:10
quoteIf we're just talking about a tiny drop of fluid or a drop of little decimated skin, sebum that kind of comes out periodically, those can be watched for a while.↗
▶Ep 1 · 20:18
quoteThe usual complaint is the mom doesn't even see the fluid. They see a spot on the kid's clothing, and there's just a spot on the kid's clothing, you know, and it comes there every few days, and that's why they do it.↗
▶Ep 1 · 22:10
clinicalSurgical 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.↗
▶Ep 1 · 24:05
epidemiologicalA Nebraska study showed no VCUG or ultrasound findings changed management of urachal remnants; preoperative imaging is not necessary.↗
▶Ep 1 · 24:40
clinicalInfected 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.↗
▶Ep 1 · 25:51
clinicalLaparoscopic 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.↗
▶Ep 1 · 26:23
clinicalPatent 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.↗
▶Ep 1 · 26:23
quoteSo that will not close on its own. So now you're talking about an ocutaneous fistula, so a patently phallo mesenteric duct, and even more dangerous than that is there's a loop of intestine right underneath.↗
▶Ep 1 · 26:40
quoteThat's an operation before you go home from the hospital.↗
▶Ep 1 · 26:48
clinicalPatent 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.↗
▶Ep 1 · 28:06
clinicalEpigastric 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.↗
▶Ep 1 · 28:30
quoteDon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole.↗
Umbilical Cord Defects with Dr. Kenneth Azarow
▶Ep 5 · 2:30
quoteno matter How much you tell the mom that this is purely elective does not necessarily have to be done right now. In fact, doesn't have to be done for another year or 2 or 3, that argument doesn't always persuade the day.↗
▶Ep 5 · 2:58
clinicalMost umbilical hernias will close spontaneously in the first year and some in the second year.↗
▶Ep 5 · 3:05
opinionAge 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).↗
▶Ep 5 · 3:47
opinionA long proboscis does not affect the decision to operate early on an umbilical hernia.↗
▶Ep 5 · 4:12
clinicalLarger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery.↗
▶Ep 5 · 4:40
opinionRace or ethnicity of the child does not affect the decision on timing of umbilical hernia repair.↗
▶Ep 5 · 5:38
clinicalTrue incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed).↗
▶Ep 5 · 5:49
clinicalRed, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel.↗
▶Ep 5 · 6:09
clinicalIncarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics.↗
▶Ep 5 · 6:19
opinionDr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia.↗
▶Ep 5 · 7:11
quoteFirst thing I ask him, I say, Is the child vomiting? He said, No, child's, you know, sucking on a bottle. I say, Fine, no problem.↗
▶Ep 5 · 7:47
clinicalLMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent.↗
▶Ep 5 · 8:01
quoteif they cannot give you adequate relaxation of the abdominal wall, it's going to be a long day as the omentum and intestine are pushing out at you as you're trying to close this hole.↗
▶Ep 5 · 8:26
clinicalPDS 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).↗
▶Ep 5 · 8:51
opinionDr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice.↗
▶Ep 5 · 10:19
opinionUmbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result.↗
▶Ep 5 · 10:24
quoteI think your best chance to make it stick in a cosmetic format is to excise some skin right at the beginning.↗
▶Ep 5 · 10:37
clinicalUmbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision.↗
▶Ep 5 · 11:42
clinicalTacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis.↗
▶Ep 5 · 12:13
quoteif it's not flat when you come out of the operating room, no matter how much you counsel parents, they're not going to like the way it looks.↗
▶Ep 5 · 12:22
clinicalA pressure dressing should remain in place for 3 days after umbilical hernia repair.↗
▶Ep 5 · 12:37
clinicalGastroschisis 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).↗
▶Ep 5 · 13:00
quoteI think we now know based on the way these close, it really is an umbilical ring defect because the natural history of the hole is to close on its own, and that doesn't happen outside of the umbilical ring↗
▶Ep 5 · 13:24
clinicalOver half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years.↗
▶Ep 5 · 14:13
quotewhen you put sutures in, even if you don't have to cut the fascia at all, you're making the edge of the ring ischemic when you put those sutures in, you know, you're really tying it tight and bringing it together. And you're destroying the integrity of the umbilical ring↗
▶Ep 5 · 14:13
clinicalSuturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously.↗
▶Ep 5 · 15:00
opinionOmphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake.↗
▶Ep 5 · 15:13
quoteif you think you're guaranteed to put in a piece of mesh, just wait longer because you'll have to use mesh sometimes, but a lot of these you'll be able to get primarily closed, and they'll surprise you if you just wait long enough.↗
▶Ep 5 · 15:13
opinionIf mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time.↗
▶Ep 5 · 15:34
clinicalParents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable.↗
▶Ep 5 · 15:37
quotewhen the child lies flat on the back, if you start seeing the flanks start bulging out, that means the abdominal girth is getting bigger and the the weight of the intestine and the organs is actually bowing out the abdomen, and you might have a chance of bringing the abdominal wall together↗
▶Ep 5 · 16:48
clinicalFor large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely.↗
▶Ep 5 · 17:17
opinionRepair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms.↗
▶Ep 5 · 17:23
clinicalA 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort.↗
▶Ep 5 · 19:08
opinionInfants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery.↗
▶Ep 5 · 19:17
epidemiologicalA Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months.↗
▶Ep 5 · 19:23
quoteif you operate on these kids in the 1st 3 months, the only thing that's going to happen is your complication rate is going to go up. If you actually watch these kids after about 6 months, a lot of these things will spontaneously resolve.↗
▶Ep 5 · 19:29
opinionDr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas.↗
▶Ep 5 · 20:59
clinicalUmbilical granulomas can be treated with silver nitrate application; many resolve without surgery.↗
▶Ep 5 · 21:11
opinionOffice ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily.↗
▶Ep 5 · 21:49
clinicalSteroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas.↗
▶Ep 5 · 22:10
clinicalFor 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.↗
▶Ep 5 · 22:32
clinicalThe distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus.↗
▶Ep 5 · 24:05
quotewe looked at, I think it was either 10 or 15 years' worth of data, and there was, there was no VCUG finding or ultrasound finding that changed anything that we did↗
▶Ep 5 · 24:05
epidemiologicalA Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging.↗
▶Ep 5 · 24:52
clinicalInfected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology.↗
▶Ep 5 · 25:01
clinicalAfter cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess.↗
▶Ep 5 · 25:31
clinicalElective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome.↗
▶Ep 5 · 26:23
clinicalPatent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge.↗
▶Ep 5 · 26:36
clinicalPatent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract.↗
▶Ep 5 · 26:56
clinicalPatent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract.↗
▶Ep 5 · 28:06
clinicalEpigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias.↗
▶Ep 5 · 28:29
quotedon't even refer to it as an epigastric hernia because that's a misnomer. Just refer to it as an epiplocele because that's what it is. It's just a little fat coming through a pinhole↗
▶Ep 5 · 28:46
clinicalThe fascial defect in epigastric hernias is typically only 1 millimeter in diameter.↗
Summaries Kenneth gave as host
· 32 summaries
Recaps of other experts' statements, not Kenneth's own clinical position.
Summaries Kenneth gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)8 summaries
host summaryKenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.↗
▶Ep 6 · 6:20
host summaryKenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.↗
▶Ep 6 · 14:41
host summaryKenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.↗
▶Ep 6 · 14:41
host summaryKenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.↗
▶Ep 6 · 15:11
host summaryKenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.↗
▶Ep 6 · 16:19
host summaryKenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.↗
▶Ep 6 · 19:02
host summaryKenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.↗
▶Ep 6 · 22:55
host summaryKenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.↗
Summaries Kenneth gave as host · Intestinal Rehab8 summaries
host summaryKenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.↗
▶Ep 7 · 6:20
host summaryKenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.↗
▶Ep 7 · 14:41
host summaryKenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.↗
▶Ep 7 · 14:41
host summaryKenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.↗
▶Ep 7 · 15:11
host summaryKenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.↗
▶Ep 7 · 16:19
host summaryKenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.↗
▶Ep 7 · 19:02
host summaryKenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.↗
▶Ep 7 · 22:55
host summaryKenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.↗
Summaries Kenneth gave as host · Malrotation8 summaries
host summaryKenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.↗
▶Ep 2 · 6:20
host summaryKenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.↗
▶Ep 2 · 14:41
host summaryKenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.↗
▶Ep 2 · 14:41
host summaryKenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.↗
▶Ep 2 · 15:11
host summaryKenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.↗
▶Ep 2 · 16:19
host summaryKenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.↗
▶Ep 2 · 19:02
host summaryKenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.↗
▶Ep 2 · 22:55
host summaryKenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.↗
Summaries Kenneth gave as host · Malrotation8 summaries
host summaryKenneth Azarow summarizing a resource: In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery.↗
▶Ep 2 · 6:20
host summaryKenneth Azarow summarizing a resource: In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up.↗
▶Ep 2 · 14:41
host summaryKenneth Azarow summarizing a resource: Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts.↗
▶Ep 2 · 14:41
host summaryKenneth Azarow summarizing a resource: To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required.↗
▶Ep 2 · 15:11
host summaryKenneth Azarow summarizing a resource: 63% of successful meconium ileus enemas require more than one attempt in radiology.↗
▶Ep 2 · 16:19
host summaryKenneth Azarow summarizing a resource: Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus.↗
▶Ep 2 · 19:02
host summaryKenneth Azarow summarizing a resource: throwing out the grade book in the management of isolated spleen and liver injuries.↗
▶Ep 2 · 22:55
host summaryKenneth Azarow summarizing a resource: Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment.↗
