What is the appropriate management for a white nodule at the umbilical site in a child after keyhole surgery?

White Nodule at Umbilical Port Site After Pediatric Laparoscopic Surgery

The white nodule at the umbilical port site most likely represents either an umbilical granuloma (most common), an epidermal inclusion cyst from epithelial implantation during surgery, or less commonly, an early surgical site infection—initial management should focus on clinical examination to distinguish between these entities, with simple silver nitrate cauterization for granulomas, observation for small asymptomatic cysts, and culture-guided antibiotics only if signs of infection are present. 1, 2

Differential Diagnosis by Clinical Appearance

Most Likely: Umbilical Granuloma

• Appears as a pink-to-white, moist, friable nodule at the healing umbilical incision site, representing excessive granulation tissue formation during wound healing 2
• This is the most common benign complication at umbilical surgical sites in children and typically develops within 2-4 weeks postoperatively 2

Epidermal Inclusion Cyst

• Presents as a firm, white-to-flesh-colored subcutaneous nodule that develops from epithelial tissue implanted during trocar insertion or specimen extraction 2
• These occur in up to 90% of cases with keloid-like collagen disorder following laparoscopic surgery and may be associated with delayed inflammatory response 2
• The majority result from implantation of epithelial components during the surgical procedure itself 2

Early Surgical Site Infection

• Look for periumbilical erythema, tenderness, purulent discharge, or warmth as these indicate active infection rather than simple granulation tissue 3, 4
• Umbilical port sites have significantly higher infection rates (11.6-23.5%) compared to other trocar sites in abdominal surgery, particularly when the incision traverses rather than skirts the umbilicus 1

Critical Red Flags Requiring Urgent Evaluation

• Fever, lethargy, or systemic signs suggest potential sepsis or deep-seated infection requiring immediate hospital admission and IV antibiotics 4, 5
• Periumbilical spreading erythema or induration indicates progression to cellulitis or abscess formation 3, 4
• Foul-smelling discharge with abdominal pain warrants CT abdomen/pelvis with IV contrast to evaluate for intra-abdominal complications 4

Diagnostic Approach

Initial Clinical Assessment

• Examine for discharge characteristics: clear/serous suggests granuloma; purulent indicates infection; no discharge suggests cyst 3, 4
• Palpate for consistency: soft/friable suggests granuloma; firm/mobile suggests cyst; tender/fluctuant suggests abscess 2
• Assess surrounding skin: normal skin favors granuloma or cyst; erythema/warmth indicates infection 3, 4

When to Culture

• Obtain culture if any purulent discharge is present to identify bacterial pathogens (most commonly Staphylococcus aureus, followed by Streptococci and Gram-negative bacilli) and guide antibiotic therapy 3, 4, 5

Management Algorithm

For Umbilical Granuloma (Most Common)

• Apply silver nitrate stick cauterization to the granulation tissue, which typically resolves the lesion within 1-2 applications 2
• Protect surrounding normal skin during application to prevent chemical burns 2
• If granuloma persists after 2-3 treatments, consider surgical excision 2

For Suspected Epidermal Inclusion Cyst

• Observe small asymptomatic cysts (less than 1 cm) as many remain stable or resolve spontaneously 2
• Perform surgical excision under local or general anesthesia for enlarging, symptomatic, or cosmetically concerning cysts with complete removal of the cyst wall to prevent recurrence 2
• Excision with umbilical formation procedures provides excellent cosmetic outcomes 2

For Surgical Site Infection

• Apply topical antiseptics and maintain local hygiene for superficial infections without systemic signs 3, 4
• Initiate oral antibiotics covering S. aureus (first-generation cephalosporin or anti-staphylococcal penicillin) for localized cellulitis 3, 5
• Perform incision and drainage plus broad-spectrum IV antibiotics (covering S. aureus, Streptococci, Gram-negative bacilli, and anaerobes) for abscess formation 3

Critical Pitfalls to Avoid

Do Not Dismiss Painless Lesions

• Even painless white nodules warrant evaluation as they may represent early infection with potential for serious complications due to the umbilicus's direct vascular access to the portal system 3, 4
• Case-fatality rates as high as 13% have been reported for untreated umbilical infections in children 4, 5

Surgical Technique Matters for Prevention

• Pre-operative umbilical cleansing and incisions that skirt rather than traverse the umbilicus reduce infection rates from 23.5% to 11.6% in laparoscopic procedures 1
• Careful surgical manipulation to avoid epithelial implantation prevents cyst formation 2

When Conservative Management Fails

• Surgical excision is reserved for persistent granulomas after multiple cauterizations, enlarging cysts, or failed conservative treatment of infection 3, 4, 2
• Complete removal with adequate suturing prevents recurrence and provides optimal cosmetic results 2