INTRODUCTION

Umbilical lesions in children are relatively uncommon and include congenital anomalies, inflammatory conditions, and postoperative complications such as suture granuloma. Schloffer’s tumor is a foreign-body granuloma arising near abdominal surgical scars. It was first described in 1809 by Schloffer, who reported four cases of chronic inflammatory tumors of the abdominal wall following inguinal hernioplasty [1].

Suture granulomas represent a chronic foreign-body reaction to suture material, often due to bacterial colonization or the antigenicity of silk fibers. Non-absorbable silk sutures have a reported granuloma incidence of 0.6–7.1% [2]. Development typically involves two phases: an initial local tissue reaction from needle passage, followed by a specific inflammatory response to the suture material [3].

CASE REPORT

A previously healthy 5-year-old girl presented to our dermatology clinic with a protruding umbilical lesion. She had undergone umbilical hernia repair (open primary repair) 10 months previously (Fig. 1).

Figure 1: Polypoid yellow-brown mass measuring approximately 0.5 cm protruding from the umbilicus at presentation.

Laboratory findings—including complete blood count, biochemical tests, and thyroid function tests—were normal. C-reactive protein was negative, and erythrocyte sedimentation rate was 22 mm/h. No bacterial growth was detected in cultures.

Ultrasound revealed a well-defined hypoechoic solid lesion measuring 11 × 7.5 mm on the skin surface, containing internal calcifications suggestive of scar tissue. No herniation or fistulization was detected during the Valsalva maneuver. Although ultrasonographic evaluation supported the diagnosis, the original ultrasound image could not be retrieved from the institutional archiving system at the time of manuscript preparation. Importantly, direct visualization and removal of retained suture material during cauterization, followed by complete clinical resolution, provided additional confirmation of the diagnosis.

The lesion was diagnosed as a suture granuloma. Silver nitrate cauterization was performed, during which a suture thread was visualized and excised. Wound dressing was applied (Fig. 2).

Figure 2: Clinical appearance immediately after silver nitrate cauterization, showing complete removal of the lesion without residual mass).

During silver nitrate cauterization, retained suture material was directly visualized and removed. As the lesion completely resolved following cauterization and no residual tissue remained, histopathological examination could not be performed. At 1-month follow-up, the lesion had completely resolved (Fig. 3).

Figure 3: Follow-up examination one month after treatment demonstrating complete resolution of the lesion and normal umbilical appearance.

DISCUSSION

Schloffer’s tumor typically presents as a chronic abscess containing non-absorbable suture material [1]. Staphylococcus species are frequently isolated, and the lesion is encased by dense fibrous tissue. Macroscopically, these tumors are firm and adherent to surrounding tissues, ranging from small nodules to large masses weighing several kilograms. Histologically, they show fibrous granulation tissue and lymphocytic infiltration associated with a foreign-body reaction.

The tumors may arise months to years postoperatively and have been reported after appendectomy, hernioplasty, hysterectomy, oophorectomy, gastrectomy, cholecystectomy, biliary, and colon surgeries. Although benign, they can mimic malignancy due to infiltrative growth.

Ultrasonographically, suture granulomas appear as hypoechoic lesions with hyperechoic linear structures (“rail-like” lines) [4], aiding preoperative diagnosis.

Schloffer’s tumor should be considered in the differential diagnosis of umbilical masses in pediatric patients with a history of abdominal surgery as well as in FDG-PET–positive abdominal lesions in postoperative patients [5]. Other considerations include desmoid tumors, organized hematomas, and fibrosarcomas [1].

A South Korean study analyzing 19 patients with benign umbilical tumors reported dermatofibroma (26.3%) as the most common lesion, followed by keloid, soft fibroma, and verruca vulgaris [6].

Histopathological confirmation could not be obtained in this case, as the lesion was entirely eliminated during silver nitrate cauterization following the identification and removal of the retained suture material. Although histopathological confirmation was not available, direct intra-procedural visualization and removal of retained suture material with complete clinical resolution strongly supported the diagnosis.

Dermatologists frequently evaluate umbilical lesions in pediatric patients. Awareness of delayed postoperative foreign-body reactions is essential, as such lesions may clinically mimic neoplastic or congenital conditions. Early recognition allows minimally invasive management and may prevent unnecessary surgical exploration or oncologic work-up.

CONCLUSION

Delayed umbilical suture granuloma should be considered in children presenting with umbilical masses following abdominal surgery. Dermatologic evaluation may facilitate early diagnosis and allow minimally invasive treatment, thereby avoiding unnecessary surgical exploration. Our case was rare because the granuloma appeared 10 months post-hernia repair as a protruding umbilical mass. Trauma may have contributed to lesion development, although this association remains speculative. Further case reports and studies are needed to clarify whether this represents a coincidental event or a pathogenic mechanism.

REFERENCES

1.  Yazyi FJ, Canullan CM, Baglietto NF, Klappenbach RF, Alonso Quintas F, Alvarez Rodriguez J, et al. Schloffer’s tumor:Case report and review of the literature. Int J Surg Case Rep. 2014;5:1234-7.

2.  Takano Y, Haruki K, Tsukihara S, Abe T, Koyama M, Ito D, et al. Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery:a case report. Surg Case Rep. 2021;7:210.

3.  Seçil M, Mungan U, Yorukoglu K. Suture granuloma after orchiectomy:sonography, Doppler and elastography features. J Clin Ultrasound. 2015;41:813–6.

4.  Rettenbacher T, Macheiner P, Hollerweger A, Gritzmann N, Weismann C, Todoroff B. Suture granulomas:sonography enables a correct preoperative diagnosis. Ultrasound Med Biol. 2001;27:343-50.

5.  Takahara K, Kakinoki H, Ikoma S, Udo K, Tobu S, Satoh Y, et al. Suture Granuloma Showing False-Positive Findings on FDG-PET. Case Rep Urol. 2013;2013:472642.

6.  Ha DL, Yang MY, Shin JO, Kim HS, Ko HC, Kim BS, et al. Benign Umbilical Tumors Resembling Sister Mary Joseph Nodule. Clin Med Insights Oncol. 2021 Mar 24;15:1179554921995022.