Is early fascial closure necessary for omphalocele and gastroschisis?

Abstract

Before the introduction of the “silo” for gastroschisis, the main goal of surgery was to cover the defect with skin. Since the silo has been used, the goals have been (1) to cover the defect with SILASTIC ® sheets and return the extraabdominal contents to the abdominal cavity by progressive plication of the silo and (2) to eventually close the defect by fascia-to-fascia approximation, before 1 month of age. In many series, early definitive abdominal wall closure resulted in mortality rates of 10% to 30%, usually because of bowel necrosis and resulting sepsis. At the author's institution, 20 newborns with large omphaloceles or gastroschisis have been treated, and fascial closure was obtained by the second week in 10 infants. In ten babies it was impossible to obtain early fascial closure without tension, and these children were managed differently. A nonaggressive two-stage approach was used, in which the goals were (1) early return of contents to the abdominal cavity and (2) only skin and granulation coverage of the defect (without aiming for early fascial closure or partial fascial closure) with a small central SILASTIC ® patch. Stage 1 is reduction of abdominal contents to the abdomen, through plication of the silo, over a 9 to 14 day period. Stage 2 is removal of the silo and closure of the ventral abdominal wall defect using a SILASTIC ® patch to close most of the defect, after approximating fascia in the superior and inferior portions. If the skin cannot be closed, the patch usually separates in 14 to 21 days, the pellicle remaining becomes completely epithelialized in 1 to 2 months, and further surgery has not been necessary. If the skin can be approximated, the patch is removed in a few months, when fascial closure can be performed easily. Five cases of omphalocele and five of gastroschisis were treated by this method; all the patients are doing well, most without definitive fascial closure.