Primary fascial closure in infants with gastroschisis and omphalocele: A superior approach

Abstract

The optimal surgical management of neonates with gastroschisis and omphalocele remains controversial. Early attempts at primary closure were limited by respiratory and vena cava compromise and were gradually replaced by skin closure only, staged reduction of implanted prostheses, and escharification of the intact omphalocele. Advances in surgical technique, neonatal intensive care, and mechanical ventilation have made primary closure a viable alternative once again. We wish to report a consecutive series of 73 infants, including 54 with gastroschisis and 19 with omphalocele, over a 16-year period. Fifty gastroschisis patients were closed primarily, with four deaths (8%), and four with staged prostheses, with one death (25%). Sixteen omphaloceles were closed primarily, with three deaths (19%); two closed with a staged prosthesis, and one patient, closed with skin flaps only, died (100%). Overall survival for primary closure was 59/66 (89%) and for staged reduction, 5/7 (43%). In the past 5 years all patients have been closed primarily with no deaths (100% survival). All survivors were alive and well 1 to 15 years postoperatively. Our current operative technique involves vigorous manual stretching of the abdominal cavity, manual emptying of the entire Gl tract, and primary fascial closure, with no gastrostomy. Key points in postoperative management include total paralysis and mechanical ventilation, as the initially tense abdominal wall softens over 1 to 2 days, followed by weaning from the ventilator, and vigorous fluid support. Gl function returns more rapidly after primary closure (average of 3 days) and hospital stay is not prolonged. Other complications (intestinal obstruction, two patients; fistulae, one patient, etc) are much less frequent.(ABSTRACT TRUNCATED AT 250 WORDS)