Closure Of Abdominal Wall Defects Research Articles

Review of the evidence on the closure of abdominal wall defects

Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.

116 Measuring of Intra-Abdominal Pressure in Critically Ill Children by Nurses

Objective of the study: Delayed diagnosis of increased intra-abdominal pressure in PICU patients increases morbidity and mortality rates. In 2007 our PICU implemented a protocol for indirect intra-abdominal pressure (IAP) measurements by an indwelling bladder catheter using a pressure transducer. One of the indications to start IAP measurement is an increased abdominal distension. The aim of this study was to evaluate the effects of this protocol, including the nurses' compliance. Methods: This retrospective study included patients admitted between 2007-2009. Children who underwent IAP measurements and/or abdominal girth measurements were identified from the Patient Data Management System and their records were analyzed. Results: Over the study period 36 children (19 male) with a mean age of 23 months (±49.3) underwent IAP measurements and 175 underwent three or more abdominal girth measurements. Both measurements were performed in 23 children. IAP measurements were mostly performed in neonates (52.8%) after closure of abdominal wall defects. The median number of IAP measurements was 14 (range 3-79); the median IAP was 8 mmHg (range 1-44). Eleven children (31%) had an IAP > 20 mmHg, indicating abdominal compartment syndrome. Most patients were treated conservatively and three underwent a surgical intervention. Conclusions: This study shows that after implementation of the IAP protocol nurses most often applied abdominal girth measurements in cases of suspected increased intra-abdominal pressure. We can conclude the nurses' compliance is moderate with IAP protocol. Strategies should be used to improve this.

How safe is the use of prosthetic materials in the repair of abdominal-wall defects in malnourished subjects?

AbstractIncisional hernias and abdominal-wall defects consume large amounts of healthcare resources. Use of mesh is effective in treatment of these disorders and can decrease the rate of recurrence. This experimental study focused on the safety of mesh use in the setting of malnutrition, a condition that impairs wound healing. Rats were divided into two groups: normally fed and food-restricted. An abdominal-wall defect, 2 by 2 cm, was covered with polypropylene mesh, 2.5 by 2.5 cm. After sacrifice of the rats at the 21st and 60th days, tissue samples were sent for tensiometric and histopathological studies. No significant difference in infectious complications was observed between the two groups. Tensiometry revealed no significant differences between the groups. On histopathological examination, the only difference noted was in the vascularization scores of normally fed rats. For malnourished subjects that survived after surgery, the use of polypropylene mesh appeared safe in the closure of abdominal-wall defects, with no increase in infection rate and satisfactory wound healing.

PR51P THE TENSOR FASCIA LATA FLAP IN ABDOMINAL WALL RECONSTRUCTION

Introduction: The closure of abdominal wall defect after tumour ablation can be a challenging problem. The component that requires reconstruction may only consist of skin or fascia; or it could consist of a combination of these. The pedicled tensor fascia lata flap is a useful option as it could be harvested as either a fascial or fasciocutaneous flap. When the size of the defect is significant, bilateral TFL flaps could be utilised.Methods and Results: To illustrate the flexibility provided by the pedicled TFL flap in abdominal wall reconstruction, two cases are presented in which the nature of abdominal wall defect were different. The first patient had a large fascial defect in the lower abdominal wall and bilateral pedicled TFL fascial flaps were used for reconstruction. The second patient had a full thickness defect and the TFL was harvested as a fasciocutaneous flap for reconstruction. Both defects were repaired satisfactorily without herniation.Conclusion: TFL is a versatile flap and should be the method of choice for lower abdominal wall reconstruction.

The use of intraabdominal tissue expanders as a primary strategy for closure of giant omphaloceles

Background Giant omphaloceles present a unique challenge to pediatric surgeons because of the difficulty in obtaining timely, tension-free closure of tissues over the defect. Reports of the use of tissue expanders in the subcutaneous space, intramuscular space, or intraabdominal cavity have illustrated the usefulness of this technique to provide biologic closure of abdominal wall defects. However, these reports have focused on use of tissue expanders as a second-line treatment after other options, such as silastic silos or attempted primary closure, have failed. Methods We report 2 cases in which intraabdominal tissue expanders were used as a primary strategy to obtain closure of giant omphalocele defects. Case Reports The first patient was a baby boy born at 36 weeks by date who was prenatally diagnosed with a giant omphalocele. An intraabdominal tissue expander was placed at 2 weeks of age. The tissue expander was removed and his abdomen was primarily closed at 8 weeks of age. The second patient was born at 25 weeks gestation as part of a twin gestation with severe intrauterine growth retardation (600 g birth weight). Bedside reduction was not attempted because of severe pulmonary hypertension and significant loss of abdominal domain because of herniated liver and bowel. At 8 months of age, she underwent laparoscopically assisted placement of an intraabdominal tissue expander. At 9 months of age, the tissue expander was removed, all abdominal viscera were reduced, and the defect was closed using only an 8 × 8-cm piece of AlloDerm (LifeCell, Branchburg, NJ). Both children are currently at home and doing well. Conclusions We believe that early use of intraabdominal tissue expanders provides a more expedient method of obtaining closure of the defect in giant omphaloceles.

Evaluation of Acellular Dermis for Closure of Abdominal Wall Defects in a Rat Model

Background: Abdominal wall repair can be performed with synthetic or biological materials. Biological materials may reduce the risk of infections and fibrosis. The aim of this study was to evaluate two acellular human dermis products. Materials and Methods: A rat model was used to compare the two materials. One was prepared using low concentrations of NaOH; the other material was SureDerm™, which is commercially available. Full thickness defects were prepared in the abdominal wall and closed with the materials. Rats were sacrificed at 1 or 4 months after operation and the numbers of adhesions to the bowels were scored. Samples were tak- en for histological analysis and to measure the breaking strength. Results: In both groups a good functional integration of the implants with the abdominal wall was observed. There was no adhesion formation with the bowels in the group with the NaOH prototype. In the SureDerm group, 4 out of 7 rats showed only small adhesions at 4 months after operation. Breaking strength of the healed tissue was significantly higher in the NaOH prototype group at 4 months after operation (p < 0.0026). Conclusions: The results indicate that both human acellular dermis products may be used in clinical trials for closure of abdominal wall defects.

Contemporary postnatal surgical management strategies for congenital abdominal wall defects

Early definitive closure of abdominal wall defects is possible in most cases. Staged reduction does offer distinct advantages, and mortality and morbidity may be better. Risk stratification may produce outcome and tailor management of difficult cases in the form of a clinical pathway. Stem cell technology may, in the future, offer the ideal allogenic prosthesis in complex cases.

The use of acellular dermal matrix for contaminated abdominal wall defects: wound status predicts success

Background Contaminated abdominal wall fascial defects present a challenging problem. The use of human acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, NJ) provides a novel method of primary closure of abdominal wall defects in this setting. The aim of the current study was to determine what factors predicted fascial wall failure as determined by the presence of hernia on follow-up exam after AlloDerm placement. Methods All patients who underwent surgery for contaminated abdominal wall fascial defects with placement of AlloDerm from June 2003 to September 2005 at a tertiary care Veterans Affairs hospital were included in the analysis. Patients were followed until hernia recurrence or last clinic visit. Results Eighteen patients had AlloDerm placed for contaminated fascial defects and all were included in the analysis. Primary wound closure was performed on 12/18 (67%) patients, with 6/18 (33%) patients initially left with open wounds. Patients with open wounds were treated with wound vacuum-assisted closure (VAC) devices (4/6) or saline dressings (2/6). Overall ventral hernia recurrence rate was 50% (9/18) with an average follow up of 9.1 months. Patients who had primary wound closure at the completion of the operation had a 33% (4/12) recurrence rate. Patients who did not have primary wound closure had an 83.3% (5/6) recurrence rate. The significant difference shows ( P = .03) that open wound status predicts recurrence. The average size of AlloDerm sheets used was 164.0 cm 2 in the closed group and 146.2 cm 2 in the primary open wound group ( P = .64). Average cost per patient was $4680 for AlloDerm. Conclusion These data suggest that an open wound in the postoperative period after AlloDerm placement for treatment of contaminated fascial defects is associated with a high probability of hernia recurrence. Our data do not support the use of this expensive material unless there is a good chance of having a closed wound.

Comparison of Bursting Pressure of Abdominal wall Defects Repaired by Three Conventional Techniques

Still debated are the appropriate techniques for the repair of abdominal wall defects and the methods used to measure their strength. Although tension has been used in many studies to test wound strength, bursting pressure reflects more accurately the pathophysiology of wound dehiscence. The aim of the current study was to evaluate three different techniques for closure of abdominal wall defects using a new and more accurate device for bursting pressure measurements. Full thickness abdominal wall defects measuring 2 cm2 were created in 43 anesthetized rats randomly assigned to three groups: simple primary closure (n = 15), Mayo repair (n = 14), and primary closure reinforced with a mesh (n = 14). Thirty days after surgery, the rats were sacrificed. The abdominal wall was fully excised and placed over a bursting chamber made of a metal cylinder connected to a carbon dioxide source with a control valve and a manometer. Gas was gradually released while the pressure was recorded until bursting occurred. Disruption of all closures occurred at the point where the suture itself penetrated the tissue. The average bursting pressure was 1383 +/- 299 mm Hg for the primary closure group, 1200 +/- 409 mm Hg for the mesh reinforcement group, and 1607 +/- 337 mm Hg for the imbrication repair (Mayo) group (P < 0.03). The data suggests an advantage for the Mayo repair over the other two repairs. The bursting chamber tested is a new and more reliable method to study techniques and conditions influencing the strength of abdominal wall closure.

Abdominal wall partitioning (the accordion effect) for reconstruction of major defects: a retrospective review of 10 patients.

Ten patients underwent abdominal wall reconstruction using the technique of abdominal wall partitioning. All defects were closed in the midline by approximating fascia to fascia with the assistance of a general surgeon. One patient had skin grafted small bowel. Five patients had chronically infected mesh and previous failed attempts at repair. Four patients had large ventral hernias following gastric reduction operations and massive weight loss. No defect in any dimension was less than 20 cm. All patients had secure abdominal wall repair by reconstruction of a midline anchor for the abdominal wall musculature. One patient was lost to follow-up after 3 weeks. The average follow-up time for the remaining nine patients was 18.6 months (range, 6 months to 4.7 years). One patient required readmission to the hospital for management of a limited area of skin necrosis. Two patients had minor wound infections, and three patients had subcutaneous seromas, all of which were managed on an outpatient basis. One patient developed a 2 x 2-cm subxiphoid hernia recurrence. Technical details include subcutaneous undermining of the abdominal skin to the anterior axillary lines bilaterally, mobilization of the viscera to expose the white lines of Toldt bilaterally, and parallel, parasagittal, staggered releases of the transversalis fascia, transversalis muscle, external oblique fascia, external oblique muscle, and rectus fascia. These multiple releases allow expansion and translation of the abdominal wall by an accordion-like effect. This accordion-like effect allows closure of abdominal wall defects that are substantially larger than what can be closed with current techniques.

Sonographic biometry of liver and spleen size long after closure of abdominal wall defects

Little is known about the fate of the liver and spleen after closure of the abdominal cavity in patients with abdominal wall defects (AWD). Therefore, counselling families for long-term follow-up and in the case of surgery for acute disease, pregnancy or trauma may be difficult. A total of 18 patients ranging in age from 7 to 18 years, with AWD closed at birth, underwent ultrasound evaluation of liver and spleen size by determination of the index of liver size (ILS) and splenic volume (SV). These values were then correlated with some anthropometric parameters such as body mass index (BMI) and weight; correlation was also sought with some clinical features such as type of defect and direct or staged closure. Nearly all subjects exhibited weight above and BMI below the 50th percentile for age. ILS and SV were significantly above normal limits in all cases and no difference was found with regard to the type of defect. In patients having undergone surgery for abdominal wall defects, liver and spleen usually regain their normal shape and position even though size and volume appear to be larger than in normal controls.

Advancement flap umbilicoplasty after abdominal wall closure: Postoperative results compared with normal umbilical anatomy

Background/Purpose: Umbilical reconstruction frequently is an adjunct used after repair of congenital abdominal wall defects. The authors describe a new technique of umbilicoplasty and compare their results with normal neonatal umbilical anatomy. Methods: After fascial closure, 6 newborn infants with either gastroschisis (n = 3) or omphalocele (n = 3) underwent umbilicoplasty performed by advancing bilateral skin flaps including creation of an umbilical skin collar. The umbilical collar height, circumference, and distance from the xiphoid with respect to the pubis (ratio of xiphoid-umbilicus distance to xiphoid-pubis distance or XU:XP) were recorded and referenced to normal umbilical anatomy in additional 28 infants (24 to 40 weeks gestation [mean, 33.2 weeks] and age 2 to 131 days [mean, 26.5 days]). Results: After umbilicoplasty, all infants had a near-normal-appearing umbilicus (collar height, 0.75 ± 0.25 cm and circumference, 5.24 ± 1.20 cm) compared with normal umbilical anatomy (collar height, 4.36 ± 1.32 cm and circumference, 1.03 ± 0.38 cm). However, after umbilicoplasty, the neoumbilicus was positioned more cephalad (XU:XP = 0.53 ±.05) compared with normal (mean XU:XP, 0.67 ± 0.07). The only complication encountered was a small dehiscence of the superior aspect of the abdominal wound. Conclusions: Closure of abdominal wall defects with simultaneous umbilicoplasty provides a cosmetically pleasing result. When performing umbilicoplasty, attempt should be made to position the neoumbilicus as inferior as possible, optimally at two thirds the distance from the xiphoid to the pubis. J Pediatr Surg 36:1168-1170. Copyright © 2001 by W.B. Saunders Company.

A modification of the “components separation” technique for closure of abdominal wall defects in the presence of an enterostomy

The repair of contaminated abdominal-wall defects is still a challenge for surgeons treating patients with abdominal sepsis. The use of prosthetic material to repair these defects is contraindicated because it gives disappointing results. Reconstructions with autologous material, such as free fascial or musculofascial flaps, are not satisfactory either. The operations of free fascial transplant harvesting are time-consuming and are frequently followed by functional deficits at the donor site. Functional results of those reconstructions are disappointing because of bulging of the denervated muscles, and high reherniation rates of up to 20%. In 1990 Ramirez and associates introduced the “Components Separation Technique” for closure of large abdominal-wall defects without the use of prosthetic material. Their technique is based on translation of the muscular layers of the abdominal wall, thereby enlarging the surface of the abdominal wall (Fig. 1). A compound flap is created which can be advanced more than 10cm at the waistline, at each side. The technique has 3 disadvantages. First, the skin and subcutaneous tissue must be mobilized laterally over a large distance in order to reach the aponeurosis of the external oblique muscle, which is retracted laterally into the flank. This creates a large wound surface that covers the whole ventral abdominal wall, from costal margin to pubic bone. Second, mobilization of the skin endangers its blood supply, which may lead to skin necrosis in the midline if circulation through the intercostal arteries is interrupted. Third, the technique is difficult to use in patients with an enterostomy or if a new enterostomy must be made. We describe a modification of the technique of Ramirez and colleagues, designed to preserve the blood supply of the skin and subcutaneous tissue, and to overcome the problem of stoma reconstruction in these patients.

COMPLICATIONS OF INTRAUTERINE PLACEMENT OF A VESICOAMNIOTIC SHUNT

In Brief Background Fetal obstructive uropathies complicated by severe oligohydramnios can cause neonatal death due to renal dysplasia and pulmonary hypoplasia. Case A 31-year-old multigravida was referred at 19.6 weeks with sonographic evidence of fetal megacystis and bilateral hydroureteronephrosis, and severe oligohydramnios. A vesicoamniotic shunt was placed for urinary diversion. Complications included shunt migration, intestinal evisceration, amniorrhexis, preterm labor, and preterm delivery. Bowel characteristics were assessed by measuring the intestinal lumen diameter for evidence of obstruction. The lumen diameter remained stable at 3-5 mm, and the luminal wall remained stable at 2.5 mm. After birth at 31 weeks, the infant underwent exploratory laparotomy and extraction of malpositioned shunts, vesicostomy, and closure of abdominal wall defect. He was discharged at 61 days of life after resolution of neonatal pulmonary and infectious complications. Conclusion Operative management of complete fetal obstructive uropathy is beneficial despite potential complications. Operative management of fetal obstructive uropathy is beneficial despite complications associated with placement of a vesicoamniotic shunt.

Complications of Intrauterine Placement of a Vesicoamniotic Shunt

Background: Fetal obstructive uropathies complicated by severe oligohydramnios can cause neonatal death due to renal dysplasia and pulmonary hypoplasia.Case: A 31-year-old multigravida was referred at 19.6 weeks with sonographic evidence of fetal megacystis and bilateral hydroureteronephrosis, and severe oligohydramnios. A vesicoamniotic shunt was placed for urinary diversion. Complications included shunt migration, intestinal evisceration, amniorrhexis, preterm labor, and preterm delivery. Bowel characteristics were assessed by measuring the intestinal lumen diameter for evidence of obstruction. The lumen diameter remained stable at 3–5 mm, and the luminal wall remained stable at 2.5 mm. After birth at 31 weeks, the infant underwent exploratory laparotomy and extraction of malpositioned shunts, vesicostomy, and closure of abdominal wall defect. He was discharged at 61 days of life after resolution of neonatal pulmonary and infectious complications.Conclusion: Operative management of complete fetal obstructive uropathy is beneficial despite potential complications.

Treatment of congenital abdominal wall defects —a 25-year review of 132 patients

The outcome data of 132 patients treated at the Department of Pediatric Surgery in Mainz during the last 25 years were reviewed. Prenatal diagnosis of abdominal wall defects (AWDs) and associated malformations led to increasing selection of the patient population. The aim of primary closure of the abdominal wall can be achieved more frequently in gastroschisis (GS) than omphalocele (OC), while the postoperative course is more complicated and of longer duration in GS. Delayed or secondary closure extended the hospitalization period but had no negative effects on the outcome. Reoperations or planned secondary operations were performed in 23 patients with GS and 14 with OC. Early mortality was 15/55 for OC and 21/77 for GS over the period of 25 years. In recent years, a drastic reduction in mortality has occurred, and mortality is now mainly due to additional malformations. Further development and quality of life are not significantly reduced after survival of an isolated AWD. Malpositioning of parenchymatous organs after closure of AWDs has to be considered during pregnancy and abdominal operations.

An inexpensive and readily available alternative to the silastic ?silo? for staged closure of abdominal wall defects

The successful use of 500 ml Viaflex polyvinylchloride (PVC) IV fluid infusion bags instead of traditional reinforced silastic “silos” is described in two infants with exomphalos who required staged abdominal closure. Although one infant did not survive, there were no complications related to the IV bag silo in either patient. In both cases the bag was in place for more than 7 days, and was intact at the time of removal. The PVC containers are pre-sterilised, easily handled, and provide good visualisation of the condition of the extruded organs during reduction. They are routinely available in most hospital settings throughout the world and are approximately 1% of the cost of reinforced silastic. This technique offers a safe, effective, inexpensive, and readily available alternative to the traditional silastic pouch in the management of patients requiring staged closure of abdominal wall defects.

EFFECT OF INCREASED INTRAABDOMINAL PRESSURE ON PENTANYL ELIMINATION IN NEONATAL LAMBS

Increased intraabdominal pressure (IAP) might occur during closure of abdominal wall defects. IAP has been shown to reduce clearance of fentanyl. MASEY et al. found acutely decreased portal flow with IAP. As it is important to also measure dactus venosus (DV) shunt and not hepatic blood flow to calculate clearance of fentanyl, we studied 6 neonatal lambs aged 4-48 hours. Fentanyl concentration was kept at 20 ng/ml. Organ blood flows were determined by a standard method, using radiolabelled microspheres. IAP was produced by a blood pressure cuff around the abdomen. Conclusion: Our study confirms that in neonatal lambs with IAP hepatic fentanyl clearance goes down. In addition we showed that DV shunt also decreases significantly, whereas no significant changes were found in portal or hepatic blood flow with IAP.

Pulmonary dysfunction after primary closure of an abdominal wall defect and its improvement with bronchodilators.

To determine the extent of pulmonary dysfunction following primary closure of an abdominal wall defect, we obtained pulmonary function tests (PFT) in 11 newborn infants with gastroschisis and 6 with large omphaloceles admitted to a newborn ICU in a children's hospital. Patients were 1 to 30 days of age at the time of the PFT; all required endotracheal intubation and mechanical ventilation for operative procedures or for postoperative ventilatory support. Full-term infants (n = 21) undergoing minor surgical procedures provided comparative measurements. Flow-volume curves were obtained with manual inflation of the lungs followed by forced deflation using negative pressure, or by passive expiration, under sedation and pharmacologic paralysis. Deflation flow-volume curves gave measurements of forced vital capacity (FVC) and maximal expiratory flow at 25% of vital capacity from residual volume (MEF25). Modified passive mechanics technique gave passive expiratory curves that provided measurements of respiratory system compliance (Crs) and resistance (Rrs). Tests were done: within 48 h (period A), 3-7 days (period B), and 8-30 days after surgical repair (period C). Pulmonary function testing after nebulized 0.1% isoetharine (a bronchodilator), to test for bronchial reactivity, began midway during the study period in 15 patients. Preoperative and postoperative tests were obtained in 5 patients. Closure of an abdominal wall defect decreased FVC, Crs, and MEF25 by up to 50% of normal, reference values after surgery (P less than 0.05). FVC and MEF25 approached values of normal infants by 4 weeks, whereas Crs remained 50% lower.(ABSTRACT TRUNCATED AT 250 WORDS)

Dura Covered with Fibrin Glue Reduces Adhesions in Abdominal Wall Defects

Dura can greatly facilitate the closure of abdominal wall defects. However, a main disadvantage of its use are the adhesions which develop between omentum, bowel and dura and may lead to bowel obstructions. In this study various groups of rats had either the anterior wall replaced by untreated dura or by dura covered with fibrin glue prior to implantation. Adhesions were found in 75% of sham operated rats, 100% after untreated dura implantation and 50% after the implantation of fibrin glue treated dura.