Repair Of Omphalocele Research Articles

Staged repair of giant omphalocele in the neonatal period

Background/Purpose The aim of this study was to analyze the outcome of giant omphalocele repaired in the neonatal period. Methods Twelve consecutive (1997-2004) neonates with giant omphalocele (defect >6 cm with liver herniation) were reviewed. A silo of Prolene mesh (Ethicon) was attached to the fascia and the defect was closed without opening the amniotic sac after sequential reduction. In 2 neonates with ruptured omphalocele a plastic sheet was inserted below the mesh. Data are reported as median and range. Results Gestational age was 38 weeks (range, 32-40 weeks) and birth weight was 2.9 kg (range, 1.0-3.1 kg). The final closure was achieved at 26 days (range, 16-62 days). Three neonates (25%) died before final closure (causes: ruptured omphalocele, lung hypoplasia, cardiac anomalies, and intestinal failure). In the 9 surviving neonates, mechanical ventilation was required for 8 days (range, 2-20 days), hospital stay was 42 days (range, 23-73 days), and full enteral feeding was achieved on day 12 (range, 4-53 days). Complications included wound infection in 5 neonates and midgut volvulus in 1. Prophylactic Ladd's procedure was performed laparoscopically at a later stage in 4 children. At laparoscopy, intraperitoneal adhesions were minimal and the central liver did not preclude the operation. The 9 survivors are all well after 46 months (range, 12-67 months). Conclusions Giant omphalocele can be safely repaired in the neonatal period without opening the amniotic sac. Intestinal malrotation should be excluded and Ladd's procedure can be performed laparoscopically at a later stage.

Introduction

This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations.This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as “clean,” “clean-contaminated,” “contaminated,” or “dirty or infected,” and specified duration of perioperative antibiotics as “none,” “single preoperative,” “24 hours,” or “>24 hours.” Unweighted κ score was calculated to estimate interrater reliability.Overall interrater reliability for wound classification was poor (κ = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis.There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis.

Omphalocele: clinical review and surgical experience using dura patch grafts.

Over a period of 15 years we surgically treated 50 cases of omphaloceles. The pathology occurred more frequently in boys (n = 30) than in girls (n = 20). The mean birth weight was 2995 g and mean gestational age was 38 weeks. Four infants (8%) were delivered vaginally and the rest (92%) by cesarian section. Eleven infants (22%) underwent primary closure, but in 20 infants (40%) with larger defects a primary closure of the skin was possible; however, a single solvent-dried dura graft implant was employed for the fascia enlargement. The remaining 19 infants (38%) had extremely large defects, and optimal closure of the defect required a two layered graft implantation. Twenty-five infants (50%) had associated anomalies, the majority being congenital cardiac anomalies. Five patients (10%) required secondary laparotomies due to bowel associated complications. Four patients (8%) experienced non-bowel-associated complications. The average postoperative mechanical ventilation required was for a period of 3.2 days and the average hospital stay was 45.7 days. The overall mortality rate was 8% (n = 4) and was largely due to severe congenital heart anomalies. Solvent-dried dura was successfully employed in the management of the larger defects with no major complications; only one patient (2%) had a local abscess around the area of the implant and was managed conservatively. Our experience favors the employment of solvent-dried dura graft implants for the repair of large omphaloceles. The solvent-dried dura grafts are biomaterials that promote rapid scar formation and integration with the adjacent skin tissue and do not produce any foreign body reactions at the site of implantation.

Silo construction from a sterile adhesive film and polypropylene mesh in the repair of gastroschisis and omphalocele.

A simple technique of constructing a silo for the treatment of gastroschisis (GS) and omphalocele (OMP) is described. A polypropylene mesh covered on both sides with a sterile transparent adhesive film (incise drape) was used; both these items are freely available in the operating room. The resultant silo is sterile, soft, flexible, sturdy, internally smooth, provides a reasonable barrier, and allows enough visibility of the bowel. This silo was used in the treatment of 25 cases of GS and 13 cases of OMP with acceptable results. Survival was better in patients in whom primary closure could be achieved in both OMP and GS. Silo treatment was associated with higher mortality from septic causes.

Repair of a giant omphalocele by a modified technique

Large omphaloceles that contain centrally herniated liver pose challenges to surgical closure, the most significant being the space limitation of the abdominal cavity. In addition, the "pedicled" nature of the liver on the inferior vena cava creates a predisposition to acute hepatic vascular outflow obstruction as the liver is reduced into the abdominal cavity. In such cases, the alternatives include conservative treatment or staged silo reduction. The worst complication of silastic silo (SS) placement is tension and infection of the fascia with disruption of the suture line. Once infection or premature disruption occurs, closure of the defect is difficult or impossible. This case report details a different management technique for a newborn with a giant omphalocele and presents an interesting variation of the usual SS technique that may be helpful in the management of some cases, especially in an emergency. The thick silk sutures applied in the present case absorbed the tension and the silastic sheet prevented the risks of infection and adhesions.

Cloacal exstrophy: A unified management plan

Background/Purpose: The belief that patients with cloacal exstrophy have a short and therefore useless colon is all too common. Frequently, the colon is used for urinary or vaginal reconstruction, and the possibility of a pull-through is lost. In the authors' experience, the use of a unified management plan allowed most patients to undergo pull-through and avoid a permanent stoma. Methods: Twenty-five patients were treated for cloacal exstrophy in the authors' institution from 1985 through 1999. In all patients, bladder closure, omphalocele repair, and creation of a colostomy were performed at birth. All available colon, no matter how small, was incorporated into the fecal stream. After at least 1 year, patients were assessed for the ability to form solid stool through their stoma. Normal colonic length, capacity to form solid stool, or success with a bowel management regimen through the stoma were considered indications for pull-through. Genitourinary reconstruction was contingent on the colorectal plan. Results: Colonic length ranged from normal in 12 patients, 40 to 70 cm in 3 patients, 10 to 30 cm in 4 patients, and less than 10 cm in 2 patients. All 25 patients underwent pull-through. Three are totally continent, 4 are continent with occasional soiling, 11 remain clean with a bowel management regimen, and 4 are too young to assess. One patient was clean, but now refuses bowel management. Two early patients, both with less than 10 cm of colon, now have ileostomies. Conclusions: During neonatal repair, a colostomy should be formed incorporating all pieces of colon, no matter how small. With time, most patients will be able to form solid stool, and a pull-through should be undertaken if that ability exists. Decisions regarding genitourinary reconstruction should be made only after the gastrointestinal plan is established to achieve the optimal use of available bowel. J Pediatr Surg 35:932-937. Copyright © 2000 by W.B. Saunders Company.

Prevention of the abdominal compartment syndrome

Although the abdominal compartment syndrome was not named as such until the past decade, it has been known for over 50 years. Ogilvie 1 Ogilvie WH The late complications of abdominal war-wounds. Lancet. 1940; ii: 253-256 Abstract Scopus (86) Google Scholar detailed the surgical management of the “burst abdomen”early in World War II. Gross, 2 Gross RE A new method for surgical treatment of large omphaloceles. Surgery. 1948; 24: 277-292 PubMed Google Scholar who in 1948 was the first to advocate the two-stage repair of omphalocele, described the “continual battle, often somewhat brutal, while trying to pack intestinal loops into a cavity which is too small to receive them”. He also identified the clinical triad expected when the abdominal cavity is overstuffed—respiratory failure (due to upward displacement of the diaphragm), impaired venous return (from pressure on the inferior vena cava), and intestinal obstruction (from compression of the viscera).

Umbilicoplasty in neonates with primary omphalocele closure.

A new technique of umbilicoplasty in neonates who underwent primary omphalocele repair is described and illustrated. The procedure resulted in a nearly-normal appearance of the umbilicus.

Reconstruction of an Extreme Frontal and Frontobasal Defect by Microvascular Tissue Transfer and a Prefabricated Titanium Implant

This article presents our technique of umbilical reconstruction after the repair of omphalocele and gastroschisis. We have treated 8 patients with an average follow-up period of 13 months (range, 6 approximately 24 months). No major complications have occurred; minor complications have included delayed wound healing, decreased umbilical depth, and hematoma. Our procedure is especially useful for patients who have a midline abdominal scar and relatively intact bilateral rectus abdominis muscles. Most of the patients and their parents have been satisfied with the results of umbilical reconstruction.

Umbilical Reconstruction after Repair of Omphalocele and Gastroschisis

Umbilical Reconstruction after Repair of Omphalocele and Gastroschisis

Improved survival of infants with omphalocele

The surgical management of patients with omphalocele has evolved over the past 4 decades. Despite many improvements in care, the reported mortality has been over 10%. This study reviewed the characteristics, management, and outcome of 31 patients with omphalocele who underwent surgical care between 1980 and 1995 at a single hospital. Twenty-five patients had additional congenital anomalies. All but 1 patient underwent operative repair; 13 of these patients with large defects had a silo chimney constructed initially. Fourteen patients underwent primary fascial and skin closure at the initial operation. Only 1 patient died perioperatively; another patient died without operation due to other major malformations. The results following surgical repair of omphalocele defects depend on the degree of visceroabdominal disproportion and on the severity of associated anomalies. The operative mortality for staged omphalocele repair with limited elevation of intraabdominal pressure is low, and the long-term quality of life of these patients is good.

Successful endoscopic balloon dilatation for hypertrophic pyloric stenosis

The authors successfully applied endoscopic balloon dilatation for the treatment of hypertrophic pyloric stenosis (HPS). The patient was an infant girl who had undergone repair of a giant omphalocele. Endoscopic balloon dilatation was performed using a 9-mm endoscope and an 8-mm polyethylene terephthalate (PET) balloon dilator. Dilatation was performed three times for 10 minutes. Vomiting continued after the dilatation. At the second session, dilatation was performed using a 12-mm PET balloon dilator. The 9-mm endoscope then passed through the pylorus. The patient has had no episodes of vomiting since the second treatment. This procedure is an important therapeutic option for selected patients with HPS.

Temporary Intravenous Bag Silo Closure in Severe Abdominal Trauma

Several temporary abdominal wall closure techniques have been described in the literature. We present our experience with an inexpensive and efficient method of temporary abdominal closure when bowel edema and distension preclude safe primary closure. Our technique is a variation of the silon (silo) closure used in the repair of gastroschisis and omphalocele, using a pre-gas-sterilized, soft 3-L plastic cystoscopy fluid irrigation bag cut to an oval shape and stapled or sutured to the skin edges of the wound.

Torsion of an accessory lobe of the liver in an infant

This report concerns a 6-month-old boy who had omphalocele repair as a newborn and then had torsion of an accessory hepatic lobe, resulting in necrosis. A successful outcome was achieved by resecting the torsed accessory lobe.

Umbilical preservation in omphalocele repair

A newborn with a large omphalocele is presented. A new technique of umbilical preservation is introduced. The cosmetic result was excellent, and the method is suitable for both primary and staged omphalocele repairs.

Amnion inversion in the treatment of giant omphalocele

Operative repair of giant omphaloceles remains a technical challenge to close the wide abdominal wall defect. Currently, most surgeons remove the amnion to approximate the linea alba and/or skin edges or to suture prosthetic material to the abdominal wall and cover the defect with skin flaps. In doing so, the liver commonly becomes extruded and distended with blood, compounding the problem of reducing all of the viscera within the small abdominal cavity. Furthermore, bowel obstruction from adhesions produced from opening the abdomen is a life-long threat. We describe six cases of giant omphalocele in which the amnion was left intact, and it was progressively inverted into the abdominal cavity by using the silastic silo, as it is used for gastroschisis. The birth weight of these infants ranged from 2,360 to 3,240 g. The abdominal wall defect measured 7.0 cm to 10.5 cm in width, and protruded at least 8 cm beyond the abdominal wall. The first stage of repair was to suture the silastic silo to the skin-amnion junction, and progressively reduce the bowel and liver within the abdomen. The intrabdominal pressure is monitored by nasogastric tube or by an indwelling bladder catheter to avoid pressures greater than 20 cm H 2O, which might compromise intestinal and renal circulation. The second stage consisted of incising the skin/amnion junction to expose the linea alba. The linea alba was approximated while leaving the amnion intact and folding it into the abdominal cavity. This avoids entering the peritoneum or interfering with the blood flow to and from the liver. The amnion seems to resorb, and there have not been any adverse effects over the 5-year period of follow-up.

Simultaneous Superior and Inferior Vena Cava Pressure Recordings in Giant Omphalocele Repair - A Possible Guideline for Prevention of Postoperative Circulatory Complications

Eleven children underwent second stage repair of giant omphaloceles containing the liver. Simultaneous SVC and IVC pressure before, during and after closure of the abdominal wall was recorded. In all patients with circulatory complications the SVC pressure decreased following surgery. The postoperative pressure ratios in IVC and SVC (Formula: see text) was found to be four times greater in the group with complications. It is suggested that this ratio might serve as an important index in the prediction of abdominal wall closure feasibility in giant omphaloceles.

Effect of abdominal distension on central and regional hemodynamics in neonatal lambs.

Elevations of intraabdominal pressure (IAP) can occur during surgical repair of gastroschisis and omphalocele and lead to ischemia of abdominal organs. We examined the effect of elevated IAP on central hemodynamics and regional abdominal organ blood flow, measured by radiolabeled microspheres, in 11 pentobarbital-anesthetized neonatal lambs. Stepwise increases in IAP were obtained by inflating a large bag placed intraperitoneally with air to pressures of 15, 20, and 25 mm Hg. Measurements were made at 30 min of elevated IAP and 30 min after deflating the bag. Mean aortic pressure was not significantly altered at an IAP of 15 mm Hg (78 +/- 4 mm HG) (+/- SE) or 20 mm HG (76 +/- 4 mm Hg) compared to baseline (81 +/- 4 mm Hg), but was decreased at the highest IAP (68 +/- 5 mm Hg). Stepwise decreases in blood flow to all abdominal organs, except adrenal gland, occurred with elevated IAP, and blood flows to these organs (except spleen) returned to or above baseline on bag deflation. At IAP of 15, 20, and 25 mm Hg, cardiac output was reduced by 14, 21, and 35%, respectively. Similar percent reductions of renal blood flow occurred. However, regional gastrointestinal blood flow decreased by a greater extent (35, 50, and 54% at each respective IAP). Hepatic arterial blood flow more than doubled at each IAP, but this was not sufficient to maintain total liver blood flow, or presumably total oxygen delivery to liver.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholelithiasis in infants: The role of total parenteral nutrition and gastrointestinal dysfunction

Three infants are reported, in whom gallstones developed following long term parenteral nutrition. In two of these the parenteral nutrition was required for management of the short bowel syndrome, while in one it was necessitated for severe gastrointestinal dysfunction following an omphalocele repair. It is postulated that gastrointestinal disease rather than parenteral nutrition, by producing changes in bile acid metabolism, results in gallstone formation.

Obstruction of the suprahepatic inferior vena cava as a complication of giant omphalocele repair

Obstruction of the inferior vena cava with resultant Budd-Chiari syndrome after giant omphalocele repair has not previously been reported. Such a case is presented. We hypothesize the mechanism of this blockage to be posterior displacement of the inferior vena cava during reduction of the viscera and closure of the anterior abdominal wall, thereby creating angulation and mechanical blockage of the inferior vena cava at the diaphragmatic hiatus.