Delayed external compression reduction of an omphalocele (DECRO): an alternative method of treatment for moderate and large omphaloceles

Vacuum-assisted staged omphalocele reduction: A preliminary report

INTRODUCTION

Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele.

PATIENTS AND METHODS

Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3).

RESULTS

Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery.

CONCLUSION

In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Modified sequential sac ligation and staged closure technique for the management of giant omphalocele

PURPOSE

This study aimed to describe sac ligation and sequential closure for the management of giant omphalocele (GO) and analyze its outcomes.

METHODS

The medical records of 13 neonates with GO treated at a tertiary general hospital between July 2012 and April 2020 were reviewed. Sac ligation and progressive external compression were performed on most cases immediately after birth. Staged closure with or without a prosthetic patch was conducted after a period of sac suspension.

RESULTS

Sac ligation-traction-compression was performed on 12 cases, of which 10 underwent staged closure, one with delayed closure. One patient with coexistent esophageal atresia was deemed ineligible for surgery. Among those who had undergone staged closure, 9 survived; however, one neonate who complicated with bilateral diaphragmatic eventration and severe ventilator-associated pneumonia died from multiple-organ failure. Pentalogy of Cantrell was excluded. One patient in whom primary closure was performed after birth died aged 29 h. Pneumonia was the most common infection among patients (5/13), with three having ventilator-associated pneumonia. The median durations of mechanical ventilation and hospital stay were 22.2 days (range, 1-151) and 44.2 days (range, 2-152), respectively, and 25.6 days and 46.4 days, respectively, among patients with staged closure. Among five infants who required oxygen support for more than 28 days, four had pulmonary hypoplasia.

CONCLUSIONS

Aside from abdominal wall defects, other major comorbidities and pulmonary hypoplasia influence the prognosis of GO. Sac ligation and staged closure is a effective choice for GO.

TYPE OF STUDY

Retrospective Study Level of Evidence: Level IV.

Abdominal Wall Defects-Current Treatments

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

A Rare Combination of Left-Sided Gastroschisis and Omphalocele in a Full-Term Neonate: A Case Report

BACKGROUND Left-sided gastroschisis is a rare congenital birth defect characterized by herniation of intra-abdominal organs through an abdominal wall defect to the left of the umbilicus. Approximately half of the 31 cases reported in the literature describe other associated anomalies. To the best of our knowledge, it has never been reported in association with an omphalocele. CASE REPORT Here, we present the case of a female newborn, 37 weeks gestational age, born with a 3×6 cm omphalocele and a left-sided gastroschisis with herniation of the small bowel. Both of these anomalies were managed separately, with initial placement of a silo bag on the gastroschisis defect and application of topical agents to the omphalocele until complete epithelialization was achieved. The herniated bowel at the gastroschisis site was reduced with the aid of the silo by 96 hours and the fascia then closed primarily. A gastrostomy tube (G-tube) was placed at 16 weeks of age because of poor oral intake. Definitive closure of the omphalocele and removal of the gastrostomy tube was achieved at 13 months. Her subsequent follow-up visits in the clinic have been uneventful. CONCLUSIONS Our case report highlights the importance of recognizing this combination of rare conditions and directing appropriate surgical care.

Nonoperative management of giant omphalocele leading to early fascial closure

PURPOSE

We describe our series of giant omphalocele patients treated with a serial taping method for gradual reduction of the abdominal contents and early fascial closure.

METHODS

Between 2010 and 2017 we cared for ten newborns with giant omphaloceles. The average gestational age was 35.5 weeks (range 29-38) and average birthweight was 2.84 kg. Seven infants had other major anomalies, including one with a variant of Pentology of Cantrell. Four had abnormal chromosomes. None had any attempt to primarily close the defect. Omphalocele defects were serially taped at bedside in the NICU with the child awake until the viscera were completely reduced, and the defect could be closed.

RESULTS

Mean time to closure was 13.7 days (median 14 days). Six were closed primarily without a patch. The remaining four infants required Gore-Tex patch (covered by skin) which was later removed and fascia closed in three infants (at 70 days, 75 days, and 11 months of age). Total length of stay was a mean 71.8 days (median 71).

CONCLUSIONS

Serial taping achieves early fascial closure and avoids complications of a staged surgical approach, such as multiple anesthetics, loss of fascial margin integrity, silo dehiscence, and fistula formation. Compression of the viscera is slow enough to avoid abdominal compartment syndrome and the fascia and amnion are left intact leaving the option available to use escharotic agents if required.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Dressed for success? Silver impregnated nanocrystalline dressing for initial treatment of giant omphalocele

OBJECTIVE

The purpose of this study was to describe outcomes and resource utilization in patients treated with twice-weekly silver impregnated (SI) nanocrystalline dressings for initial non-operative management of giant omphalocele (GO).

METHODS

A retrospective review of patients with GO treated with SI dressings was undertaken. Clinical parameters, cost, and complications were recorded.

RESULTS

Five patients with GO were treated with SI dressings between 2014 and 2016. Clinical characteristic (mean ± SD) included gestational age 36 ± 4 weeks, birth weight 2.6 ± 0.63 kg, GO size 10.2 ± 4.7 cm, ventilator days 7.5 ± 8.7 d, days in NICU 41 ± 20 d, days to full feeds, 30 ± 15 d, and LOS 62 ± 41 d. The average in-hospital cost of SI dressings was $110 CAD/week. This is comparable to daily silver sulfadiazine dressings ($109CAD/week) which were used historically. All patients were discharged with once- or twice-weekly dressing changes. No ruptures occurred. There was one mortality secondary to pulmonary sepsis.

CONCLUSIONS

For initial non-operative management of GO, twice weekly SI nanocrystalline dressings is safe and effective. Use of SI dressings results in decreased handling of infants, reduced physician and nursing resource utilization, and favourable outcomes.

LEVEL OF EVIDENCE

IV (Retrospective Case Series).

Topical treatment of major omphalocoele: Acacia nilotica versus povidone-iodine: A randomised controlled study

BACKGROUND

Conservative management for major omphalocoele with topical agents as escharotics therapy is well established in practice. Different agents have been used in the past, including mercurochrome and alcohol, proved later to be unsafe. The aim of this study is to evaluate the efficacy and safety of the application of Acacia nilotica paste compared to povidone-iodine solution as a primary non-surgical treatment of major omphalocoele.

PATIENTS AND METHODS

A double-blind, randomised study was conducted on 24 cases of major omphalocoele where they were randomly divided into two equal groups; Group A treated with topical application of A. nilotica paste and Group B treated with topical application of povidone-iodine solution. Cases with gastroschisis, ruptured major omphalocoele or minor omphalocoele were excluded from the study. The evaluating parameters were size of the fascial defect in cm, period of mechanical ventilation if needed, time required for full oral feeding tolerance, duration of hospital stay and any short- or long-term complications.

RESULTS

There was no statistical significant difference between both groups regarding their gestational or post-natal age, weight and the mean umbilical port defect. Patients from Group A tolerated full oral feeding earlier and had shorter total hospital stay duration than those from Group B, but without a statistical significant difference (P = 0.347 and 0.242, respectively). The overall mortality rate was 33.3% without a statistical significant difference between both groups (P = 0.667).

CONCLUSIONS

Application of A. nilotica is a safe and effective treatment of major omphalocoele as it was associated with rapid full enteral feeding tolerance, short duration of hospital stay and low mortality rate.

Past and current surgical treatment of giant omphalocele: outcome of a questionnaire sent to authors

PURPOSE

Operative treatment of giant omphalocele (OC) is still a challenge for pediatric surgeons. We were interested to ascertain whether published operative techniques for giant OC once advocated by their authors were still being used by these authors and whether the techniques had been modified or even abandoned for other techniques.

METHODS

Relevant studies concerning the treatment of giant OC were identified by an electronic search. Publication date of the articles was from 1967 to 2009. A questionnaire was sent to the first author or coauthor, unless contact details were unavailable. The described surgical techniques were categorized into primary closure, staged closure, and delayed closure.

RESULTS

Almost half of the authors (42%), independent of the initial technique used (primary, staged, or delayed closure), changed or stopped using their technique after the publication of the article. The change was not to one particular proven better technique. Herniation rate was lower in delayed closure (9% delayed vs 18% staged vs 58% primary).

CONCLUSIONS

The results of the questionnaire did not show a generally accepted method of treatment after more than 30 years of innovations in managing patients with a giant OC. There are generally 2 main treatment modalities: staged closure and delayed closure. Because of the lack of large patient numbers and late follow-up, long-term results of the published techniques are needed, and randomized multicenter trials based on these outcomes are recommended. Until then, we remain dependent on expert opinions.

Neonatal care in patients with giant ompholocele: arduous management but favorable outcomes

OBJECTIVES

The objectives of the study were to provide a review of patients with giant omphalocele managed in a single institution (2001-2006), focusing on medical management in the neonatal period, and to evaluate short-term outcomes.

METHODS

Data from 14 neonates with giant ompholocele (abdominal wall defect >5 cm and/or containing liver) and the absence of malformation and chromosomal anomalies during fetal screening were retrospectively reviewed. All were intubated and sedated before surgical treatment. Initial management consisted of progressive reduction of the herniated organs by gentle compression. After sequential reduction, abdominal wall closure was attempted at the skin and fascia level and, when necessary, with a Gore-Tex patch.

RESULTS

Median gestational age was 39 weeks (38-40), and median birth weight was 3100 g (2470-3700). Median age at closure was 6 days (0-20). A central Gore-Tex patch was inserted in 10 cases. Median ventilation length was 26 days (2-78). Full enteral diet was achieved after an average of 33 days (8-82), and median time until discharge from the intensive care unit was 24.5 days (11-85). Nine patients developed sepsis in the postoperative course. In 10 patients, at least 1 associated malformation was diagnosed in the postnatal course, among which cardiac and diaphragmatic defects were the most common. Survival rate was 85.7%.

CONCLUSION

Mortality rate of giant omphalocele without chromosomal anomaly or major malformations is low when treated by gradual reduction of the contents. Parents should be informed of the long hospitalization in the intensive care unit at birth, the potential nonthreatening associated malformations to be diagnosed after birth, and the high risk of sepsis.

A strategy for treatment of giant omphalocele

BACKGROUND

The management of giant omphalocele (GO) presents a major challenge to pediatric surgeons. Current treatment modalities may result in wound infection, fascial separation, and abdominal domain loss. We report a GO infant who required a delayed closure and was managed using sterile incision drape and polypropylene mesh.

METHODS

A 3080 g full-term female infant was born with a GO. The skin was dissected from the fascia circumferentially without opening the amniotic sac and the peritoneum. Subsequently, two polypropylene meshes of 10 x 10 cm in diameter were sutured to each other. Inner surface of the mesh silo was covered with sterile incision drape. This texture was sutured to the fascial margin. Then, the skin was sutured to the mesh and the silo was closed from the side and above. On the 4th day the reduction was started using thick sutures without anesthesia. This procedure was repeated on every 3rd day. When it came closer to the skin margins, constriction was performed using right angle clamps, each time placed 2 cm proximally to the previous sutures in a circular manner. Silo was removed easily and the skin, subcutaneous layers, and fascia were then approximated on the 42nd day.

RESULTS

The postoperative course was uneventful and the infant was well with left inguinal hernia repaired in the 3rd month.

CONCLUSION

The method we used can be performed at bedside and without the application of anesthesia, but should be tried on more patients to determine its effect.

Has the liver and other visceral organs migrated to its normal position in children with giant omphalocele? A follow-up study with ultrasonography

This study evaluates whether, on the long run, in patients born with a giant omphalocele, the liver and other solid organs reach their normal position, shape, and size. Seventeen former patients with a giant omphalocele, treated between 1970 and 2004, were included. Physical examination was supplemented with ultrasonography for ventral hernia and precise description of the liver, spleen, and kidneys. The findings were compared with 17 controls matched for age, gender, and body mass index. We found an abnormal position of the liver, spleen, left kidney, and right kidney in eight, six, five, and four patients, respectively. An unprotected liver was present in all 17 patients and in 11 controls, the difference being statistically significant (p = 0.04). In ten of the 11 patients with an incisional hernia, the liver was located underneath the abdominal defect.

CONCLUSION

In all former patients with a giant omphalocele, an abnormal position of the liver and in the majority of them, an incisional hernia was also found. The liver and sometimes also the spleen and the kidneys do not migrate to their normal position. Exact documentation and good information are important for both the patient and their caretakers in order to avoid liver trauma.

Successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair: report of a case

We report the case of a successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair. Untreated omphaloceles are rare in adulthood. A 30-year-old female patient presented with a large anterior abdominal wall defect due to an untreated omphalocele, who expressed a desire to have a baby in the near future. A laparoscopic herniorrhaphy was performed with a double-layered expanded polytetrafluoroethylene (ePTFE, Gore-Tex) mesh. The patient delivered a full-term healthy baby vaginally 2 years after surgical repair of the omphalocele.

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.

Clinical care outcomes in abdominal wall defects

PURPOSE OF REVIEW

Abdominal wall defects comprising both gastroschisis and omphalocele remain a source of significant morbidity and mortality, despite the advances in neonatal and pediatric surgical care. Survival has improved over the past few decades, especially with parenteral nutrition and surgical repair. Yet, still, many questions remain regarding the outcome of these anomalies.

RECENT FINDINGS

Outcomes of abdominal wall defects have been discussed more often in the recent publications, with analysis of databases and evaluation of prenatal series. There have been a number of new prenatal interventions in gastroschisis, and a better understanding of gestational outcomes from omphalocele. Papers have discussed the optimal surgical management of these defects as well.

SUMMARY

This review helps to bring together the most recent findings regarding outcomes and interventions for abdominal wall defects. It also illustrates the pressing need for a large prospective database to better understand these anomalies and provide better care.

Exomphalos major suspension: a novel technique

A 38-week gestation female neonate with an antenatally diagnosed exomphalos major was born with respiratory insufficiency requiring initially high frequency oscillation, nitric oxide and inotropic support. The exomphalos was vertically stabilized by means of a novel technique prior to the application of a silo and formal closure. The technique is described and compared with others.

Gastroschisis and omphalocele: treatments and long-term outcomes

Between February 1994 and April 2004, we treated 40 children with gastroschisis and 26 children with omphalocele. We recorded the course of pregnancy, pre- and post-natal complications, delivery, operation, post-operative therapy, and long-term outcomes. Additionally, we conducted follow-up examinations of 37 of these 66 children (56%). We analysed their abdominal musculature, development, cosmetic result and quality of life. The median duration of follow-up was 6.3 years (range 1-10). In 35/40 children (88%) with gastroschisis and in 18/26 children (69%) with omphalocele, there had been prenatal diagnosis. The average maternal age of 23.9 years in the gastroschisis group was lower than in the omphalocele group (29.9 years). Delivery was by caesarean section in 93% of the gastroschisis group and 65% of the omphalocele group. Outcomes following vaginal delivery were no worse than those after caesarean section. Further, congenital abnormalities were shown in 28% of gastroschisis cases, and were limited to the gastrointestinal tract. Of the omphalocele cases 81% showed further abnormalities. Direct closure of the abdominal wall defect was possible in 31/40 (78%) of the gastroschisis cases and 15/26 (58%) of the omphalocele cases. Mortality in gastroschisis was nil; two children with omphalocele died (8%). Outcomes were better after primary closure than in stepwise reconstruction. Follow-up showed good results in all categories. Developmental delays were rapidly made up after treatment, and 75% of the children had no gastrointestinal problems, or suffered from these rarely. Almost all the children were of normal weight and height, and physical and intellectual development were delayed in only one third of the children. The surgical scar was rated as good or very good in about 80% of the cases. Except for those with severe defects, the children had good ratings for quality of life. Improvements in short-term results of gastroschisis and omphalocele treatment can be attributed to recent developments in prenatal diagnosis and the advancements of centralised perinatal care. Our long-term results clearly demonstrate that initial gastrointestinal problems and developmental delays were made up during the first two years of life. Prenatal counselling can now be more optimistic.

Initial nonoperative management and delayed closure for treatment of giant omphaloceles

PURPOSE

Traditional treatment of giant omphaloceles with silo closure has been associated with respiratory insufficiency, hemodynamic compromise, dehiscence, and inability to close the abdomen with subsequent death. To minimize such complications, initial nonoperative management with delayed closure of the defect has been used.

METHODS

Between January 1981 and December 2002, 111 patients with omphaloceles were treated. Twenty-two patients with giant omphaloceles (19 containing liver) underwent initial nonoperative management consisting of silver sulfadiazine dressing changes. After pulmonary and other comorbidities stabilized, the contents were gradually reduced with a loose elastic bandage, and delayed closure was planned at 6 to 12 months. The medical records of these 22 patients were retrospectively reviewed to determine the efficacy and safety of this technique in the setting of severe associated anomalies. Those 15 patients (n = 15) from the latter 10 years were further reviewed to determine additional end points (length of hospital stay, length of intensive care unit stay, duration of mechanical ventilation, time to feed, time to closure, and type of closure).

RESULTS

Of the 15 patients treated during the latter 10 years, mean gestational age and birth weight were 38 +/- 1.4 weeks and 3.1 +/- 0.57 kg, respectively. Median length of stay after birth was 20 days (range, 5-239 days). Median time to full diet was 8 days (range, 4-80 days). Four patients were discharged on oral feedings only, 7 with combination oral/gavage, and 4 with tube feedings. Pulmonary hypoplasia or pulmonary hypertension was present in 11 (50%) of 22 patients. There were 11 patients with major cardiac anomalies, 14 with a patent ductus arteriosus, and 8 with a patent foramen ovale. Three early complications (2 ruptured sacs and 1 bleeding sac) and 1 late complication (gastric necrosis) occurred in the initial nonoperative period. In addition, 4 patients were treated for line sepsis, 1 patient for acute renal insufficiency, and 1 for aspiration pneumonia. Three patients required tracheostomy and were discharged with home ventilators. There were no complications associated with the use of silver sulfadiazine. Of the 22 patients, 16 have undergone delayed repair, 2 did not require repair, 1 is awaiting repair, 2 died before closure, and 1 was lost to follow-up. Delayed closure was achieved at a median age of 14 months (range, 2-28 months) and mean weight of 8.8 +/- 3.3 kg. Four patients required implantation of mesh for definitive closure. Median postoperative length of stay was 4 days (range, 2-21 days). Postoperative complications included prolonged ileus, recurrent ventral hernia, and prolonged intubation. Overall mortality rate was 9.1%. One death occurred after diaphragmatic hernia repair, and 1 death was from overwhelming sepsis in the patient with a late gastric perforation.

CONCLUSION

The use of silver sulfadiazine dressing changes for initial nonoperative management of giant omphaloceles is a safe and effective bridge to delayed closure. We recommend this method as initial nonoperative management given the high incidence of associated cardiopulmonary malformations because it may facilitate enteral feeding, minimize respiratory compromise, and reduce morbidity and mortality.

Successful Sequential Sac Ligation for an Unruptured Giant Omphalocele: Report of a Case

A giant omphalocele is difficult to treat and various methods have been tried with varying results. We describe a technique of sequential sac ligation to achieve rapid and gentle reduction of the herniated abdominal contents, followed by delayed primary closure of the abdominal wall defect.

Vacuum-assisted closure: a new method for treating patients with giant omphalocele

INTRODUCTION

Closure of giant omphalocele can present a surgical challenge. Neither silo, skin flap, nor primary closure has been successful in treating all patients. We present a novel application of the vacuum-assisted closure (VAC) device, which allows for improved results in these difficult cases.

METHODS

The VAC device (KCI, San Antonio, Tex) consisted of a sponge applied directly to the bowel and liver, covered with impermeable transparent dressing, and attached to a low negative pressure system. The sponge was changed every 3 to 5 days under local sedation.

PATIENTS

All 3 patients had giant omphaloceles. The first infant, a 34 week gestational age (WGA) male, was initially treated with silo reduction, which disrupted after 21 days. The large mass of bowel and liver made primary closure impossible. The VAC was applied for 45 days. The viscera was easily reduced and subsequently covered with acellular dermal matrix (AlloDerm). The VAC was reapplied, and the small remaining defect was skin-grafted. The second male infant was a 34 WGA male infant who became septic after failure of prosthetic mesh closure. The VAC was applied for 22 days after removal of the mesh. The infection resolved, and the defect size was reduced, allowing for skin flap closure. Mesh infection and development of an enterocutaneous fistula in the last patient, a 37 WGA female child, were treated by mesh removal and application of the VAC for 36 days. The VAC allowed for control of the fistula output and development of a healthy granulation bed.

RESULTS

Vacuum-assisted closure was associated with (1) rapid shrinkage and reduction of the viscera (22-45 days); (2) cleansing of the wound; (3) excellent granulation; (4) maintenance of a sterile environment; and (5) ease of use, with changes possible at the bedside.

CONCLUSION

The VAC device should be considered a safe and effective alternative in treating complicated cases of giant omphalocele until a more definitive closure method can be used.

A comparison of ATV-related behaviors, exposures, and injuries between farm youth and nonfarm youth

CONTEXT

All terrain vehicles (ATVs) are a popular form of transportation and recreation for youth. ATVs are also convenient for farm-related activities. However, the impact of the farming environment on ATV-related injuries is not clear.

PURPOSE

To determine differences in ATV-related behaviors, exposures, risk factors, and injuries between farm youth and their nonfarm peers.

METHODS

A cross-sectional study design was used. A survey was administered to 652 youths in agricultural education programs throughout the state of Arkansas.

RESULTS

A majority (60%) of students have operated ATVs within the past month. Cross tabulations found that farm youth who rode ATVs were more likely to be white and male, to own a 3-wheel ATV, and to ride more often with a single rider. Risk factors for sustaining an ATV-related injury were frequency of use and the number of persons on the ATV.

CONCLUSIONS

Study findings suggest that ATV use among farm youth does differ from their nonfarm peers. ATV use among all youth is a safety concern in Arkansas because of the behaviors and exposures that the youth cited.

Closure of the ventral hernia in the management of giant exomphalos: a word of caution

Giant exomphalos containing liver as its major component and with visceroabdominal disproportion presents difficult management options to a paediatric surgeon. At Starship Children's Hospital, we deal with these with primary skin closure, if possible, followed by staged repair of the ventral hernia beginning in the 2nd year of life. During the closure of a ventral hernia, we encountered major hepatic venous bleeding resulting from the inadvertent injury to the right hepatic vein, resulting in the death of the child. An autopsy report showed the position of the hepatic veins superficially just beneath the skin. Subsequently, we performed magnetic resonance imaging (MRI) of the abdomen to look at the hepatic venous and caval anatomy in two children before closure of the ventral hernia. This was of immense help in limiting the dissection in the area and thus avoiding catastrophe. We recommend routine imaging with MRI before closure of a ventral hernia in children with giant exomphalos.

Management of ventral hernia after giant exomphalos with external pressure compression using helmet device

PURPOSE

The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele.

METHODS

The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation.

RESULTS

The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia.

CONCLUSIONS

The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.

Treatment of high imperforate anus with large omphalocele in a baby boy

Synchronous treatment of high imperforate anus with large omphalocele is a challenge for pediatric surgeon. A case of this unusual condition in a male neonate is presented. The high imperforate anus was repaired by primary one-stage posterior sagittal anorectoplasty, and the omphalocele was treated nonoperatively. Recovery was uneventful.

Uso primário da membrana amniótica na redução de onfaloceles gigantes

OBJETIVO: Demonstrar a eficiência da redução de grandes onfaloceles utilizando o âmnio como "silo". MÉTODO: Doze pacientes com onfaloceles gigantes submetidos à redução progressiva pela inversão do âmnio. RESULTADOS: Obtida redução completa entre cinco e dez dias, sem necessidade de prótese, em dez pacientes. Foram colocados dois "silos" por ruptura do âmnio durante a redução, com um óbito por septicemia. CONCLUSÕES: Apesar da casuística ser pequena, o método se mostrou confiável e eficaz no tratamento definitivo das grandes onfaloceles.

Left-lung-collapse bronchial deformation in giant omphalocele

Five infants with giant omphalocele had persistent collapse of the left lung and required prolonged respiratory support. Narrowing of the left main bronchus, reversible with positive end-expiratory pressure, was identified radiographically in 3 infants, and we postulate that this relates to distortion of the bronchus within the constraints of the elongated, narrow thoracic cavity characteristic of these patients. The lung collapse may be precipitated by manipulation (reduction or attempted reduction) of the omphalocele. J Pediatr Surg 36:846-850.

Abdominal wall defects in infants with very low birth weight

Management strategies for infants with very low birth weight (VLBW) who have abdominal wall defects essentially are the same as for those in larger infants. The authors favor primary closure in infants with gastroschisis, and have achieved this goal in 91% of infants since 1985. Treatment of infants with omphalocele is based on the size of the defect and the presence of respiratory insufficiency or severe associated anomalies. Nonoperative treatment is used initially for infants with large defects or associated anomalies, with planned closure of the resultant ventral hernia when the infant weighs 20 pounds or is 1 year old. This technique helps avoid the complications associated with mechanical ventilation and with tight primary closure such as intestinal dysfunction and wound problems.

Gastroschisis and omphalocele

The survival rate of patients with abdominal wall defects has gradually improved with the advances in the investigation and treatment modalities. The present paper reviews the results of various treatment modalities and also analyses the long term results in these patients. A meta-analysis was performed via a medline search of English written clinical studies containing the text words "abdominal wall defects", gastroschisis and 'omphalocele or exomphalos" from 1953 to 1998. The present consensus on operative management of abdominal wall defect is to provide primary closure, if it can be achieved without haemodynamic or respiratory compromise. Patients with primary closure on analysis were found to have better survival rates, reduced risk of sepsis and overall, a shorter hospital stay. However, resumptions of oral feeds, duration of total parenteral nutrition (usually lasting 10-15 days) and ventilatory support required postoperatively did not significantly differ in the primary and silo technique. Long term outcome of these patients is generally good, but they have high incidence of GER (40-50%) for which they should be on regular follow up.