Bipedicled skin flaps for reconstruction of the abdominal wall in newborn omphalocele

Management of giant omphaloceles: A systematic review of methods of staged surgical vs. nonoperative delayed closure

PURPOSE

Despite the numerous methods of closure for giant omphaloceles, uncertainty persists regarding the most effective option. Our purpose was to review the literature to clarify the current methods being used and to determine superiority of either staged surgical procedures or nonoperative delayed closure in order to recommend a standard of care for the management of the giant omphalocele.

METHODS

Our initial database search resulted in 378 articles. After de-duplification and review, we requested 32 articles relevant to our topic that partially met our inclusion criteria. We found that 14 articles met our criteria; these 14 studies were included in our analysis. 10 studies met the inclusion criteria for nonoperative delayed closure, and 4 studies met the inclusion criteria for staged surgical management.

RESULTS

Numerous methods for managing giant omphaloceles have been described. Many studies use topical therapy secondarily to failed surgical management. Primary nonoperative delayed management had a cumulative mortality of 21.8% vs. 23.4% in the staged surgical group. Time to initiation of full enteric feedings was lower in the nonoperative delayed group at 14.6days vs 23.5days.

CONCLUSION

Despite advances in medical and surgical therapies, giant omphaloceles are still associated with a high mortality rate and numerous morbidities. In our analysis, we found that nonoperative delayed management with silver therapy was associated with lower mortality and shorter duration to full enteric feeding. We recommend that nonoperative delayed management be utilized as the primary therapy for the newborn with a giant omphalocele.

Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes

Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.

Neonatal abdominal wall defects

Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.

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.

Bilateral anterior abdominal bipedicle flap with permanent prosthesis for the massive abdominal skin-grafted hernia

BACKGROUND

Fascial closure after damage control or decompression laparotomy is not always possible. The result is a ventral hernia covered with skin grafts. Massive hernias impair bowel, bladder, and respiratory function and are displeasing aesthetically. Most repair methods provide inadequate closure of large full-thickness abdominal wall defects. We describe our method of repair using bilateral anterior abdominal bipedicle flaps over permanent mesh.

METHODS

We reviewed 6 patients who underwent this repair method. This staged repair first involves flap elevation followed by delay. In the next stage, the hernia skin graft is excised, mesh is placed, and flaps are advanced to midline to cover the mesh.

RESULTS

The average hernia size was 885 +/- 274 cm2 (28-cm wide x 31-cm vertical), with a range of up to 37-cm wide. An average of 3 surgeries were required for closure, with a mean hospital stay of 22 days. No patients developed hernia recurrence with a mean follow-up period of 23 months.

CONCLUSIONS

This method provides successful and durable closure of massive skin-grafted hernias.

The use of Alloderm in the closure of a giant omphalocele

Giant omphaloceles are associated with a considerable loss of abdominal domain. Early primary repair of the fascia is either not possible or poorly tolerated by the infant. Current surgical options result in a ventral hernia requiring future surgery or involve the chronic use of prosthetic patches with or without tissue expanders. This case presentation describes an alternative surgical approach that results in early fascial closure using an interposition graft of Alloderm.

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.

CONCLUSION

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.