Presentation for post graduate

1. MANAGEMENT OF NEONATES WITH
ABDOMINAL WALL DEFECT

2. Outline
Prenatal management
Postnatal management
Research Ethiopia
Gastroschisis
Primary closure
Staged closure
Suturless closure
Omphalocele
Giant omphalocele

3. Perinatal management
US scanning to look for associated anomalies
 Delivery route is mainly determined by obstetric indication
Usually CS is performed for giant omphalocele
Perinatal counseling by multidisciplinary team

4. Postnatal management
Fluid management
 For gastroschisis: boluses of 20ml.kg+ high maintenance rate
 For omphalocele ; 140-150ml/kg/day
Hypoglycemia…….beckwith wiedeman syndrome
Hypothermia
 Place the neonate in plastic wrap
 Put in incubator

5. …ctd
Decompress abdomen
 insert NG tube
 Catheterize
 Evacuate meconium
Start on broad spectrum IV antibiotics
Assess the bowel and cover with warm saline soaked gauze

6. Where are we?

7. Over 4 year 39 neonates with AWD : 29 O, 10 G
Gastroschisis
 90% primary closure, 10% silo/iv bag/
 Mortality rate:=70%
Omphalocele
 Conservative with GV :55.2%.......MR =43.3%
 Primary closure : 37.9%...............MR=25%
 Staged closure: 6.9%.......................MR=33.3%

8. Gastroschisis
Primary closure Will be considered In suitable condition
 Those who came early
 Easily reducible bowel

9. Technique
1) Extend defect vertically
2) Inspect bowel
3) Evacuate meconium
4) Reduce bowel and close abdomen

10. Concern in primary closure is the occurrence of ACS
ACS occur when Elevated intraabdominal pressure lead to
decreased venous return and cardiac output
 it will result in Hypo perfusion of intraabdominal organs
Respiratory :Impaired ventilation and oxygenation

12. Measuring intraabdominal
pressure
Direct way is insert intraperitoneal catheter and connect it to
transducer measure pressure
Indirect ways
 intragastic pressure
 intravesical pressure
Peak inspiratory pressure >20mmhg

13. Normal IAP is below 10mmhg
Indirect measurement of IAP by
IVP ,IGP is reliable
 when PIP and IVP greater than 20
primary closure should be
abandoned

14. Staged closure with a silo
Earlier hand sewn silo bags were commonly used
Currently preformed silo bags are available with a ring size of 2-12cm
We use urine bag as a silo bag

17. 1) suture silo/urine bag to the abdominal wall
2) Dress the silo base with povidone ointed gauze
3) sequentially reduce silo content by twisting Better if reduced within
1 week
4) Take to the OR for closure

18. Bianchi suture less closure
technique…1998
Elective delayed reduction and no anesthesia
Recent cosmetically sound and effective technique
Decompress
meconium from colon
Insert NG tube
Wrap bowel with bowel wrap,keep umblical cord long
Prepare abdomen with antiseptic

19. Give minimal sedation
Reduce bowel content slowly and turn by turn over hours
Cut umbilical cord long and use that to cover the defect
Apply adhesive plaster
sutureless closure can also be done with intubation

21. Conversion criteria to silo with
GA
Non reducible matted bowel loop
Sign of peritonitis after closure
Poor general condition
Vital sign derangement with respiratory and circulatory compromise
Need for Mechanical ventilator
Very narrow defect
Major associated anomaly

22. Female condom as a silo
Used in 20 neonates in Brazil
16 undergo primary closure after 4 days
4 staged closure
1 death due to sepsis from the study

24. Intubated vs non intubated
53 neonates undergo suturless umbilical closure
 23 non intubated closure attempted : 15 successful ………..1death
 8 needs intubation then 6 undergo closure
 2 converted to silo
 30 intubated suturless closure
Both in the intubated and non intubated group rate of complication,
need for mechanical ventilation and rate of silo conversion was similar

25. Omphalocele
Management differs based on the size and associated congenital
anomalies
Neonatal mortality rate as high as 17-40% depending on associated
anomalies reported
Initial Work up
• Echo for all
• Abdominal US
• RBS
• karyotyping

26. Risk factor
•Associated anomalies
•Size of omphalocele
•Respiratory insufficiency ,pulmonary hypoplasia
•Rupture of omphalocele sac
•Low birth weight ,prematurity
•DEFECT size
•Presence of rupture

27. Immediate repairs
For small –medium sized omphalocele
Abdominal defect less than 5 cm
Those who have good abdominal domain
Availability of mesh
Stable cardiorespiratory condition

28. Primary closure
1) Excision of the sac and skin and fascia closure
2) Reduction
3) Stretch the abdomen manually
4) Reduce midgut followed by liver
5) Leave part of the sac over the liver to prevent hepatic veins injury
6) Leave part of the sac over the bladder
7) Vertical/transverse fascial closure
8) Skin closure and umblicolasty

29. Giant omphalocele
Defect of 5-6cm ,contains most of the liver
Has Mortality rate of 30-46%
For giant omphalocele there are two approaches
◦ 1.non operative
◦ 2.operative

30. ◦ Primary closure is preferred way of treatment when it is
feasible
◦ Omphalocele circumference/abdomen circumference ratio
helps to predict success of primary closure
◦ OC/AC ratio of <.26 high chance of primary closure success

32. Paint and wait
Escharotic therapy
Gradual epithelization of omphalocele sac using
Povidone iodine
Alcohol
Mercuchrome
Silver sulfidizine,silver nitrate
With or without compression

33. Indication
Chromosomal abnormality
Respiratory insufficiency
Major associated anomalies
Giant omphalocele

34. Side effects from scarification
treatement
Alcohol toxicity
Hypothyroidism
Silver toxicity: seizure, raised LFT AND RFT, leucopenia
Mercury poisoning

35. Comparing povidone iodine
and Acacia
In Egypt they used powder of Acacia niolitica with GV
Works by coagulation of protein
Make the sac more firm and tough
Epithelization completed in 7.8+- 4.8 week
Mortality of 25 %

37. Comparing saline vs honey
Honey is also used as eschcarotic
Has no side effect and less rupture and fistula risk
Promotes faster healing, full healing 45+-6.8 days
# Honey is a good escharotic agent

39. 24 NEONATES
TOPICAL THERAPY:12.34= -2.12 DAYS
NO HYPOTHYRODISIM, NO SAC RUPTURE
6 DEATHS

41. Reduction of omphalocele
with compression

42. Primary closure for large
omphalocele
In case of difficult fascial closure the following can be used
• Skin Flaps
• Bridge fascia with mesh
• Absorbable, non absorbable,biologic(Gortex,Vicryl,Alloderm)
• Component separation
• Fascial patch

44. Staged closure/Schuster
method
1) For a large defect omphalocele with a high volume of eviscerated
viscera
2) Excise sac
3) Apply silo: Silastic sheeting is sewn to the fascia/spring loaded silo
4) Serial reduction cutting out a portion of each sheet
5) After full reduction fascial closure or Prosthetic,mesh closure

45. USE OF BIOLOGIC MESHS: A STERILE ACELLULAR
SHEET DERIVED FROM DERMAL COLLAGEN

47. Ventral hernia repair
 6mont-1year after
 Primary fascial closure
 Component separation
 Mesh repair

48. Component separation
technique
Degloving of Abdominal skin up to anterior mid axillary line
 then Fasciotomy to separate External oblique from Rectus abdominus
The fasciotomy Will serve as a relaxing incision
Rectus abdominus will be sutured at midline

50. Prognostic factor
>Associated anomalies: cardiac, pulmonary hypoplasia
>Giant omphalocele has higher mortality due to the surgical
management difficulty
>High OC/AC ratio
>Liver herniation
>Low birth weight, prematurity

51. Ruptured Omphalocele
Cover the bowel
Do silo bag
Use of biologic mesh
Case reports of successful sac repair

52. NEW INNOVATIVE METHOD
◦ Use of tissue expander
◦ Put tissue expanders in the subcutaneous or
intermuscular layer
◦ Will result in increase in abdominal capacity

53. complication
Intestinal obstruction with adhesion
Wound infection, dehiscence
Neurodevelopmental delay
GERD