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Management of ventral hernia after giant exomphalos with external pressure compression using helmet device
Management of Ventral Hernia After Giant Exomphalos With External Pressure Compression Using Helmet Device By V.P. Mali, K. Prabhakaran, and J.Z. Patankar Singapore
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 escharinducing 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.
N
EONATES WITH a giant exomphalos have an abdominal cavity that is small and underdeveloped.1 Primary closure is not possible without compromising the hemodynamics or respiration. Hence, management strategies must consist of a staged approach wherein either a silo reduction is achieved or the giant omphalocoele is converted to a ventral hernia.1-5 We attempted an alternative approach wherein the giant exomphalos was first converted into a ventral hernia, and then this ventral hernia was reduced using external pressure compression with a helmet device (Jones P., Personal Communication).6
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. J Pediatr Surg 39:E26. © 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Exomphalos, omphalocoele, helmet device, external pressure.
sive force from inflation, this cuff needed to be covered by a noncompliant envelope. To achieve this, the whole body wall was encased by a chest cuirass that consisted of 2 separate but symmetrical hard plastic domes/shells that were clamped together in the midline with elastic Velcro (Fig 3). To achieve a perfect fit, these domes were custom made from a plaster cast of the patient’s trunk. The inflatable cuff was connected to an external sphygmomanometer out with of the plastic shell. The child was clinically stable when external compression was initiated. The helmet apparatus was worn continuously. Manual pressure was applied daily starting with 5 mm Hg. This was increased daily up to a maximum pressure of 8 to 10 mm Hg. During external compression, care was taken to avoid intraabdominal hypertension using the manometer readings, which were corroborated with observations of respiration, pulse, blood pressure, and peripheral perfusion.
MATERIALS AND METHODS
RESULTS
A full-term male neonate was born with an isolated giant exomphalos (Fig 1). The evisceration consisted of intestinal loops and liver. The abdominal wall defect was about 7 ⫻ 7 cm, which was deemed to be significant considering the small size of the baby. As a primary stage, it was decided to manage the exomphalos nonoperatively. Daily application of triple dye was initiated as an eschar-inducing agent. Triple dye is an organic dye, which has been used as an umbilical disinfectant in newborn infants.7,8 An eschar formed within 7 days. This became epithelialized over 1 month to form a skin-covered ventral hernia. Because the resultant ventral hernia was large, it was decided to reduce the size of the evisceration as well as enlarge the abdominal cavity. External pressure compression was applied using a specially constructed helmetlike device (Fig 2). The principle was to place a sphygmomanometer cuff on top of the hernia and compress the hernia contents by controlled inflation of this cuff. A custom made, uniformly expanding sphygmomanometer cuff was constructed by the bioengineer staff to fit onto the surface of the exomphalos sac. A sterile incise drape was placed to protect the covering skin. To achieve a compres-
There was no hemodynamic compromise, respiratory distress, or drop in saturation. The child was on full oral feedings throughout. The patient responded to standard conservative antireflux measures administered for occasional vomiting episodes. Within months, the treatment resulted in reduction of the ventral hernia (Fig 4). The
Journal of Pediatric Surgery, Vol 39, No 8 (August), 2004: E26
From the Department of Paediatric Surgery, National University Hospital, Singapore. Address reprint requests to A/Prof K. Prabhakaran, Chief, Department of Paediatric Surgery, Director, Liver Transplant Programme, National University Hospital, 5, Lower Kent Ridge Rd, Singapore 119074. © 2004 Elsevier Inc. All rights reserved. 1531-5037/04/3908-0035$30.00/0 doi:10.1016/j.jpedsurg.2004.04.041 e1
e2
MALI, PRABHAKARAN, AND PATANKAR
Fig birth.
hernia defect was repaired surgically using a standard double breasting technique, and the redundant excoriated skin was excised. Recovery was uneventful. Further follow-up findings untill the age of 15 years were normal. DISCUSSION
Eschar induction is indicated either in the initial treatment of a giant omphalocoele or in the event of a prosthetic silo failure or when primary definitive surgery is not possible because of associated anomalies.9 However, this alone does not reduce the evisceration. Because the muscles of the anterior abdominal wall are normally developed, primary closure of the ventral hernia has been attempted. But this results in respiratory and circulatory
Fig 2. Helmet device around the body wall (a) before (b) after external compression.
1.
Giant
exomphalos
at
compromise and may even cause hepatic and renal failure.1 An alternative is to enlarge the peritoneal cavity using progressive pneumoperitoneum as popularized by Ravitch.9 However, this was an invasive procedure in which a silicone catheter had to be placed intraperitoneally. The potential complications included air embolism, subcutaneous emphysema, hepatic vein thrombosis, and intestinal perforation. Other attempts at enlarging the abdominal cavity have included splenectomy, right hepatic lobectomy,10 partial hepatectomy,11 and transverse division of rectii.12 Another strategy was to delay the repair until the age of 5 years to allow for a natural increase in the size of the abdominal cavity with an associated decrease in infantile potbelly.13 However, these methods have not gained acceptance. Preoperative
HELMET COMPRESSION OF OMPHALOCELE
Fig 3. baby.
e3
Helmet device around the
elastic bandaging has been attempted successfully followed by single-stage operative closure of the ventral hernia.14 The external compression can be monitored using several clinically applicable parameters such as measurements of intragastric pressure, central venous pressure, and intravesical pressure.14 The prerequisite is that the amniotic sac needs to be intact, and the hernia defect needs to be large enough to allow uncomplicated reduction. In this instance, manometric measurement of
the applied compression is noninvasive and corroborates well with the respiration and hemodynamics. Further evaluation of the device is needed with respect to the use of tissue expanders in place of the cuff, estimation of force per unit of surface area, and correlation with simultaneous measurement of intraabdominal pressure. This should also give evidence as to the maximum pressure that can be applied safely so as to achieve a faster reduction of the ventral hernia.
Fig 4. Ventral hernia reduced after 9 months of external compression.
e4
MALI, PRABHAKARAN, AND PATANKAR
REFERENCES 1. Nuchtern JG, Baxter R, Hatch EI Jr: Nonoperative initial management versus Silon chimney for treatment of giant omphalocoele. J Pediatr Surg 30:771-776, 1995 2. Gross R: A new method for surgical treatment of large omphalocoele. Surgery 24:277-292, 1948 3. Schuster SR: A new method for staged repair of large omphalocoele. Surg Gynecol Obstet 125:837-850, 1967 4. Allen RG, Wrenn EL: Silon as a sac in the treatment of omphalocoele and gastroschisis. J Pediatr Surg 4:3-8, 1969 5. Grob M: Conservative treatment of exomphalos. Arch Dis Child 38:148-150, 1963 6. Othersen HB Jr, Smith CD: Pneumatic reduction bag for treatment of gastroschisis and omphalocoele. Ann Surg 203:512-516, 1986 7. Reynolds JEF: Martindale: The extra pharmacopoeia (CD— ROM version). Micromedex Inc, Denver, Co, 1988 8. Swartz KR, Harrison MW, Campbell JR, et al: Ventral hernia in
the treatment of omphalocoele and gastroschisis. Ann Surg 201:347350, 1985 9. Ravitch MM: Omphalocoele. Secondary repair with the aid of pneumoperitoneum. Arch Surg 99:166-170, 1969 10. Buchanan RW, Cain WL: A case of complete omphalocoele. Ann Surg 143:552, 1956 11. Kleinhauss S, Kaufer N, Boley SJ: Partial hepatectomy in omphalocoele repair. Surgery 64:484, 1968 12. Safer DJ: Rectus muscle transection for visceral replacement in gastroschisis. Surgery 63:988, 1968 13. Dickey JW: Delayed repair of large omphalocoele. J Fla Med Assoc 53:285, 1966 14. Brown MF, Wright L: Delayed external compression reduction of an omphalocoele (DECRO): An alternative method of treatment for moderate and large omphalocoeles. J Pediatr Surg 33:1113-1116, 1998
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 escharinducing 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.
N
EONATES WITH a giant exomphalos have an abdominal cavity that is small and underdeveloped.1 Primary closure is not possible without compromising the hemodynamics or respiration. Hence, management strategies must consist of a staged approach wherein either a silo reduction is achieved or the giant omphalocoele is converted to a ventral hernia.1-5 We attempted an alternative approach wherein the giant exomphalos was first converted into a ventral hernia, and then this ventral hernia was reduced using external pressure compression with a helmet device (Jones P., Personal Communication).6
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. J Pediatr Surg 39:E26. © 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Exomphalos, omphalocoele, helmet device, external pressure.
sive force from inflation, this cuff needed to be covered by a noncompliant envelope. To achieve this, the whole body wall was encased by a chest cuirass that consisted of 2 separate but symmetrical hard plastic domes/shells that were clamped together in the midline with elastic Velcro (Fig 3). To achieve a perfect fit, these domes were custom made from a plaster cast of the patient’s trunk. The inflatable cuff was connected to an external sphygmomanometer out with of the plastic shell. The child was clinically stable when external compression was initiated. The helmet apparatus was worn continuously. Manual pressure was applied daily starting with 5 mm Hg. This was increased daily up to a maximum pressure of 8 to 10 mm Hg. During external compression, care was taken to avoid intraabdominal hypertension using the manometer readings, which were corroborated with observations of respiration, pulse, blood pressure, and peripheral perfusion.
MATERIALS AND METHODS
RESULTS
A full-term male neonate was born with an isolated giant exomphalos (Fig 1). The evisceration consisted of intestinal loops and liver. The abdominal wall defect was about 7 ⫻ 7 cm, which was deemed to be significant considering the small size of the baby. As a primary stage, it was decided to manage the exomphalos nonoperatively. Daily application of triple dye was initiated as an eschar-inducing agent. Triple dye is an organic dye, which has been used as an umbilical disinfectant in newborn infants.7,8 An eschar formed within 7 days. This became epithelialized over 1 month to form a skin-covered ventral hernia. Because the resultant ventral hernia was large, it was decided to reduce the size of the evisceration as well as enlarge the abdominal cavity. External pressure compression was applied using a specially constructed helmetlike device (Fig 2). The principle was to place a sphygmomanometer cuff on top of the hernia and compress the hernia contents by controlled inflation of this cuff. A custom made, uniformly expanding sphygmomanometer cuff was constructed by the bioengineer staff to fit onto the surface of the exomphalos sac. A sterile incise drape was placed to protect the covering skin. To achieve a compres-
There was no hemodynamic compromise, respiratory distress, or drop in saturation. The child was on full oral feedings throughout. The patient responded to standard conservative antireflux measures administered for occasional vomiting episodes. Within months, the treatment resulted in reduction of the ventral hernia (Fig 4). The
Journal of Pediatric Surgery, Vol 39, No 8 (August), 2004: E26
From the Department of Paediatric Surgery, National University Hospital, Singapore. Address reprint requests to A/Prof K. Prabhakaran, Chief, Department of Paediatric Surgery, Director, Liver Transplant Programme, National University Hospital, 5, Lower Kent Ridge Rd, Singapore 119074. © 2004 Elsevier Inc. All rights reserved. 1531-5037/04/3908-0035$30.00/0 doi:10.1016/j.jpedsurg.2004.04.041 e1
e2
MALI, PRABHAKARAN, AND PATANKAR
Fig birth.
hernia defect was repaired surgically using a standard double breasting technique, and the redundant excoriated skin was excised. Recovery was uneventful. Further follow-up findings untill the age of 15 years were normal. DISCUSSION
Eschar induction is indicated either in the initial treatment of a giant omphalocoele or in the event of a prosthetic silo failure or when primary definitive surgery is not possible because of associated anomalies.9 However, this alone does not reduce the evisceration. Because the muscles of the anterior abdominal wall are normally developed, primary closure of the ventral hernia has been attempted. But this results in respiratory and circulatory
Fig 2. Helmet device around the body wall (a) before (b) after external compression.
1.
Giant
exomphalos
at
compromise and may even cause hepatic and renal failure.1 An alternative is to enlarge the peritoneal cavity using progressive pneumoperitoneum as popularized by Ravitch.9 However, this was an invasive procedure in which a silicone catheter had to be placed intraperitoneally. The potential complications included air embolism, subcutaneous emphysema, hepatic vein thrombosis, and intestinal perforation. Other attempts at enlarging the abdominal cavity have included splenectomy, right hepatic lobectomy,10 partial hepatectomy,11 and transverse division of rectii.12 Another strategy was to delay the repair until the age of 5 years to allow for a natural increase in the size of the abdominal cavity with an associated decrease in infantile potbelly.13 However, these methods have not gained acceptance. Preoperative
HELMET COMPRESSION OF OMPHALOCELE
Fig 3. baby.
e3
Helmet device around the
elastic bandaging has been attempted successfully followed by single-stage operative closure of the ventral hernia.14 The external compression can be monitored using several clinically applicable parameters such as measurements of intragastric pressure, central venous pressure, and intravesical pressure.14 The prerequisite is that the amniotic sac needs to be intact, and the hernia defect needs to be large enough to allow uncomplicated reduction. In this instance, manometric measurement of
the applied compression is noninvasive and corroborates well with the respiration and hemodynamics. Further evaluation of the device is needed with respect to the use of tissue expanders in place of the cuff, estimation of force per unit of surface area, and correlation with simultaneous measurement of intraabdominal pressure. This should also give evidence as to the maximum pressure that can be applied safely so as to achieve a faster reduction of the ventral hernia.
Fig 4. Ventral hernia reduced after 9 months of external compression.
e4
MALI, PRABHAKARAN, AND PATANKAR
REFERENCES 1. Nuchtern JG, Baxter R, Hatch EI Jr: Nonoperative initial management versus Silon chimney for treatment of giant omphalocoele. J Pediatr Surg 30:771-776, 1995 2. Gross R: A new method for surgical treatment of large omphalocoele. Surgery 24:277-292, 1948 3. Schuster SR: A new method for staged repair of large omphalocoele. Surg Gynecol Obstet 125:837-850, 1967 4. Allen RG, Wrenn EL: Silon as a sac in the treatment of omphalocoele and gastroschisis. J Pediatr Surg 4:3-8, 1969 5. Grob M: Conservative treatment of exomphalos. Arch Dis Child 38:148-150, 1963 6. Othersen HB Jr, Smith CD: Pneumatic reduction bag for treatment of gastroschisis and omphalocoele. Ann Surg 203:512-516, 1986 7. Reynolds JEF: Martindale: The extra pharmacopoeia (CD— ROM version). Micromedex Inc, Denver, Co, 1988 8. Swartz KR, Harrison MW, Campbell JR, et al: Ventral hernia in
the treatment of omphalocoele and gastroschisis. Ann Surg 201:347350, 1985 9. Ravitch MM: Omphalocoele. Secondary repair with the aid of pneumoperitoneum. Arch Surg 99:166-170, 1969 10. Buchanan RW, Cain WL: A case of complete omphalocoele. Ann Surg 143:552, 1956 11. Kleinhauss S, Kaufer N, Boley SJ: Partial hepatectomy in omphalocoele repair. Surgery 64:484, 1968 12. Safer DJ: Rectus muscle transection for visceral replacement in gastroschisis. Surgery 63:988, 1968 13. Dickey JW: Delayed repair of large omphalocoele. J Fla Med Assoc 53:285, 1966 14. Brown MF, Wright L: Delayed external compression reduction of an omphalocoele (DECRO): An alternative method of treatment for moderate and large omphalocoeles. J Pediatr Surg 33:1113-1116, 1998