Is early fascial closure necessary for omphalocele and gastroschisis?

Is Early Fascial Closure Necessary for Omphalocele and Gastroschisis? By Irwin H. Krasna

New Brunswick, New Jersey • Before the introduction of the "silo" for gastroschisis, the main goal of surgery was to cover the defect with skin. Since the silo has been used, the goals have been (1) to cover the defect with SILASTIC ® sheets and return the extraabdominal contents tO the abdominal cavity by progressive plication of the silo and (2) to eventually close the defect by fascia-tofascia approximation, before 1 month of age. In many series, early definitive abdominal wall closure resulted in mortality rates of 10% to 30%, usually because of bowel necrosis and resulting sepsis. At the author's institution, 20 newborns w i t h large omphaloceles or gastroschisis have been treated, and fascial closure was obtained by the second week in 10 infants. In ten babies it was impossible to obtain early fascial closure without tension, and these children were managed differently. A nonaggressive two-stage approach was used, in which the goals were (1) early return of contents to the abdominal cavity and (2) only skin and granulation coverage of the defect (without aiming for early fascial closure or partial fascial closure) with a small central SILASTIC ® patch. Stage 1 is reduction of abdominal contents to the abdomen, through plication of the silo, over a 9 to 14 day period. Stage 2 is removal of the silo and closure of the ventral abdominal wall defect using a SILASTIC ® patch to close most of the defect, after approximating fascia in the superior and inferior portions. If the skin cannot be closed, the patch usually separates in 14 to 21 days, the pellicle remaining becomes completely epithelialized in 1 to 2 months, and further surgery has not been necessary. If the skin can be approximated, the patch is removed in a few months, when fascial closure can be performed easily. Five cases of omphaloceie and five of gastroschisis were treated by this method; all the patients are doing well, most without definitive fascial closure. Copyright © 1995 by W.B. Saunders Company

used instead of Teflon. The first stage was placement of the "silo" and progressive tightening of the silo over 3 to 14 days. This rapid method of pushing the liver and the bowel to be flush with the abdominal wall enabled the second stage to be performed early. The second stage involved removal of the synthetic material and definitive fascia-to-fascia closure, under considerable tension. In light of the many reports of infection and sepsis related to SILASTIC®, 7,8 the pendulum was swung back, especially in cases of gastroschisis, and vigorous stretching of the abdominal wall and primary fascial closure and ventilatory support was recommended.! T M This aggressive approach to omphalocele and gastroschisis--by the silo technique with rapid tightening and definitive fascial closure, or by primary closure under tension--was not without serious complications (Table 1). Many of the sepsis deaths and intestinal deaths were related to associated anomalies and to pressure on the viscera when the fascia was closed under tension. This results in bowel necrosis or strangulation, necrotizing enterocolitis (NEC), and disruption of the closure (ventral hernia). Reported herein is our institution's experience with five cases of gastroschisis and five of omphalocele in which the fascia could not be closed without tension. Our preferred operative management is outlined. MATERIALS AND METHODS

INDEX WORDS: Omphalocele; gastroschisis; SILASTIC ® patch.

HE TREATMENT of large omphaloceles and gastroschisis entered a new era in 1967, when Schuster I introduCed the use of temporary Teflon and polyethylene sacs to close the defects and to reduce the abdominal contents gradually by progressive tightening of the synthetic pouch. He described its use in cases of secondary omphalocele reduction in children who were treated initially by simple skin coverage as well as cases of primary repair of large omphaloceles in newborns who had intact or ruptured sacs. The survival rates were much higher for these infants, especially those with gastroschisis for whom previous methods of treatment had been ineffective. 2-1° The operation was performed in two stages, and reinforced SILASTIC ® (Dow Coming, Midland, MI) was

T

Journal of Pediatric Surgery, Vo130, No 1 (January), 1995: pp 23-28

We modified the aggressive approach to definitive fascial closure by primary closure under tension or by rapid reduction of the silo. We recommend (1) tightening the silo more gradually--usually over 14 days and (2) removing the silo at 14 days, without attempting to achieve definitive fasial closure at 14 days if it is under tension. As much fascia as can be approximated is closed without tension, leaving a large tear-shaped patch of SILASTIC ® sutured to the fascia, closing the defect. This patch usually separated in another 14 to 21 days, and surprisingly, no bulge was present. Most of the children are well, without definitive fascial

From the Divisions of Pediatric Surgery and Pediatrics, UMDNJRobert Wood Johnson Medical School, New Brunswick, NJ. Date accepted: January 31, 1994. Address reprint requests to Irwin H. Krasna, MD, UMDNJ-Robert Wood Johnson Medical School, One Robert Wood Johnson PI, CN-19, New Brunswick, NJ 08903-0019. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3001-0006503.00/0

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IRWIN H. KRASNA

Table 1. Literature Regarding Early Fascial Closure for Omphalocele and Gastroschisis Reference; Type & No. of Cases

Gilbert et al 2 (1968) Gastroschisis: 17 Rubin et al 7 (1976) Omphalocele: 8 Gastroschisis: 23 Stringel et al s (1979) Omphatocele: 79 Gastroschisis: 44 King et aP (1980) Gastroschisis: 59 Wesley et al 1° (1981) Omphalocele: 9 Gastroschisis: 16 Bower et a112(1982) Gastroschisis: 24 Canty et a113(1983) Omphalocele: 18 Gastroschisis: 54 Mabogunje et al TM (1984) Omphalocele: 33

Gastroschisis: 64

Yazback et a118(1986) Omphalocele: 79

DiLorenzo et al TM (1987) Gastroschisis: 59 Oldham et a117(1988) Gastroschisis: 54 Caniano et al TM (1990) Gastroschisis: 70 Yokomori et a119(1992) Omphalocele: 22 Swift et al 2° (1992) Gastroschisis: 24 Novotny et a121(1993) Gastroschisis: 69

Total no. of cases: 825 Gastroschisis: 577 Omphalocele: 248

Procedure

No, of Deaths (%)

8 Primary closure 7 Silon pouch (8-19 d)

3 (38) 4 (57)

8 Silon pouch 23 Silon pouch (12-23 d)

1 (13) 8 (35)

45 Primary closure 7 Silon pouch 16 Primary closure 26 Silon pouch (10-15 d)

8 (17) 0 2 (13) 10 (38)

10 Primary closure 44 Silon pouch (5-12 d)

No report 4 (8)

9 Silon pouch (5.3 d) 16 Silon pouch (4.7 d)

2 (22) 5 (32)

24 Primary closure

3 (13)

16 Primary closure 2 Silon pouch 50 Primary closure 4 Silon pouch

3 (19) 2 (100) 4 (8) 1 (25)

11 Silon pouch 8 Primary closure 11 Skin closure 3 Mercurochrome 11 Primary closure 39 Siton pouch 14 Skin closure

3 (27) 6 (18) 13 (24)

60 Primary closure 12 Silon pouch 7 Mercurochrome

12 (30) 5 (42) 6 (85)

39 Primary closure 20 Silon pouch

5 (13) 3 (15)

29 Primary closure 25 Silon pouch

11 (20)

36 Primary closure 34 Silon pouch

6 (8)

22 Silon pouch (7 d)

3 (14)

17 Primary closure 7 Silon pouch

1 (4)

56 Primary closure 13 Silon pouch (7-8 d)

3 (4)

425 Primary closure 334 Silon pouch 66 Other

137 (17)

closure. The fibrosis that remained when the patch Separated and was then covered by skin was very strong and prevented herniation in all the cases of gastroschisis and most of those of omphalocele. Five babies with large omphalocele and five with gastroschisis were treated. All were operated on within 3 hours of birth, and only one has associated congenital anomalies. After birth, the omphalocele sacs and the exposed bowel (in cases of gastroschisis) are covered with large moistened pads, and the baby's body, up to the neck, is enclosed in a "bowel bag"; the patient is taken to the operating room, and stage 1 is performed.

Stage 1 The rectum is irrigated gently, and vigorous rectal stretching is performed. In cases of gastroschisis, the bowel is not handled or milked. In omphalocele cases, the vessels are ligated, and an incision is made around the skin-omphalocele junction, and a strip of skin is removed. With gastroschisis, the vessels are ligated and the defect is opened superiorly and inferiorly so that no constriction is present at the skin or fascia level, and the abdomen is vigorously stretched. Two sheets of .007 Dacron-reinforced SILASTIC ® are sutured to the skin edges with heavy silk or Ethib0nd (Ethicon, Inc, Somerville, NJ) sutures, and then sutured to each other. Four separate continuous sutures are placed and tied to each other. Umbilical tape is placed at the top of the silo and suspended from a hole in the isolette or from the top of the infant warmer. At the beginning of our experience, the baby was returned to the operating room every few days for tightening and trimming of the SILASTIC ® (cases 1 and 2). We then changed to daily tightening at the bedside. A piece of umbilical tape is placed around the top of the silo, and by progressive tightening of the silo, the abdominal contents are gradually pushed into the peritoneal cavity (Fig 1). ! f some sutures pull away from the skin, they can be reinforced at the bedside. Usually by 12 to i4 days, the abdominal contents are flush with the abdominal wall, and the sutures holding the SILASTIC ® to the skin are pulling through. The baby is returned to the operating room for stage 2.

C

//

D

Fig 1. Stage 1 and postoperative tightening of the silo. (A) At the end of the procedure, two sheets of .007 Dacron-reinforced SILASTIC ® sheets are sutured to the skin edges and to each other. (B, C, and D) Gradual tightening of the silo by securing umbilical tape to it daily, until all the abdominal contents are returned to the abdominal cavity.

NONAGGRESSIVEMANAGEMENTOF GASTROSCHISIS

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Stage 2 The entire lower body is prepared and kept in the surgical field. The SILASTIC ® pouch is completely removed and the defect irrigated with saline. Skin flaps are dissected from the fascia so that the fascial edges can be seen clearly. In cases of omphalocele, the amnion is seen and may be covered with granulation tissue. In cases of gastroschisis, the bowel is seen, and usually the "peel" is thinner, and loops of bowel may adhere to each other. No attempt is made to separate the loops. The fascia usually can be approximated superiorly and inferiorly, using silk or Ethibond sutures (usually two sutures above and below). Among these ten cases, there was no possibility of completely approximating the fascia without tension. A sheet of .007 Dacron-reinforced SILASTIC ® is used to cut a patch that will fill the defect, and this is sutured with similar sutures to close the defect, keeping all the abdominal contents flush with the abdominal wall (Fig 2). The color of the lower extremities is observed, and a sterile Doppler probe is used to follow the pulsations of the posterior tibial and anterior tibial vessels. If possible, the skin is approximated over the patch, and a Penrose drain is left in. If the skin cannot reach, it is approximated as much as possible, leaving a gap in the middle, over the patch. (In one case (no. 2), after 3 weeks the granulation tissue was so thick that a SILASTIC ® patch was not inserted.) Until this point, the patient has had nothing by mouth and has been on hyperalimentation and antibiotics. The antibiotics are discontinued after 3 days, and feeding is begun. If complete skin coverage was not possible, the patch usually separated by itseff in another 14 to 21 days. If the skin was approximated, but separated after a few days, the patch separated similarly. The patch is kept on until it separates, by itself, completely. If the skin remains intact, the patch may not separate. When the patch separates, there will be a clean layer of healthy red granulation tissue covering the amnion or the bowel (Fig 3); the defect is left exposed, and the baby may be sent home, having normal feedings. If the patch does not separate, it can be removed in a few months and definitive fascial closure obtained.

ILLUSTRATIVE CASE REPORTS

Case 1

A full-term black male was born with a large omphalocele. A Silon pouch (Dow Corning, Midland, MI) was inserted, and skin coverage was obtained. He

Fig 2, Stags 2. After removal of the silo, the fascia is approximated superiorly and inferiorly (E), and a tear-shaped patch of SILASTIC ® is placed in the center of the defect and sutured to the fascia (F). If the skin can be brought together over the patch, it is closed (GI); if not, the patch is left exposed (G2).

Granulation tissue I

Fig 3. Two to 3 weeks after stage 2, the patch usually separates or is almost off (H), It is removed (I), and usually healthy granulation (J) is present underneath it, covering the amnion or the bowel, It is left exposed and will be covered by skin in a few weeks. In most cases, no further fascia] closure was performed, and the hernia was not present.

was returned to the operating room three times for pouch tightening. On day 16, the pouch was removed, and three sutures of wire were placed superiorly and inferiorly, but the defect could not be closed. A tear-shaped patch of SILASTIC ®was placed, and the skin was approximated. Six months later, elective removal of the patch was performed, and fascia-tofascia closure was obtained. Case 2

A full-term white boy was born with a large ruptured omphalocele. The area of rupture was sutured, and a Silon pouch was inserted. Skin closure was not possible. Gradual tightening of the pouch was performed in the operating room, over 3 weeks. Fungal infection ensued, and the pouch separated and was removed. After pouch separation, healthy granulation covered the entire defect, and there was no evidence of the omphalocele sac. The SILASTIC ® patch was not used in this case because of infection and the thickness of the granulation tissue. Peripheral hyperalimentation was continued for 60 days, and the wound was completely covered by skin. After 1 year, a central defect was present, but no hernia was evident. Case 3 A full-term white boy was born with gastroschisis. The opening was enlarged, a Silon pouch was created, and a gastrostomy was placed. The pouch was tightened daily, and by day 14 the contents were flush with the abdominal wall. He was taken to the operating room, where the pouch was removed and a central SILASTIC ® patch was inserted after placing two sutures at the superior and inferior edges of the defect. The skin could not be closed over the patch; the patch separated completely on day 28 (2 weeks

26

IRWIN H. KRASNA

after patch insertion), and healthy graulation tissue covered the defect completely. No further surgery was performed, and he had a large defect without a hernia. At 11 years of age, because of cosmetic reasons, the area of the defect was deepithelialized, and full-thickness skin flaps were advanced, without closing the fascia or entering the peritoneal cavity. The scar was removed, and an umbilicus was created. Case 7

A full-term girl was born with gastroschisis. The opening was enlarged, a Silon pouch was created, and a gastrostomy was placed. The pouch was tightened daily; on day 10, the abdominal contents were flush with the abdominal wall, and the baby was returned to the operating room. The pouch was removed, and sutures were placed at the upper and lower portions of the defect, but the fascia could not be approximated in the center. A SILASTIC® patch was placed in the center, and the skin was closed over the patch. Fourteen days later, because of Candida sepsis, the patch was removed. All the sutures were intact, there was no infection under the patch, and there was a healthy layer of pink granulation tissue underneath. Over the next 2 months, skin covered the granulation tissue. She had a central defect, but no bulge. At 22 months of age, small bowel obstruction developed, secondary to adhesions, and definitive closure was performed at that time. RESULTS

Table 2 is a summary of the results of the 10 cases described. There were no deaths and no major complications; one baby (no. 9) had multiple congeni-

tal anomalies. Most of the patients (nos. 2 through 5 and 8) never had a ventral hernia (bulge) and did not need an operation to obtain fascia-to-fascia repair. Three patients had fascia-to-fascia closure at a later date (no. I at 6 months, no. 6 at 1 month, no. 7 at 24 months), without any problem of tension, and all are well and have no defect or hernia. In one patient (no. 9) with an omphalocele and multiple anomalies, who was never fed, complete evisceration (with an intact sac) occurred when the patch separated at 41 days of age. Another patient (no. 10) with an omphalocele, whose patch staYed in place for 40 days, had a ventral hernia at 5 months of age. DISCUSSION G r o s s 22 was the first to describe the two-stage technique for repair of large omphaloceles. The first stage was skin closure over the intact omphalocele sac (amnion inversion), followed in 2 years by definitive fascial closure. This was accomplished by binding of the abdomen, use of trusses, and massaging the abdominal contents into the peritoneal cavity. In his early textbook, there is no chapter concerning gastroschisis. Ravitch23 described pneumoperitoneum as a method to enlarge the peritoneal cavity in preparation for definitive fascial closure. Schuster I (in 1967) advanced the surgical treatment of these newborns when he described the Teflon sac technique for managing large omphaloceles. The technique was widely used for gastroschisis2,3,5,6 as well as omphalocele. As this technique was widely applied, the time for the second-stage closure was shortened; some investigators described complete return of abdominal contents to the abdominal cavity by 5 days 9,1° o r 7 to

Table 2. Two-Stage Repair of Silon Pouch Case No.

Diagnosis

Stage 1

Stage 2

S pouch S pouch

3 4 5 6

Omphalocele Ruptured omphalocele Gastroschisis Gastroschisis Gastroschisis Omphalocele

S pouch S pouch S pouch S patch

7

Gastroschisis

S pouch

Patch at 14 d Removal of silo, no patch Patch at 14d Patch at 11 d Patch at 10 d Removal at 4 wk, fascial closure Patch at 10 d

8 9

Gastroschisis Omphalocele

S pouch S pouch

10

Omphalocele

S pouch

1 2

Abbreviation: S, SILASTIC®.

Patch Separation

Follow-Up

No separation No patch

Patch removal at 6 mo, fascial closure Excellent, no fascial repair

14d 16 d 18 d No separation

Excellent, no fascial repair Excellent, no fascia] repair Excellent, no fascial repair Excellent, fascial closure

Patch at 7 d Patch at 14 d

14 d, removed surgically, no separation 12d 27 d

Patch at 14d

40d

Reoperation 2 years later for adhesions, fascial closure Excellent, no fascial closure Patch separation after 27 days resulted in evisceration of sac, treated successfully with mercurochrome; multiple congenital defects, tracheotomy, malnutrition No bulge for 4V2 too, then ventral hernia developed

NONAGGRESSIVE MANAGEMENT OF GASTROSCHISIS

27

10 days, 2,8,21 with definitive fascial closure being obtained at that time. The complications of bowel necrosis, NEC, and wound separation were significant, and the mortality rate ranged from 8% 9 to 30%. 2,7,8,1° It is clear that if the a b d o m e n is closed under tension, before the abdominal cavity has enlarged sufficiently, bowel damage can be anticipated. After the initial wide acceptance of this technique, there was disillusion because of infection secondary to the silo and resultant sepsis, t1,12,14 and primary closure of gastroschisis, under tension and with ventilatory support, was recommended. 12,13 The incidence of bowel necrosis, NEC, and wound separation was significant in light of the tension resulting from primary closure, n,1%14 However, sepsis and wound infection were reduced, and it was believed that by not feeding the baby and through use of ventilatory support, the tension would decrease. Indeed, forceful stretching of the abdominal wall, with primary closure and ventilatory support, was the preferred method of treatment for gastroschisis at many centers. 11-14,t8,2° Some investigators r e c o m m e n d e d an individualized approach to these lesions, which depended on the size of the defect, the amount of bowel herniated, and the tension during closure. 18 This approach is reasonable because many of these defects can be closed without tension, and many need the silo and gradual return of viscera to the abdominal cavity. Table 1 is a summary of the studies in which both approaches were used, and the mortality rate is close to 16%; death usually resulted from bowel ischemia. There is no doubt that definitive fascial closure (when possible) by delay or other methods is preferred and should be the goal in stage 2, if it can be achieved without tension. For the 10 cases reported herein, during the second procedure it was impossible to

achieve fascial closure without tension, and in most it was also impossible to close the skin. After some fascia was approximated, a large SILASTIC ® patch was placed. When the patch separated, in 14 to 21 days, healthy granulation tissue covered the defect, which became epithelialized within 1 month, and no further surgery was necessary. No hernia (bulge) was present, although there was a central defect when fascial approximation was not possible. The eschar resulting from the patch placement was very solid, even though no fascia covered the central defect. In the cases in which fascial closure was obtained in 1 to 24 months (nos. 1, 6, and 7), the procedure was not difficult, and no ventral herniae were seen. We believe that it is safer to obtain delayed fascial closure or no fascial closure by using a large S I L A S T I C ® patch during the second procedure; to insist on early definitive fascial closure carries the risk of bowel damage. We had a similar n u m b e r of cases (five omphalocele and five gastroschisis) in which primary fascial closure or silo followed by fascial closure was successful, because the defects were smaller and the abdomen could be closed without tension. The 10 cases presented herein, treated by Silon pouch followed by SILASTIC ® patch closure, represent another m a n a g e m e n t option for patients with large omphaloceles or gastroschisis. The goal should be to close the defect with definitive fascial closure, without tension. If fascial closure without tension cannot be obtained, the defect can be closed with a temporary S I L A S T I C ® patch, or be permitted to granulate, even if the fascia is not closed. The fascia can be closed after a few months or may never need to be closed.

REFERENCES

1. Schuster SR: A new method for the staged repair of large omphaloceles. Surg Gynecol Obstet 125:837-850, 1967 2. Gilbert MG, Mencia LF, Brown WT, et al: Staged surgical repair of large omphaloceles and gastroschisis. J Pediatr Surg 3:702-709, 1968 3. Allen RG, Wrenn EL Jr: Silon as a sac in the treatment of omphalocele and gastroschisis. J Pediatr Surg 4:3-8, 1969 4. Ein SH, Fallis JC, Simpson JS: Silon sheeting in the staged repair of massive ventral hernias in children. Can J Surg 13:127135, 1970 5. Hollabaugh RS, Boles ET Jr: The management of gastroschisis. J Pediatr Surg 8:263-270, 1973 6. Girvan DP, Webster DM, Shandling B: The treatment of omphaloceles and gastroschisis. Surg Gynecol Obstet 139:222-224, 1974 7. Rubin SZ, Ein SH: Experience with 55 silon pouches. J Pediatr Surg 11:803-807, 1976

8. Stringel G, Filler RM: Prognostic factors in omphalocele and gastroschisis. J Pediatr Surg 14:515-519, 1979 9. KingDR, Savrin R, Boles ET: Gastroschisis update. J Pediatr Surg 15:552-557, 1980 10. WesleyJR, DrongowskiR, Coran AG: Intragastric pressure measurement: A guide for reduction and closure of the Silastic chimney in omphalocele and gastroschisis. J Pediatr Surg 16:264270, 1981 11. Ein SH, Rubin SZ: Gastroschisis: Primary closure or silon pouch. J Pediatr Surg 15:549-551, 1980 12. Bower RJ, Bell MJ, Ternberg JL, et al: Ventilatory support and primary closure of gastroschisis. Surgery 91:52-55, 1982 13. Canty TG, Collins DL: Primary fascial closure with gastroschisis and omphalocele: A superior approach. J Pediatr Surg 18:707-712, 1983 14. DiLorenzo M, Yazbeck S, Ducharme JC: Gastroschisis: A 15-yearexperience. J Pediatr Surg 22:710-712, 1987 15. Mabogunje OA, Mahour GH: Omphalocele and gastroschi-

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sis: Trends in survival across two decades. Am J Surg 148:679-686, 1984 16. Yazbeck S, Ndoye M, Khan AH: Omphalocele: A 25-year experience. J Pediatr Surg 21:761-763, 1986 17. Oldham KT, Coran AG, Drongowski RA, et al: The development of necrotizing enterocolitis following repair of gastroschisis. A surprisingly high incidence. J Pediatr Surg 23:945-949, 1988 18. Caniano DA, Brokaw B, Ginn-Pease ME: An individualized approach to the management of gastrosehisis. J Pediatr Surg 25:297-300, 1990 19. Yokomori K, Ohkura M, Kitano Y, et al: Advantages and

IRWIN H. KRASNA

pitfalls of arnnion inversion repair for the treatment of large unruptured omphalocele: Results of 22 cases. J Pediatr Surg 27:882-884, 1992 20. Swift RI, Singh DA, Ziderman M, et al: A new regime in the management of gastroschisis. J Pediatr Surg 27:61-63, 1992 21. Novotny DA, Klein RL, Boeckman CR: Gastroschisis: An 18-year review. J Pediatr Surg 28:650-652, 1993 22. Gross RE: A new method for surgical treatment of large omphaloceles. Surgery 24:277-292, 1948 23. Ravitch MM: Omphalocele: Secondary repair with aid of pneumoperitoneum. Arch Surg 99:166-170, 1969