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Lateral plication of synthetic sack for large gastroschisis and omphalocele defects
Lateral Plication of Synthetic Sack for Large Gastroschisis and Omphalocele Defects By WALTON K. T. SHIM
T
HE USE OF SYNTHETIC FABRIC SACKS to cover temporarily the intestines of a gastroschisis or giant omphalocele has been made an integral part of the surgeon’s armamentarium. l-3 However, the larger defects of 4 cm or more in diameter are closed with great difficulty especially when the intestinal mass is edematous and bulky. This communication will describe a technique of lateral plication of the prosthetic sack to facilitate closure of these large abdominal defects. SURGICALTECHNIQUE
The infant is placed upon a circulating warm water blanket and surrounded by sterile rubber gloves filled with warm water. A femoral vein is cannulated with a #lQO polyethylene tube, which is passed into the inferior vena cava for monitoring venous pressure and for fluid infusion. Blood transfusion is rarely needed. The intestines or omphalocele sac is washed with warm benzalkonium (Zephiran) and the field draped. A vigorous surgical prep is not necessary if the infant is less than 6 hr old. All debris is removed from the exposed intestines in gastroschisis, and the sack of a giant omphalocele is excised. The edges of the defect are not freshened. Finger exploration of the diaphragm and abdominal organs is rapidly performed. A cylinder of polyester mesh* lined on the inside with a silicone rubbert sheet is formed and sutured to the full thickness of the abdomen with a continuous suture of 4-O nylon, taking care to place the bites close together (Fig. 1 A and B). After the edges of the prosthetic have been apposed to form a cylinder, the end is tied to form a sack (Fig. 1C) while monitoring the inferior vena cava pressure, keeping it less than 20 cm of saline. After the sack and abdomen are liberally coated with Polymyxin BNeomycin-Gramicidin creamt the infant is placed in a sterile incubator. Within 1 or 2 days the sack will be much less tense and the venous pressure will have decreased. The intestines are then squeezed out of the sack with heavy silk ties. This procedure is repeated with ties progressively obliterating the sack (Fig. 1D). From the Kauikeoluni Children’s Hospital and the University of Hawaii School of Medidnc, Honolulu, Hawaii. Supported in the part by the National Foundation March of Dimes Birth Defects Center, Kauikeolani Children’s Hospital, Honolulu, Hawaii. WALTON K. T. SHIM, M.D.: Chief of Surgery and Assistant Director, Birth Defects Center, Kauikeolani Children’s Hospital; Assistant Clinical Professor of Surgery (Pediatric), Univedty of Hawaii School of Medicine, Honolulu, Hawaii. ‘Mersilene, Ethicon CO. tsilastic, Dow-Corning Co. SNeosporin-G, Burroughs Wellcome. JOURNALOF PEDIATRICSURGERY,VOL. 6, No. 2 (APRIL), 1971
143
144
WALTON
K. T. SHIM
Fig. l.-(A) Polyester mesh is lined with a silicone rubber sheet and sutured with 4-O nylon to full thickness of the abdominal wall, taking care to place bites close together. (B) A cylinder of polyester mesh and silicone is formed and its end tied, (C), to form a sack prothesis which is progressively reduced, (D), squeezing the intestines into the abdomen. (E) Plication of the prosthetic is started with #2 silk sutures as illustrated and continued in several layers, (F), taking care not to perforate the underlying layer of silicone rubber. (G) The sack is excised and the abdominal wall closed in layers. When the sack is obliterated to a degree that further silk ties cannot be applied, the rectus edges are approximated by plicating the polyester mesh with a heavy silk suture (Fig. 1E and F) taking special care not to perforate the sheet of silicone rubber used as the inner lining, which merely crumples under the plicated polyester mesh. After several of these plications it will be found that the abdominal wall has stretched and the rectus edges are sufficiently close to allow for excision of the sack and closure in layers (Fig. 1G). As is always the concern of surgeons using prosthetics, infection is a problem. Aseptic technique must be studiously practiced and the baby handled with gloved hands. The surrounding abdominal skin and perineum of the infant are washed twice daily with pHisoHex, and both sack and abdomen are coated with Polymyxin B-Neomycin-Gramacidin cream every 6 hr. Using this technique bacterial cultures of the sack have been sterile. Systemic antibiotics in the form of kanamycin and penicillin are administered. Maintenance of skin temperature in a themoneutral range is mandatory to keep ventilation and oxygen demand at a minimum. The infant is maintained on intravenous fluids while the sack is in place. A gastrostomy is not used in the presence of the prosthetic as contamina-
LATERAL PLICATION OF SYNTHETIC SACK
145
tion from leaking gastric contents around the gastrostomy tube may give rise to infection. Instead, intermittent suction through a nasogastric tube is utilized, and a gastrostomy is established when the sack is excised if prolonged decompression is deemed necessary as in cases of gastrochisis. Intestinal decompression is mandatory while they are being squeezed into the stretching abdomen. A case of gastroschisis (Fig. 2) and one of giant omphalocele (Fig. 3) are shown as examples of this technique. The abdominal defects were 4 and 6 cm, respectively. DISCUSSION
Others have described use of fabric sacks to replace the intestines when they have lost the “right of domicile.” However, it has been our experience that closure of the defect after the intestines have been squeezed back is always a problem if its diameter were more than 2 or 3 cm. Defects of 4 cm or more require a reduction of the prosthesis in two stages; first the displaced viscera have to be replaced, and secondly the gap has to be narrowed. It is the second stage that is most difficult and challenging. The plication technique herein described will not only allow for replacement of the intestines, but also for gradual stretching of the abdominal wall to narrow the gap. The problems of multiple-stage operative procedures on the neonate are mostly in the realm of anesthesia4 and cooling.5.s The insult of exposure of the intestine also poses potential hazards of contamination and dehydration. Respiratory problems are frequent complications,4 and inferior vena cava compression may compromise cardiac filling.’ The method of gradually returning the displaced intestines to the abdomen herein described obviates these hazards. Since the prosthetic sack is not cov-
WALTON K. T. SHIM
Fig. 3.-(Top) An unruptured 15 X 12 X 12 cm omphalocele with a 6-cm defect. (Center) The prosthetic sack is partially obliterated and covered with antibiotic cream. The defect is lar e and linear closure would be impossibBe without plication. (Bottom) The prosthetic has been excised after plication and apposition of the lateral edges of the defect. A gastrostomy has been inserted as part of the second procedure. ered by skin, no administration of anesthetic is required while obliterating the sack. The intestines also are never exposed as they are squeezed into the abdomen.
SUMMARY A modification of the treatment of giant omphaloceles and gastroschisis by the use of synthetic fabrics to extend the peritoneal cavity consists of two stages: first, the intestines are squeezed out of the sack into the abdomen, and, second, the defect is closed by lateral plication of the prosthetic. The main advantage is that it is suitable for large defects. Other advantages of this method are that obliteration of the sack can be performed in the incubator while asepsis is rigidly practiced, and the hazards of peritoneal contamination and cooling of the infant are obviated. Anesthesia is not required because the skin is not manipulated.
147
LATERAL PLICATIONOF SYNTHETICSACK
REFERENCES 1. Schuster, S. Ft.: A new method for the staged repair of large omphaloceles. Surg. Gynec. Obstet. 12583’7, 1967. 2. Gilbert, M. G., Mencia, L. F., Brown, W. T., and Linn, B. S.: Staged surgical repair of large omphaloceles and gastroschisis. J. Pediat. Surg. 3:702, 1968. 3. Allen, R. G. and Wrenn, E. L., Jr.: Silon as a sac in the treatment of omphalocele and gastroschisis. J. Pediat. Surg. 4:3, 1969. 4. Jones, P. G.: Exomphalos. Arch. Dis.
Child. 38:180, 1963. 5. Oliver, T. K.: Temperature regulation and heat production in the newborn. Pediat. Clin. N. Amer. 12:765, 1965. 6. Bruck, K.: Temperature regulation in the newborn infant. Biol. Neonat. 3:65, 1961. 7. Free, E., and Takamoto, R.: Measurement of inferior vena caval pressure at the time of closure of omphaloceles. Presented at a meeting of the American Academy of Pediatrics, Section of Surgery, Washington, D.C., October 1967.
T
HE USE OF SYNTHETIC FABRIC SACKS to cover temporarily the intestines of a gastroschisis or giant omphalocele has been made an integral part of the surgeon’s armamentarium. l-3 However, the larger defects of 4 cm or more in diameter are closed with great difficulty especially when the intestinal mass is edematous and bulky. This communication will describe a technique of lateral plication of the prosthetic sack to facilitate closure of these large abdominal defects. SURGICALTECHNIQUE
The infant is placed upon a circulating warm water blanket and surrounded by sterile rubber gloves filled with warm water. A femoral vein is cannulated with a #lQO polyethylene tube, which is passed into the inferior vena cava for monitoring venous pressure and for fluid infusion. Blood transfusion is rarely needed. The intestines or omphalocele sac is washed with warm benzalkonium (Zephiran) and the field draped. A vigorous surgical prep is not necessary if the infant is less than 6 hr old. All debris is removed from the exposed intestines in gastroschisis, and the sack of a giant omphalocele is excised. The edges of the defect are not freshened. Finger exploration of the diaphragm and abdominal organs is rapidly performed. A cylinder of polyester mesh* lined on the inside with a silicone rubbert sheet is formed and sutured to the full thickness of the abdomen with a continuous suture of 4-O nylon, taking care to place the bites close together (Fig. 1 A and B). After the edges of the prosthetic have been apposed to form a cylinder, the end is tied to form a sack (Fig. 1C) while monitoring the inferior vena cava pressure, keeping it less than 20 cm of saline. After the sack and abdomen are liberally coated with Polymyxin BNeomycin-Gramicidin creamt the infant is placed in a sterile incubator. Within 1 or 2 days the sack will be much less tense and the venous pressure will have decreased. The intestines are then squeezed out of the sack with heavy silk ties. This procedure is repeated with ties progressively obliterating the sack (Fig. 1D). From the Kauikeoluni Children’s Hospital and the University of Hawaii School of Medidnc, Honolulu, Hawaii. Supported in the part by the National Foundation March of Dimes Birth Defects Center, Kauikeolani Children’s Hospital, Honolulu, Hawaii. WALTON K. T. SHIM, M.D.: Chief of Surgery and Assistant Director, Birth Defects Center, Kauikeolani Children’s Hospital; Assistant Clinical Professor of Surgery (Pediatric), Univedty of Hawaii School of Medicine, Honolulu, Hawaii. ‘Mersilene, Ethicon CO. tsilastic, Dow-Corning Co. SNeosporin-G, Burroughs Wellcome. JOURNALOF PEDIATRICSURGERY,VOL. 6, No. 2 (APRIL), 1971
143
144
WALTON
K. T. SHIM
Fig. l.-(A) Polyester mesh is lined with a silicone rubber sheet and sutured with 4-O nylon to full thickness of the abdominal wall, taking care to place bites close together. (B) A cylinder of polyester mesh and silicone is formed and its end tied, (C), to form a sack prothesis which is progressively reduced, (D), squeezing the intestines into the abdomen. (E) Plication of the prosthetic is started with #2 silk sutures as illustrated and continued in several layers, (F), taking care not to perforate the underlying layer of silicone rubber. (G) The sack is excised and the abdominal wall closed in layers. When the sack is obliterated to a degree that further silk ties cannot be applied, the rectus edges are approximated by plicating the polyester mesh with a heavy silk suture (Fig. 1E and F) taking special care not to perforate the sheet of silicone rubber used as the inner lining, which merely crumples under the plicated polyester mesh. After several of these plications it will be found that the abdominal wall has stretched and the rectus edges are sufficiently close to allow for excision of the sack and closure in layers (Fig. 1G). As is always the concern of surgeons using prosthetics, infection is a problem. Aseptic technique must be studiously practiced and the baby handled with gloved hands. The surrounding abdominal skin and perineum of the infant are washed twice daily with pHisoHex, and both sack and abdomen are coated with Polymyxin B-Neomycin-Gramacidin cream every 6 hr. Using this technique bacterial cultures of the sack have been sterile. Systemic antibiotics in the form of kanamycin and penicillin are administered. Maintenance of skin temperature in a themoneutral range is mandatory to keep ventilation and oxygen demand at a minimum. The infant is maintained on intravenous fluids while the sack is in place. A gastrostomy is not used in the presence of the prosthetic as contamina-
LATERAL PLICATION OF SYNTHETIC SACK
145
tion from leaking gastric contents around the gastrostomy tube may give rise to infection. Instead, intermittent suction through a nasogastric tube is utilized, and a gastrostomy is established when the sack is excised if prolonged decompression is deemed necessary as in cases of gastrochisis. Intestinal decompression is mandatory while they are being squeezed into the stretching abdomen. A case of gastroschisis (Fig. 2) and one of giant omphalocele (Fig. 3) are shown as examples of this technique. The abdominal defects were 4 and 6 cm, respectively. DISCUSSION
Others have described use of fabric sacks to replace the intestines when they have lost the “right of domicile.” However, it has been our experience that closure of the defect after the intestines have been squeezed back is always a problem if its diameter were more than 2 or 3 cm. Defects of 4 cm or more require a reduction of the prosthesis in two stages; first the displaced viscera have to be replaced, and secondly the gap has to be narrowed. It is the second stage that is most difficult and challenging. The plication technique herein described will not only allow for replacement of the intestines, but also for gradual stretching of the abdominal wall to narrow the gap. The problems of multiple-stage operative procedures on the neonate are mostly in the realm of anesthesia4 and cooling.5.s The insult of exposure of the intestine also poses potential hazards of contamination and dehydration. Respiratory problems are frequent complications,4 and inferior vena cava compression may compromise cardiac filling.’ The method of gradually returning the displaced intestines to the abdomen herein described obviates these hazards. Since the prosthetic sack is not cov-
WALTON K. T. SHIM
Fig. 3.-(Top) An unruptured 15 X 12 X 12 cm omphalocele with a 6-cm defect. (Center) The prosthetic sack is partially obliterated and covered with antibiotic cream. The defect is lar e and linear closure would be impossibBe without plication. (Bottom) The prosthetic has been excised after plication and apposition of the lateral edges of the defect. A gastrostomy has been inserted as part of the second procedure. ered by skin, no administration of anesthetic is required while obliterating the sack. The intestines also are never exposed as they are squeezed into the abdomen.
SUMMARY A modification of the treatment of giant omphaloceles and gastroschisis by the use of synthetic fabrics to extend the peritoneal cavity consists of two stages: first, the intestines are squeezed out of the sack into the abdomen, and, second, the defect is closed by lateral plication of the prosthetic. The main advantage is that it is suitable for large defects. Other advantages of this method are that obliteration of the sack can be performed in the incubator while asepsis is rigidly practiced, and the hazards of peritoneal contamination and cooling of the infant are obviated. Anesthesia is not required because the skin is not manipulated.
147
LATERAL PLICATIONOF SYNTHETICSACK
REFERENCES 1. Schuster, S. Ft.: A new method for the staged repair of large omphaloceles. Surg. Gynec. Obstet. 12583’7, 1967. 2. Gilbert, M. G., Mencia, L. F., Brown, W. T., and Linn, B. S.: Staged surgical repair of large omphaloceles and gastroschisis. J. Pediat. Surg. 3:702, 1968. 3. Allen, R. G. and Wrenn, E. L., Jr.: Silon as a sac in the treatment of omphalocele and gastroschisis. J. Pediat. Surg. 4:3, 1969. 4. Jones, P. G.: Exomphalos. Arch. Dis.
Child. 38:180, 1963. 5. Oliver, T. K.: Temperature regulation and heat production in the newborn. Pediat. Clin. N. Amer. 12:765, 1965. 6. Bruck, K.: Temperature regulation in the newborn infant. Biol. Neonat. 3:65, 1961. 7. Free, E., and Takamoto, R.: Measurement of inferior vena caval pressure at the time of closure of omphaloceles. Presented at a meeting of the American Academy of Pediatrics, Section of Surgery, Washington, D.C., October 1967.