A “Plastic” sutureless abdominal wall closure in gastroschisis

A “Plastic” Sutureless Abdominal Wall Closure in Gastroschisis By Anthony Sandler, John Lawrence, John Meehan, Laura Phearman, and Robert Soper Iowa City, Iowa Background/Purpose: Several techniques are described for closure of the gastroschisis abdominal wall defect. The authors describe a technique that allows for spontaneous closure that is simple, cosmetically appealing, and minimizes intraabdominal pressure after bowel reduction. Methods: Under either general anesthetic or analgesia with sedation, the gastroschisis bowel is decompressed, and the bowel is primarily reduced. The gastroschisis defect is covered with the umbilical cord tailored to fit the opening, and 2 Tegaderm (3M Healthcare, MN) dressings reinforce the defect (“plastic closure”). Intragastric pressure is monitored during and after the procedure. If primary reduction is not possible, the bowel is reduced daily via a spring-loaded silo (Bentec Medical, CA). After reduction of the bowel, the defect is allowed to close spontaneously using the “plastic closure” technique. The authors prospectively treated a cohort of patients with gastroschisis that included simple to complex cases using this technique. G ASTROSCHISIS is a congenital anomaly of the anterior abdominal wall that results in uncovered abdominal contents protruding through an abdominal wall defect. The defect is usually to the right side of the umbilicus resulting in asymmetry of the abdominal wall. Traditionally, gastroschisis is managed by reducing the abdominal contents and closing the abdominal wall defect surgically. If primary closure is not possible because of insufficient size of abdominal domain, an artificial pouch or silo is constructed to contain the eviscerated abdominal contents. Premade SILASTIC威 (Dow Corning, Midland, MI) silos with spring-loaded rings as well as various techniques for silo construction are used.1-4 With the silo From the Division of Pediatric Surgery, The Children’s Hospital of Iowa, Iowa City, IA. Presented at the 35th Annual Meeting of the Canadian Association of Paediatric Surgeons, Niagara-on-the-Lake, Ontario, Canada, September 18-21, 2003. Address reprint requests to Anthony Sandler, MD, Department of Surgery, Division of Pediatric Surgery, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3905-0016$30.00/0 doi:10.1016/j.jpedsurg.2004.01.040 738 Results: Ten children with gastroschisis were treated; 6 of these children had a primary reduction and simple closure of their defect using the “plastic closure.” In the remaining 4 children, the plastic closure was used either primarily or secondarily to silo placement, despite the need for repair of complex intestinal anomalies. The average times to first feeding and discharge were 12.5 and 28.3 days, respectively. Six of the 10 children (60%) had small umbilical hernias, and only 1 underwent operative repair at 13 months of age. Conclusions: The plastic closure of gastroschisis is simple, safe, and cosmetically appealing. Intraabdominal pressures are well controlled, and the umbilical position remains centrally located in this sutureless technique. Umbilical defects can occur but are observed for spontaneous closure like most primary umbilical hernias. J Pediatr Surg 39:738-741. © 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Gastroschisis, spontaneous closure, abdominal defect. in place, the gut is reduced gradually, until the right of abdominal domain is achieved. Based on the above principles, several techniques are described for closure of the gastroschisis abdominal wall defect. In this presentation, we describe a series of patients who were allowed to undergo spontaneous closure of the abdominal wall defect using a technique that is simple, cosmetically appealing, and minimizes intraabdominal pressure after bowel reduction. This technique was used either primarily or secondarily after silo placement. MATERIALS AND METHODS Technique Children with gastroschisis diagnosed prenatally are delivered at term. After delivery, the eviscerated bowel is covered with polyethylene wrap and a nasogastric tube placed to low intermittent suction. Intravenous access is established for volume resuscitation and for antibiotic administration (ampicillin and gentamicin). The patients are initially stabilized and then transferred to the operating room or treated in the neonatal intensive care unit (NICU). After induction of anesthesia and intubation, the bowel is inspected carefully, and meconium is irrigated out with warm saline enemas and intestinal manipulation if deemed necessary. The intestine and (other eviscerated organs) are carefully reduced while intragastric abdominal pressure is measured via manometry. The umbilical cord is left deliberately long at the time of birth so that it can be used as a biologic dressing. The gastroschisis defect is covered with the umbilical cord cut and tailored to fit the Journal of Pediatric Surgery, Vol 39, No 5 (May), 2004: pp 738-741 SUTURELESS CLOSURE FOR GASTROSCHISIS 739 Fig 1. Closure of the abdominal defect in a simple case of gastroschisis using the “plastic” spontaneous technique for primary closure. (A) Gastroschisis bowel before reduction. Note eviscerated right testis. (B) Defect after intestinal and testicular reduction. (C) Tailored umbilical cord filling the defect covered with Tegaderm dressing. (D) Same child at 18 months of age with a small vanishing umbilical hernia. The right testis also descended spontaneously in this child. opening, and 2 Tegaderm dressings (3M Health Care, MN) are used to reinforce the defect (“plastic” closure; Fig 1). The skin around the opening is protected with Skin Gel protective dressing wipe (Hollister Inc, IL). The Tegaderm dressings are removed on the third postoperative day, and the umbilical cord is allowed to dry while the defect closes spontaneously by secondary circumferential healing. If primary reduction is not possible because of high intragastric pressure (⬎16 mm Hg) or inability to reduce the bowel, a spring-loaded silo (Bentec Medical, CA) is placed. The cord is wrapped in Vaseline gauze and kept moist while the silo is in place in preparation for use after the silo is removed. After daily progressive reduction of the bowel, the silo is removed when it no longer maintains its intraabdominal position or when the intestine is completely reduced. The remaining defect is then allowed to close spontaneously. The opening is initially reinforced with Tegaderm, and if the umbilical cord remains viable, it also is included as the biologic dressing, held in position by the Tegaderm dressing. Dry dressings are substituted for the plastic dressing once the bowel is fixed in the abdominal cavity, and granulation tissue starts to cover the open defect. Percutaneous intravenous catheters are placed for parental nutrition. Feedings are started once nasogastric aspirations are low, in either primary or secondary closure, and patients are discharged home when full feedings are well tolerated. Data Collection We prospectively treated a cohort of 10 patients using this technique for both simple and complex cases of gastroschisis at The Children’s Hospital of Iowa between 1998 and 2003. Data collected included type of defect, associated intestinal anomalies, mode of gastroschisis closure, hospital course, and times to first feed and discharge. The institutional review board (IRB) approved review of the data presented (#200306050). RESULTS Of the 10 children with gastroschisis treated in this manner, 6 children underwent primary reduction and simple closure of their defect using the plastic closure technique described above (Fig 1). In the remaining 4 children, the plastic closure was used either primarily or secondarily to silo placement, despite the need for repair of complex intestinal anomalies. Of these 4 patients, 2 patients underwent bowel resection with primary anastomosis and “plastic” spontaneous closure. In 2 other cases, we were not able to primarily reduce the bowel, thus, silos were placed to gain the right of abdominal domain. After reduction of the bowel, silos were removed in the neonatal intensive care unit, and closure was allowed by secondary intention, using the umbilical cord remnant and Tegaderm dressing (Fig 2). The umbilical cord was kept deliberately moist for later use while the silo was in place. 740 SANDLER ET AL Fig 2. The management a gastroschisis defect that necessitated silo placement for bowel reduction and use of the “plastic” spontaneous technique for secondary abdominal wall closure. (A) Gastroschisis bowel before reduction. (B) Placement of silo in defect. At a week of age the silo was removed in the neonatal unit as the ring eviscerated, and the bowel and umbilicus were covered with Tegaderm. (D) A marked decrease in the defect size was noted within 1 week. This child started enteral feedings at 3 weeks of age before complete closure of the umbilical defect. (E) The umbilical port at the time of discharge (5 weeks of age). Dry dressings were applied at home. (F) The child’s abdomen at 8 weeks with a scarless abdomen and a cosmetically acceptable appearance of the umbilicus. The overall average times to first feeding and discharge in the 10 patients were 12.5 (range, 7 to 22) and 28.3 (range, 14 to 45) days, respectively. Feedings were initiated as described in the Methods Section, and in 2 cases, enteral feeding was tolerated well before complete wound closure was achieved. One child was discharged home with dressing changes of the umbilical wound (Fig 2). Six of the 10 children (60%) had small umbilical hernias that were managed conservatively. Only 1 of these children has undergone operative repair at 13 months of age, and 2 others defects have closed spontaneously. Two patients had periumbilical cellulitis and were treated with antibiotics alone. All patients are alive and well and have thrived since discharge. DISCUSSION The management of gastroschisis is aimed at reducing the bowel, gaining abdominal domain, and preserving a cosmetically appealing umbilicus. Many techniques are described for closure of the abdominal wall defect associated with gastroschisis.1-4 Limitations to achieving complete primary closure are increased intraabdominal pressure that may result in compromised gut circulation, ischemia, and intestinal infarction. The monetary cost of caring for gastroschisis patients is high, particularly because of gastrointestinal, respiratory, and operative complications associated with their care.5 The technique described in this report not only exploits the innate healing ability of the newborn but also limits elevation of the intraabdominal pressure because the fascia or skin overlying the defect is not closed and gastrointestinal, respiratory, and operative complications are most likely diminished. This technique also utilizes the body’s tendency to close the periumbilical defect circumferentially, allowing for an appealing cosmetic result. The genesis of the technique described occurred from our observation of a child with gastroschisis that aspirated meconium at birth. Before developing pulmonary compromise, the child’s bowel was easily reduced, and the defect was closed surgically with intraabdominal pressures no greater than 10 mm Hg. Because of increased respiratory pressures and respiratory impairment SUTURELESS CLOSURE FOR GASTROSCHISIS 741 6 hours after abdominal closure sutures were removed from the gastroschisis closure in the neonatal intensive care unit (NICU) in an attempt to prevent the need for extracorporeal membrane oxygenation for respiratory failure. Pulmonary pressures decreased satisfactorily after suture removal, and the bowel remained in the intraabdominal position. A Tegaderm dressing was placed over the abdominal defect to maintain a clean environment and reinforce the opening. It was our expectation at the time of reopening the defect to take the child back to the operating room for surgical closure once she had stabilized. However, within 2 weeks, the abdominal wall closed spontaneously by secondary intention with cicatrization around the umbilicus. The umbilicus remained central with an excellent cosmetic appearance and without an umbilical hernia. Following our observation of spontaneous closure in this child described above, Bianchi and Dickson2 published a series of 14 patients with gastroschisis in 1998 that underwent reduction of abdominal contents on the ward without general anesthesia. In their technique, the umbilical port was closed by capping it with the umbilical cord sutured to the rectus sheath to cover the defect. In our technique, the cord also is used to cover the defect, but it is not sutured, and spontaneous healing is allowed to occur. Our technique is done under general anesthesia or at least under heavy analgesia and sedation, with monitored anesthesia care, whereas they used no anesthesia or sedation. Unlike 2 of their 14 patients,2 all patients in this study had an excellent outcome without any adverse effects. Nevertheless, the ability to compare various techniques of gastroschisis repair is challenged by the lack of standardized risk categorization. Low-risk (simple) and high-risk (complex) categories are described by specific criteria with variable outcomes, postsurgical complications, length of stay, and mortality rates.6 The technique described in this report can be used for both low-risk and high-risk cases of gastroschisis. The ability to maintain a low intraabdominal pressure while gaining abdominal domain is a particular benefit of this technique. Feedings are initiated relatively early, as soon as bowel function is evident, even if the abdominal defect is not completely healed. The umbilical cord is preferentially preserved for closure of the defect. In patients with a relatively large defect and short cord there will be incomplete coverage, but this is not a contraindication to using this delayed healing technique (Fig 2). Additional advantages of this technique are its simplicity and its appealing cosmetic outcome. Cicatrization and secondary healing of the defect centralize the umbilical position. Although umbilical hernias occur quite frequently (6 of 10), they were not functionally significant, and only 1 of the patients in this series underwent umbilical herniorrhaphy. The remaining patients continue to be followed up, and several of their hernias have closed spontaneously. We have used this technique of spontaneous closure in 2 other patients with gastroschisis that are not included in this series. These patients were excluded, because the rectus fascia was incised during bowel reduction. In these 2 cases, opening the rectus fascia was considered necessary because of the small size of the gastroschisis opening and large size of the edematous gastroschisis bowel. In both cases, however, although satisfactory spontaneous closure occurred, an abdominal wall hernia persisted that necessitated operative closure. We therefore recommend surgical repair of defects necessitating fascial incision, even if the “plastic” spontaneous closure technique is used. In our experience, this minimally invasive approach of “plastic” spontaneous closure is simple, safe, and cosmetically appealing. Intraabdominal pressures are well controlled, and the umbilical position remains centrally located with this sutureless technique owing to the process of cicatrization. Umbilical defects can occur but are observed for spontaneous closure like most primary umbilical hernias. This procedure can be performed in the operating room or in the NICU under either general anesthesia or deep analgesia with sedation and monitored anesthesia care. This method is also appropriate for primary closure or delayed secondary closure after silo placement and is proposed as an alternate approach in the treatment of children with gastroschisis defects. A randomized controlled trial comparing outcomes and cost of care between this technique and surgical closure of the fascia should be performed. REFERENCES 1. Kidd JN, Levy MS, Wagner CW: Staged reduction of gastroschisis: a simple method. Pediatr Surg Int 17:242-244, 2001 2. Bianchi A, Dickson AP: Elective delayed reduction and no anesthesia: “Minimal intervention management” for gastroschisis. J Pediatr Surg 33:1338-1340, 1998 3. Kimble RM, Singh SJ, Bourke C, et al: Gastroschisis reduction under analgesia in the neonatal unit. J Pediatr Surg 36:1672-1674, 2001 4. Lee S-C, Jung S-E, Kim W-K: Silo formation without suturing in gastroschisis: Use of steridrape® for delayed repair. J Pediatr Surg 32:66-68, 1997 5. Sydorak RM, Nijagal A, Sbragia L, et al: Gastroschisis: Small hole, big cost. J Pediatr Surg 37:1669-1672, 2002 6. Molik KA, Gingalewski CA, West KW, et al: Gastroschisis: A plea for risk categorization. J Pediatr Surg 36:51-55, 2001