Management of abdominal wall defects-Jimma University

1. Hakim J. Jamba
Moderator: Dr. Dawit Teare, Consultant Surgeon

2. Contents
 Perinatal Management
 Preoperative
 Gastroschisis
 Exomphalo
 Umbilical hernia
 Other anomalies
 Summary
 References
2

3. Perinatal Management
 Maternal screening
 - Alpha fetoprotein
 90% exoph , 10% gastro
 U/S scanning
 dilated bowel; 7-25 mm
 Prenatal Counselling
 Mode of delivery
3

4. Preoperative Manag.
 Fluid Management
 IV bolus 20 ml/kg LR/NS
 D10¼NS 2-3 maintenance rate
 Heat Management
 Sterile wrap or sterile bowel bag
 Radiant warmer
 Hypoglycaemia (Beikwith Weidemann Synd)
 Positioning
4

5.  Nutrition
 NPO and TPN
 Gastric Distention
 OG/NG tube
 Infection Control
 Associated Defects
5

6. Gastroschisis 6

7.  Primary closure
 If bowel easily reduced
 Fascial grafts with skin mobilization and closure
 May need skin flaps and secondary healing of the
new defects
 Silastic covering to prevent evisceration then closed
4-5 days later after improvement of the pulmonary
state and intra-abdominal pressure
7

8.  Staged closure:
 Silo/Springed, sequential ligation
 Taking 1-14 days
 hospitalization, ventilation & early feeding
 Definitive closure;
 Skin flaps
 Horizontal fascia closure
 Linear skin closure (keyhole)/Purse-string
 Umbilical Plastic closure
 Cord/bowel directly covered by adhesive dressing
 60-84% ventral hernia, majority close spontaneously
8

9.  Associated atresia:
 10%
 Treated at wall closure or 4-6 weeks after
 Stoma for distal atresias
 Perforation:
 REEA if minimal inflammation
 Ostomy and closure at a later date
 Exteriorized through the silo
9

10. 10
 Vanishing bowel;
 a very small
abdominal wall
defect
 Necrosis and
disappearance of
some or all of the
intestine
 it usually results
in short bowel
syndrome.

11. Postoperative course
 Feeding delayed for weeks
 Oral stimulation/sucking reflex
 Dysmotility;
 prokinetics may improve i.e. erythromycin,
cisapride, metocloprimide
11

12. Long term outcome
 Generally excellent if no atresia
 NEC:
 18.5% of neonates more with formula
 Bowel loss short bowel syndrome
 Cryptorchidism:
 15-30%
 Due either being outside/prematurity
 Replacement and orchidopexy by 1 yr
 60% have psychosocial stress if umbilicus scrificed
12

13. Exomphalo 13

14.  Treatment options depend on the size, gestational
age, and associated anomalies
 Escharotic therapy/ Conservative;
 Gradual epithelialization of the omphalocele sac
 Mercurochrome, iodine, polymer membrane, silver
sulfadiazine, 70-90% alcohol, and Nystatin powder
 It usually takes many months to granulate and
epithelialize then managed as a ventral hernia
14

15.  70-90% alcohol
 Closed dressing for intact sacs
 Abdomen cleansed using plain antiseptic
 2-3 layers of soft cotton gauze placed
 Soft crepe bandage 4-6 inches applied
 Kept for 24-48 hrs
 Changed daily if moist
 Twice daily if infection is evident
 7-10 days hospitalization only
 Leaves a ventral hernia
15

16.  Primary closure may be appropriate for small
defects
 consists of excision of the sac and closure of the
fascia and skin over the abdominal contents
 Delayed closure
 medium-sized,
 the hepatic veins are located just under the
epithelium/sac interface in the midline and can be
injured
 haemorrhage can result from tears in Glissen’s
capsule or bladder injury
16

17.  Large defects;
 Bilateral flaps
 Component separation
 Tissue expanders in the cavity
 Fascial patch;
 Marlex, Gore-Tex infection
 Dura, SB submucosa,
17

18.  Staged closure:
 Historically; skin flaps with resultant large ventral
hernias
 Moderate ones with thick sacs can be considered
as silo
 Silo fashioning;
 Sac excised
 Silo sewn to rectus fascia/full thickness
18

19. Postoperative course
 Ventilation
 Feeding;
 No bilious output
 Minimal volume
 Bowel activity
 48 hrs Antibiotics
 Hernia dealt with at 1 yr old
 12% increased IAP & acute hepatic congestion
 25% skin and fascia dehiscence
19

20. Long-Term outcome
 Small; recover well
 Large;
 Gastro-oesophageal reflux - 43%
 Majority improve over time
 20% pulmonary insufficiency
 Respiratory Infections
 Asthma
 Feeding difficulties;
 60% with giant Exomph
 May need gastrostomy for feeding
 Failure to thrive
20

21. UMBILICAL HERNIA
 Defect in linea
alba,
subcutaneous
tissue and skin
covering the
protruding bowel
 Frequent in
premature infants
21

22. PENTALOGY OF CANTRELL
 Omphalocoele
 Anterior diaphragmatic hernia
 Sternal cleft
 Ectopia Cordis
 Intracardiac defect
22

23. 23

24. BECKWITH-WIEDEMANN
SYNDROME
 Macrosomia
 Macroglossia
 Organomegaly
 Abdominal wall
defects
 Embryonal tumors
24

25. Compendium
Omphalocoele Gastroschisis
Incidence 1:6,000-10,000 1:20,000-30,000
Delivery Vaginal or CS CS
Covering Sac Present Absent
Size of Defect Small or large Small
Cord Location Onto the sac On abdominal wall
Bowel Normal Edematous, matted
25

26. Omphalocoele Gastroschisis
Other Organs Liver often out Rare
Prematurity 10-20% 50-60%
IUGR Less common Common
NEC If sac is ruptured 18%
Associated
Anomalies
>50% 10-15%
Treatment Often primary Often staged
Prognosis 20%-70% 70-90%
26

27. References 27

28. 28

29. Intra-abdominal pressure
 10-15 mmHg kidney & bowel hypoperfusion
 Use Silo/Patch if
 IAP: >20 mmHg
 CVP: > 4 mmHg increment
 Bladder: >20 mmHg
 Splanch Perfusion pressure: <44 mmHg
29

30. 30

31. Dilatation 31

32. Component separation 32

33. Conservative 33

34. Skin Flaps
34

35. Primary Closure
35

36. 36

37. 37

38. Primary closure 38

39. 39

40. Bandage 40

41. Staged Closure 41

42. 42

43. Staged 43

44. 44

45. Primary Omph 45

46. 46

47. Silo bag 47

48. Fascial graft 48

49. 49

50. Umbilicus 50

51. Prenatal Counselling
 Description and cause of
abdominal wall defects
 Size of the defect and
how that may influence
management
 What organs are involved
in the abdominal wall
defect
 Other anomalies the
infant may have
 Timing of delivery
 Management following
birth, including
resuscitation and the
possible need for
intubation
 Neonatal intensive care
unit
 Treatment goals
 Surgical options
 Anticipated fetal course
 Treatment options and
timeline of treatment
 Potential complications
 Prognosis and quality-of-
life issues
51

52. Anomalies 52

53. 53

54. GASTROSCHISIS
 Defect of the anterior abdominal wall just lateral
to the umbilicus
54

55. Incidence
 1:20,000-30,000
 Sex ratio 1:1
 10-15% have associated anomalies
 40% are premature/SGA
55

56. Pathophysiology
 Abnormal involution of right umbilical vein
 Rupture of a small omphalocoele
 Failure of migration and fusion of the lateral folds
of the embryonic disc on the 3rd-4th week of
gestation
56

57. Lateral folds
 Form
 Lateral abdominal wall
 Future umbilical ring
57

58. 58

59. Clinical Findings
 Defect to the right
of an intact
umbilical cord
allowing extrusion
of abdominal
content
 Opening  5 cm
 No covering sac
59

60.  Bowels often
thickened, matted
and edematous
 10-15% with
intestinal atresia
60

61. 61

62. OMPHALOCOELE
 Anterior abdominal wall defect at the base of the
umbilical cord with herniation of the umbilical
contents
62

63. Incidence
 Small omphalocoele 1:5000
 Large omphalocoele 1:10000
 Male to female ratio 1:1
 Pacific Islanders have low risk for omphalocoele
63

64. Pathophysiology
 Failure of the midgut to return to abdomen by the
10th week of gestation
64

65. 65

66. Clinical Findings
 Covered clinical
defect of the
umbilical ring
 Defect may vary
from 2-10 cm
 Sac is composed
of amnion,
Wharton’s jelly and
peritoneum
66

67.  50% have
accompanying
liver, spleen,
testes/ovary
 >50% have
associated defects
 Location:
 Epigastric
 Central
 Hypogastric
 Cord attachment is
on the sac
67

68. PRUNE BELLY SYNDROME
 Thin, flaccid abdominal wall
 Dilation of bladder, ureter and renal collecting
system
 1:30,000-50,000
 95% are male
68

69. 69

70. BLADDER EXTROPHY
 Defective enfolding
of caudal folds
 3.3 in 100,000 births
 Associated with
prolapsed vagina or
rectum, epispadias,
bifid clitoris or penis
70