Gravitational Autoreposition for Staged Closure of Omphaloceles

Abstract

Introduction Management strategies for large omphaloceles remain controversial. In this study, we discuss the use of GRAVITAS (gravitational autoreposition sutures), the method used at our institution when successful primary closure is deemed questionable. Patient's primary clinical course and long-term outcomes were analyzed.

Materials and Methods This is a single-center retrospective analysis of all consecutive patients with omphaloceles treated between 1997 and 2018. Decision for GRAVITAS was made when the defect was estimated too large for primary closure. Traction sutures were placed in the fascia surrounding the defect and then suspended from the top of the incubator to allow gravitational autoreposition of the herniated organs. Ventilation and muscle relaxation were maintained until secondary closure, which was performed after the obtruding viscera had been reduced by repeated adjustment of the suture's tension. Data are presented as mean ± standard deviation.

Results Out of 49 patients with omphaloceles, 12 were treated with GRAVITAS, 33 underwent primary closure, and 4 were treated using Schuster's technique. Mean time to secondary closure after GRAVITAS was 7 ± 10 days. In nine of the patients who had isolated omphalocele, secondary closure was achieved after 4 ± 2 days. Ventilation time was 5 ± 2 days, and time to full feeds was 18 ± 16 days. In three patients (one with Fallot's tetralogy, one with Cantrell's pentalogy, and one with lung hypoplasia), abdominal closure was achieved after 17 ± 15 days. Due to cardiorespiratory comorbidity, ventilation time was >30 days. Five patients received initial closure of the skin and secondary fascial closure after 18 ± 15 months. One patient with prior fascial closure underwent later repair of an abdominal wall hernia. During follow-up (30 ± 35 months), one patient with gastrointestinal obstruction due to adhesions required laparotomy, and one patient with gastroesophageal reflux disease underwent fundoplication.

Conclusion GRAVITAS is a feasible method for staged closure of large omphaloceles when successful primary closure is deemed questionable.

Keywords

omphalocele - staged closure - congenital abdominal wall defect

• References

• 1 Marven S, Owen A. Contemporary postnatal surgical management strategies for congenital abdominal wall defects. Semin Pediatr Surg 2008; 17 (04) 222-235
• 2 Roux N, Jakubowicz D, Salomon L. , et al. Early surgical management for giant omphalocele: Results and prognostic factors. J Pediatr Surg 2018; 53 (10) 1908-1913
• 3 Akinkuotu AC, Sheikh F, Olutoye OO. , et al. Giant omphaloceles: surgical management and perinatal outcomes. J Surg Res 2015; 198 (02) 388-392
• 4 Mortellaro VE, St Peter SD, Fike FB, Islam S. Review of the evidence on the closure of abdominal wall defects. Pediatr Surg Int 2011; 27 (04) 391-397
• 5 van Eijck FC, de Blaauw I, Bleichrodt RP. , et al. Closure of giant omphaloceles by the abdominal wall component separation technique in infants. J Pediatr Surg 2008; 43 (01) 246-250
• 6 Bauman B, Stephens D, Gershone H. , et al. Management of giant omphaloceles: a systematic review of methods of staged surgical vs. nonoperative delayed closure. J Pediatr Surg 2016; 51 (10) 1725-1730
• 7 Schuster SR. A new method for the staged repair of large omphaloceles. Surg Gynecol Obstet 1967; 125 (04) 837-850
• 8 Adetayo OA, Aka AA, Ray AO. The use of intra-abdominal tissue expansion for the management of giant omphaloceles: review of literature and a case report. Ann Plast Surg 2012; 69 (01) 104-108
• 9 Kogut KA, Fiore NF. Nonoperative management of giant omphalocele leading to early fascial closure. J Pediatr Surg 2018; 53 (12) 2404-2408
• 10 Morabito A, Owen A, Bianchi A. Traction-compression-closure for exomphalos major. J Pediatr Surg 2006; 41 (11) 1850-1853
• 11 Brown MF, Wright L. Delayed external compression reduction of an omphalocele (DECRO): an alternative method of treatment for moderate and large omphaloceles. J Pediatr Surg 1998; 33 (07) 1113-1115
• 12 Hendrickson RJ, Partrick DA, Janik JS. Management of giant omphalocele in a premature low-birth-weight neonate utilizing a bedside sequential clamping technique without prosthesis. J Pediatr Surg 2003; 38 (10) E14-E16
• 13 Baird R, Gholoum S, Laberge J-M, Puligandla P. Management of a giant omphalocele with an external skin closure system. J Pediatr Surg 2010; 45 (07) E17-E20
• 14 Bawazir OA, Wong A, Sigalet DL. Absorbable mesh and skin flaps or grafts in the management of ruptured giant omphalocele. J Pediatr Surg 2003; 38 (05) 725-728
• 15 Dingemann C, Dietrich J, Zeidler J. , et al. Surgical management of congenital abdominal wall defects in germany: a population-based study and comparison with literature reports. Eur J Pediatr Surg 2017; 27 (06) 516-525
• 16 van Eijck FC, Aronson DA, Hoogeveen YL, Wijnen RMH. Past and current surgical treatment of giant omphalocele: outcome of a questionnaire sent to authors. J Pediatr Surg 2011; 46 (03) 482-488
• 17 Mehrabi V, Mehrabi A, Kadivar M, Soleimani M, Fallahi A, Khalilzadeh N. Staged repair of giant recurrent omphalocele and gastroschesis “camel-litter method”-a new technique. Acta Med Iran 2012; 50 (06) 388-394
• 18 Pacilli M, Spitz L, Kiely EM, Curry J, Pierro A. Staged repair of giant omphalocele in the neonatal period. J Pediatr Surg 2005; 40 (05) 785-788
• 19 Kruit AS, Al-Ani SA, Jester I, Jester A. Multilayered flap technique: a method for delayed closure of giant omphalocele. Ann Plast Surg 2016; 76 (06) 680-683
• 20 Parida L, Pal K, Al Buainain H, Elshafei H. Staged closure of giant omphalocele using synthetic mesh. APSP J Case Rep 2014; 5 (03) 27
• 21 De Ugarte DA, Asch MJ, Hedrick MH, Atkinson JB. The use of tissue expanders in the closure of a giant omphalocele. J Pediatr Surg 2004; 39 (04) 613-615