Abdominal-Wall-Defects.ppt by batte John Marvin.

Surgery

1. ABDOMINAL WALL DEFECTS
OMPHALOCELE GASTROSCHISIS

2. •Exomphalos and gastroschisis are two different congenital anomalies
•Overall incidence is approximately 1: 3000 live births
•Usually diagnosed prenatally on ultrasound
•Exomphalos and gastroschisis can usually be differentiated prenatally
•Do not inevitably require delivery by caesarian section
•Differ markedly in their clinical appearance

3. Exomphalos (omphalocele)
•CONGENITAL Anterior abdominal wall defect at the base of the
umbilical cord with herniation of the abdominal contents

4. Pathophysiology
•Failure of the midgut to return to abdomen
by the 10
th
week of gestation

5. Clinical Findings
•central defect of the abdominal wall beneath the umbilical ring.
•Defect may vary from 2-10 cm
•Always covered by sac
•The sac may be intact or ruptured
•Sac is composed of amnion, Wharton’s jelly and peritoneum
•The umbilical cord inserts directly into the sac in an apical or occasionally lateral position.
•Sac contains intestinal loops, liver, spleen and bladder , testes/ovary
•>50% have associated defects
•Prognosis depends on theses associated anomalies
•Mortality is approximately 40%

6. GASTROSCHISIS
•Congenital defect of the anterior abdominal
wall just lateral to the umbilicus

7. Pathophysiology
•Rapid dissolution of the right umbilical vein after
the standard period of organogenesis leaves an
area of relative weakness in the mesenchyme
through which bowel or abdominal viscera can
herniate and eventually rupture.
•Rupture of a small omphalocoele

8. Clinical Findings
•Defect to the right of an intact umbilical cord allowing extrusion of abdominal content
•Umbilical cord arises from normal place in abdominal wall
•Opening  5 cm
•No covering sac (never has a sac )
•Evisceration usually only contains intestinal loops
•Bowels often thickened, matted and edematous
• Infants have better prognosis than those with an omphalocele (Mortality is approximately
10% )
•10-15% have associated anomalies (intestinal atresia)
•40% are premature/SGA

9. Omphalocoele Gastroschisis
Incidence
more
less
Covering Sac
Present
Absent
Size of Defect
Small or large
Small
Cord Location
Onto the sac
On abdominal wall
Bowel
Normal
Edematous, matted
Other Organs
Liver often out
Rare
Prematurity
10-20%
40%
Associated
Anomalies
>50%
10-15%
Treatment
Often primary
Often staged
Prognosis (mortality)
40%
10%

10. MANAGEMENT
1.ABC
2.Heat Management
1.Sterile wrap or sterile bowel bag
2.Radiant warmer
3.Fluid Management
1.IV bolus 20 ml/kg RL/NS
2.D10¼NS 2 maintenance rate
4.Nutrition
1.NPO and TPN
5.Gastric Distention
1.OG/NG tube
6.Infection Control
1.Ampicillin and Gentamicin
7.Associated Defects
8.Closure of the defect (see next slides)

11. Omphalocele
Conservative treatment
1.Reduction by squeezing the sac or placement of a silo for sequential
tightening and staged closure
2. Children with giant omphaloceles or concomitant problems that make
them poor anesthetic risks may be treated with topical application of
Betadine ointment or silver sulfadiazine to the intact sac. This allows
secondary eschar formation and eventual epidermal ingrowth. Residual
abdominal wall hernias are then repaired at 1 year of age.
Surgical treatment
1.Primary closure
2.Staged closure

12. Gastroschisis
•Often be treated by direct full-layer closure of abdominal wall
•May be associated with postoperative gut dysfunction Usually require
postoperative nutritional and ventilatory support

13. UMBILICAL HERNIA
•all pediatric umbilical hernias are congenital and form as a hernia through a
persistent umbilical ring.
•subcutaneous tissue and skin covering the protruding bowel
•Incidence : one in every six live birth
•Premature and low birth weight infants have a higher incidence than full-term
infants
•spontaneous resolution rates of 83% to 95% by 6 years of age, so it
seems very safe to simply observe the hernia to allow closure to occur.
•If complications occur, the defect is large or defect not close
spontaneously surgical closure is indicated

14. EPIGASTRIC HERNIA
•Hernias of the abdominal wall through the midline linea alba, termed
epigastric hernias,
•Presents as small masses, between the umbilicus and xiphoid process.
• usually contains extra peritoneal fat.
•Can be multiple.
•Epigastric hernias do not resolve and should be repaired.

15. Staged Closure

16. Skin Flaps