J Ped Surg Case Reports 1 (2013) 267e269

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Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports.com

The use of Alloderm for a giant omphalocele with a ruptured sac

and inadequate skin coverage
Anna C. Shawyer*, Karen A. Bailey, Brian H. Cameron
McMaster University, Department of Surgery, Division of Pediatric Surgery, McMaster Children’s Hospital, 1200 Main Street W., Hamilton, ON, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Giant omphaloceles often present with a loss of abdominal domain. An intact sac may permit simple
Received 2 July 2013 daily dressings to promote epithelialization for a delayed operative closure; a ruptured sac presents
Received in revised form challenges. There may be insufficient native tissue for adequate coverage; tissue expanders or grafts may
23 July 2013
be needed. We present a case of a ruptured omphalocele sac in which non-operative management was
Accepted 24 July 2013
not possible e silo placement and reduction was unsuccessful due to a lack of abdominal domain. We
used an acellular human dermal matrix (Alloderm, Life Cell, Branchburg, NJ), sutured to the patient’s
fascia to provide coverage of the omphalocele contents. There was insufficient skin to cover the majority
Key words:
Giant omphalocele
of the graft. Tissue expanders had to be removed due to infection. With regular dressing changes, the
Ruptured sac tissue underneath the graft granulated and epithelialized and the graft lifted off. Skin grafting was not
Acellular dermal matrix required. Alloderm’s biologic properties render it less prone to infection than a synthetic graft; there was
no evidence of graft infection in this patient. This ruptured omphalocele was managed with Alloderm
coverage and minimal native skin.
Ó 2013 The Authors. Published by Elsevier Inc. Open access under CC BY license.

Omphaloceles occur in 1 in 4000e6000 live births [1]. Im- 1. Case report

provements in antenatal, neonatal, surgical and anesthetic care of
neonates with abdominal wall defects have resulted in increased
survival rates [2,3]. Prognostic indicators include the size of the
defect, antenatal rupture of the sac, low birth weight, gestational
age, associated anomalies, and perinatal respiratory distress
[1,4,6]; the morbidity and mortality are dramatically higher with
giant omphaloceles, i.e., the diameter of the defect is greater than
5 cm and the sac contains liver [3,4,7e9].
Small- to medium-sized defects should be repaired. Giant
omphaloceles are challenging to manage e there is often a large de-
gree of visceroabdominal disproportion such that primary reduction
and closure of the abdominal wall is prohibited [10,11]. This challenge
is compounded by the presence of associated anomalies [6,12]. A
forced closure can result in increased intra-abdominal pressure and/
or kinking of visceral blood vessels leading to renal failure, pulmonary
failure and superior mesenteric artery occlusion [5,7,13e15].
* Corresponding author. Tel.: þ1 905 521 2100x75231; fax: 1 905 521 9992.
E-mail address: shawyeac@mcmaster.ca (A.C. Shawyer).
A 1.7 kg girl was delivered by elective cesarean section for in-
trauterine growth restriction at 35 weeks of gestation and an
antenatally diagnosed large omphalocele. There was a maternal
history of chronic hypertension, carpal tunnel syndrome, and
marijuana use. The abdomen was initially wrapped in plastic
sheeting and the baby was transferred to the neonatal intensive
care unit. Examination revealed bowed and shortened lower ex-
tremities, absence of the right great toe and oligodactyly of the left
foot. As well, there was a giant omphalocele involving the stomach,
liver, spleen, small and large bowel. There was a large rent in
the sac, and given the exposed liver, a primary sac repair was not
performed (Fig. 1). A 7.5 cm spring-loaded silo (Bentec Medical Inc.,
Woodland, CA) was placed around the sac and secured. Despite
attempts at serial reduction, there had been minimal progress, and
10 days later the silo was replaced another one with the ring
portion removed e this was sewn directly to the abdominal skin
(after trimming the sac from the skin edges). We received approval
for the use of Alloderm e 10 days later the second silo was removed.
We noted a fibrinous peel on the small bowel but felt it insufficient
to simply proceed with topical management. Skin flaps were raised
from the underlying fascia and the Alloderm was sewn circum-
ferentially to the fascia under moderate tension. The Alloderm was

2213-5766 Ó 2013 The Authors. Published by Elsevier Inc. Open access under CC BY license.
http://dx.doi.org/10.1016/j.epsc.2013.07.014
268 A.C. Shawyer et al. / J Ped Surg Case Reports 1 (2013) 267e269

Fig. 2. Omphalocele covered in Alloderm.

acellular dermal matrix [25,28]. An intraperitoneal tissue expander

has been used to create peritoneal domain followed by primary
closure [29].
Non-operative management can be applied to omphaloceles
with an intact sac by topical treatment of the omphalocele
membrane to promote epithelialization followed by secondary
repair of the ventral hernia [3,22,30]. Non-operative management
may result in lower complication rates than staged reductions
with a silo [2,3], and removes the need for major surgery in the
newborn period [2]. Our patient, however, presented with a
ruptured sac so topical treatment was not possible.
The management of ruptured omphalocele sacs can be more
Fig. 1. Ruptured omphalocele. complicated. Some may respond to simple silo placement and
serial reduction [2], whereas others may require the use of grafts
to achieve interim organ coverage [31]. Alloderm is an acellular
then sewn to itself across the top of the defect (two sheets of
human dermal matrix with a tensile strength similar to human
8  16  0.78 mm each). The skin edges were tacked up the sides of
fascia; its properties make it less susceptible to infection or to an
the Alloderm with interrupted sutures.
inflammatory reaction, including the formation of adhesions, than
There was insufficient skin to cover the Alloderm e dressings
synthetic grafts [32e36]. Its structure supports tissue ingrowth to
were applied with non-adherent, moisturizing, gel and dry gauze
layers, and were changed two to three times per week.
Subcutaneous tissue expanders were placed in each flank but
had to be removed on post-operative day 2 due to concerns
about infection (overlying cellulitis and purulent discharge).
Intra-abdominal expansion was not performed as the patient
required significant ongoing respiratory support. Overtime,
granulation tissue appeared at the skin-Alloderm interface and
the Alloderm retracted to the most ventral portion of the
omphalocele (Figs. 2 and 3). The remaining Alloderm was ulti-
mately removed at 15 months of age. The baby had a trache-
ostomy placed at 2 months of age for pulmonary complications
(pneumonitis secondary to reflux of feeds) and bronchmalacia,
and was on continuous nasojejunal feeds. She was discharged
using a home-ventilator at 8 months of age with her mother
performing dressing changes.

2. Discussion

Ladd and Gross originally used skin flaps [11,16], but other
methods have been applied to achieve closure of giant omphalo-
celes. Schuster introduced the staged silo closure [17], and then
others used tissue expanders [18,19], serial sac clamping [20,21],
topical management [22,23], component separation [24], or grafts
[23,25e27]. Others have recently employed negative-pressure Fig. 3. Omphalocele with only small amount of Alloderm remaining (8 months post
therapy to reduce the viscera, followed by grafting with an application).
 A.C. Shawyer et al. / J Ped Surg Case Reports 1 (2013) 267e269
initiate angiogenesis [34,37]. Alloderm has typically been used
with subsequent coverage by skin or skin grafts [31,32,38]. Our
patient is unique in that there was insufficient skin to cover the
graft, and the infant was too small to provide enough skin for
allografting. Additionally, the surgically placed tissue expanders
had to be removed due to infection. We used serial dressings to
achieve granulation and epithelialization of the tissue exposed as
the Alloderm lifted off overtime. Given its native properties, it was
unusual that the Alloderm lifted off. Ultimately, we plan for serial
reductions and removal of excess epithelialized tissue.
3. Conclusion
As giant omphaloceles are uncommon, it is difficult to carry out
a prospective evaluation of the different treatment modalities
available [39]. There are many ways to attempt closure, depending
on the patient comorbidities, relative size of the defect, and extent
of native tissue available. For patients with giant omphaloceles and
a ruptured sac, Alloderm, or other biologic grafts may provide an
option for visceral coverage even in the absence of adequate skin
coverage.
The patient in this case is doing well at home. She is almost 2
years of age, continues on nasojejunal feeds, and is slowly weaning
from her home-ventilator.
Acknowledgment
The authors would like to thank Janet Rowe for her assistance in
editing the manuscript.
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