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ABDOMINAL WALL DEFECTS

OMPHALOCELE GASTROSCHISIS
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


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

Failure of the midgut to return to abdomen


by the 10th week of gestation
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, Whartons 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%
GASTROSCHISIS

Congenital defect of the anterior abdominal


wall just lateral to the umbilicus
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


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


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 >50% 10-15%


Anomalies
Treatment Often primary Often staged

Prognosis 40% 10%


(mortality)
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. D10NS 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)
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
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


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
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.
Staged Closure
Skin Flaps