Tricks - Omphalocele - Approach & Component Separation For Suture Closure &...
With Dr. Bob Langer & Dr. Holly Williams · hosted by Dr. Todd Ponsky · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In patients without pulmonary hypoplasia or bad heart problems, first choice is to try early coverage because it is quicker and easier.
For patients with pulmonary hypoplasia, bad hearts, prematurity, or where the omphalocele is too big and there isn't enough skin to get over, the escharotic technique is used.
Silver sulfadiazine (Flamazine in Canada) has been used for many years for omphalocele escharization, as taught by Sigy Ein.
Silver-impregnated sponges offer the same advantage as Silvadene but are less messy and don't require painting.
Silver Aquacel stuck to the omphalocele sac and became incorporated, failing to fall off as expected once it hardened underneath.
Component separation requires going up every day to adjust the compression, which is work-intensive.
The most difficult cases are patients with pulmonary hypoplasia or bad hearts where intra-abdominal pressure cannot be safely increased.
Concern exists about whether abdominal wall musculature after component separation in a 1.3kg infant will function normally at 20 years of age.
Using an absorbable patch leaves the abdominal wall musculature intact, and as the child grows, the patch becomes a smaller percentage of the abdominal wall area.
Surgisis was used for a long time but had many recurrences; now Strattice is used with better results.
Many omphaloceles have defects that go right up to the costal margin, making it difficult to close that area even with component separation.
Often the lower part of the defect is closed primarily, but a patch is needed along the costal margin.
Component separation dissection to the mid-axillary line is necessary to adequately mobilize tissue and achieve closure.
Six-ply Surgisis with 22 tension lines works better, allowing tension on the patch while bringing the fascia together.
Component separation is technically highly complicated with a huge surgical area in such a small child, and complications would be very big.
Delayed primary closure at 6-7 months after escharization with fatty gauzes is a safer alternative to early complex surgery.
With escharization and delayed closure, children go home, play, are active regular kids, epithelialize the whole omphalocele, and can be fixed when older with component separation techniques.
Most patients managed with painting and delayed primary closure can be closed without using a patch when they are older.
The Duoderm technique was successful on two giant omphaloceles with liver out, performed over a longer period with gradual progress, redoing the Duoderm patch only every 3 days.
Babies with giant omphaloceles managed with Duoderm can be kept on nasal cannula with morphine during manipulation and don't need intubation until the actual repair.
In neonates, the Duoderm can pull the rectus out laterally when cut into diamonds, allowing primary closure at the edges so the defect requiring a patch is much smaller.
Alloderm is used as a bridge patch, and leaving the amnion provides a protective layer; the patch appears to turn into thick fascia over time, resulting in a relatively small central defect similar to rectus diastasis.
The benefit of early closure with Duoderm and patch is that muscle edges don't continue to get farther apart, whereas with painting and waiting, the muscle stays way out laterally and over time the defect appears bigger.
The most challenging situation is smaller defects with the whole liver out, where the liver doesn't go back in with painting and waiting because it's locked out, requiring enlargement of the fascial defect to reduce the contents.
Livers in small-defect omphaloceles can have a mushroom or dumbbell shape, making reduction very difficult.
The objectives of component separation are to minimize postoperative risk of abdominal hypertension and compartment syndrome, increase abdominal capacity at closure, facilitate anatomically definitive midline closure regarding rectus muscles, and limit evisceration and incisional hernias.
The case presented was a 28-week gestation, 1,130g premature female with giant omphalocele including the liver, identified by prenatal ultrasound.
After 10 days of manipulation with the Duoderm silo, the peritoneal sac was still covered, thick, and manageable.
The incision is made 0.5 to 1 centimeter outside the semilunar line, with dissection of the lateral fascia towards the external oblique.
By dissecting the fascia to the mid-axillary line, you can gain between 2 and 4 centimeters of advancement.
This case represents the probable smallest patient with lowest weight and giant omphalocele treated with Abello method and component separation for definitive anatomic closure without evisceration.
Dr. Abello has long-term follow-up with the Duoderm technique showing all patients healed well without problems.
Dr. Abello's algorithm starts with a relaxation test to determine how much the patient can tolerate and how much silo manipulation is needed to achieve primary closure.
If primary closure is not possible after Duoderm silo, the next step is component separation; if intra-abdominal pressure is still too high after component separation, a mesh can be placed.
If at any moment intra-abdominal pressure is too high or pulmonary hypertension occurs, the procedure can be aborted and traditional painting and waiting can be used.
Dr. Abello has never had to abort the process due to patient intolerance, including in patients with cardiomyopathy or pulmonary hypertension.