Update Course Rewind: Omphalocele & Gastroschisis 2020

Published: 2026-07-29

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Miguel Guelfand

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Girardo — host
Ellen Sisko — host
Speaker 3 — guest

Chapters

0:00Introduction and Giant Omphalocele Study Overview — Hosts introduce the episode topic and Dr. Sean St. Peter presents a two-center retrospective study of 97 giant omphalocele survivors over 20 years.
1:03Giant Omphalocele Outcomes and Pulmonary Hypertension — Discussion of study findings including respiratory insufficiency, pulmonary hypertension in 56 patients, and late-onset pulmonary hypertension associated with sepsis.
3:46Omphalocele Closure Techniques and Ladd Procedure — Review of closure options including Dr. Guilfant's hydrocolloid dressing technique achieving 92% closure within 15 days, and discussion of Ladd procedure for non-rotation.
6:10Massive Abdominal Wall Defect Management — Dr. Salim Islam presents a case of large abdominal wall defect with eviscerated liver, discussing biologic mesh scaffolding, skin grafting including foreskin use, and tissue expander placement.
10:16Ventral Hernia Repair Techniques — Discussion of tissue expanders and component separation technique for closing large ventral hernias in children aged 7 days to 10 years.
12:25Gastroschisis Management Strategies — Dr. Islam reviews complex gastroschisis outcomes, sutured versus sutureless closure showing reduced infections with less antibiotics, and randomized trial showing no difference between silo and immediate closure.

Key claims

0:36Giant omphalocele is typically defined as five centimeters or greater or liver in the sac — Speaker 3
0:36In a two-center retrospective study of 97 giant omphalocele survivors over 20 years, patients had greater time to full feeds, required more TPN, had more chromosomal anomalies, and higher incidence of respiratory insufficiency — Speaker 3
1:1456 of 97 giant omphalocele patients were identified as having pulmonary hypertension, most diagnosed within the first week of life — Speaker 3
1:14Five patients with giant omphalocele had no signs of pulmonary hypertension in first echo within seven days but subsequently developed severe pulmonary hypertension, all associated with sepsis episodes — Speaker 3
1:14Two of the five patients who developed late pulmonary hypertension died, and one required pulmonary vasodilator for more than a year — Speaker 3
2:28Treatment options for giant omphalocele include painting the sac, removing sac and placing silo with passive or active reduction, keeping sac with active reduction, or definitive immediate closure — Ellen Sisko
3:54Hydrocolloid dressing technique for giant omphalocele achieved closure in 97% of 40 patients within 30 days and 92% within 15 days — Ellen Sisko
4:26Hydrocolloid dressing should be placed within first 24 hours before the sac becomes stiff, and the dressing keeps the sac smooth and hydrated — Speaker 3
4:20Patients with hydrocolloid dressing for omphalocele are kept in ICU, ventilated and completely paralyzed during reduction — Speaker 3
4:45For ruptured omphalocele, the sac can be sutured and then hydrocolloid dressing applied — Speaker 3
5:17Patients with omphalocele have increased risk of midgut volvulus compared to gastroschisis patients — Speaker 3
5:17Patients with omphalocele have increased risk of adhesive bowel obstruction with gastroschisis, but higher risk of midgut volvulus — Speaker 3
5:17Non-rotation does not exclude the possibility of anatomy with narrow base of mesentery and two ends being fairly close together — Speaker 3
5:17If exposing intestines in omphalocele patient, Ladd procedure is worthwhile because patients have non-rotation or mal-rotation — Speaker 3
7:14In gastroschisis, the liver is not expected to be eviscerated — Speaker 3
7:14For massive abdominal wall defects with no amnion, options include leaving silo and squeezing down, creating separate silastic silo sewn to fascia or skin, creating silo with PTFE or biologic mesh sewn to fascial edges — Speaker 3
8:18Proline mesh can be used for giant defects as it stays in place until closure, with bowel protected within a plastic bag — Speaker 3
8:49Spring-loaded Bentec silo creates outward forces that can make the defect bigger over time in giant abdominal wall defects — Speaker 3
9:14Biologic mesh creates a scaffold that sticks to bowel and allows skin to epithelialize — Speaker 3
9:14Foreskin from circumcision can be used as a skin graft for abdominal wall coverage — Speaker 3
10:26Component separation technique involves separating tissue at external oblique about one centimeter beyond rectus sheath on both sides, creating space by dissecting between external and internal oblique — Ellen Sisko
10:26Incision on anterior rectus sheath can provide additional centimeter of space for closure — Ellen Sisko
10:26Texas report of component separation in nine children aged 7 days to 10 years achieved fascial closure in vast majority, mostly for omphaloceles and giant defects — Ellen Sisko
12:25Complex gastroschisis has worse outcomes than simple variety in all measures: hospital length of stay, requirement for further operations, and sepsis rates — Speaker 3
12:25Sutureless gastroschisis closure involves placing silo or tucking bowel in with occlusive dressing, changed at five days, with defect mostly closed by next change — Speaker 3
12:25Sutured versus sutureless gastroschisis closure showed no difference in time to full feeds, TPN use, or hospital stay duration — Speaker 3
12:25Sutureless gastroschisis closure resulted in fewer anesthetics, less frequent antibiotic use, and fewer infections and septic events — Speaker 3
12:25Randomized trial of over 50 gastroschisis patients found no difference between immediate closure and silo placement — Speaker 3

Cases discussed

6:42Infant with massive abdominal wall defect with eviscerated stomach, intestine, and liver, no covering sac

Open questions

What is the optimal timing for Ladd procedure in omphalocele patients with non-rotation?
Should all giant omphalocele patients be screened for pulmonary hypertension beyond the first week of life?
What is the optimal antibiotic regimen for gastroschisis patients given that less antibiotic use correlates with fewer infections?
When should component separation be performed versus tissue expanders for large ventral hernias in pediatric patients?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Managing a Massive Abdominal Wall Defect Without a Sac

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

The Presentation

An infant was born with a massive abdominal wall defect — stomach, intestine, and the entire liver eviscerated, with no covering sac and almost no abdominal domain 7:14. The team placed a silo initially 7:14. The defect was too large and the liver too completely herniated to be gastroschisis, where the liver is not expected to be eviscerated 7:14. They called it a ruptured omphalocele 7:14.

The Decision Point

With no sac and no domain, the surgical options narrowed quickly 7:14. The team could leave the silo and attempt gradual reduction, create a separate silastic silo sewn to fascia or skin, or use mesh — either PTFE or biologic — sewn to the fascial edges 7:14. One discussant noted that spring-loaded silos create outward forces that can enlarge the defect over time in giant abdominal wall defects 8:49. Another described using proline mesh for such cases, keeping the bowel protected within a plastic bag, because the mesh stays in place until closure can be achieved 8:18.

The team chose biologic mesh as a scaffold 9:14. The reasoning: biologic mesh sticks to bowel and allows skin to epithelialize over it 9:14.

What They Did

After placing the biologic mesh, the team performed a circumcision and used the foreskin as a skin graft for abdominal wall coverage 9:14. Plastic surgeons then placed tissue expanders and created flaps to achieve skin coverage 9:14. Before the mesh became fully incorporated, the team serially resected portions of it, reducing and stretching the fascia incrementally 9:14.

The patient survived with skin coverage achieved, but a large ventral hernia remained 9:14.

The Remaining Problem

The child had intact skin but a ventral hernia large enough that the abdominal contents appeared ready to herniate with any exertion 9:14. For such defects, the discussants outlined two main approaches 10:26. Tissue expanders — placed either intraperitoneally or subcutaneously — can increase abdominal domain over time 10:26. Component separation offers another option: the external oblique is separated about one centimeter beyond the rectus sheath bilaterally, with dissection between the external and internal oblique creating additional space 10:26. An incision on the anterior rectus sheath can provide another centimeter 10:26. A Texas series of children aged seven days to ten years — most with omphaloceles and giant defects — achieved fascial closure in the vast majority using component separation, sometimes with bridging mesh 10:26.

The case was presented without stating which approach was ultimately chosen or what the final outcome was.

What This Case Changes

Massive abdominal wall defects without a sac force a choice between temporizing strategies that risk enlarging the defect and scaffolding approaches that accept a long reconstruction timeline 7:14 7:14 8:49. Biologic mesh creates a platform for epithelialization but does not solve the domain problem — it defers it 9:14. Serial mesh resection before incorporation is one way to stretch fascia gradually, but the endpoint is still a large ventral hernia requiring definitive reconstruction 9:14. Component separation, familiar to adult surgeons, is feasible even in neonates and should be considered early in the planning rather than as a salvage technique 10:26. The foreskin graft is a reminder that in extreme resource scarcity, autologous tissue from any source becomes useful 9:14.

Takeaways from this story

Spring-loaded silos create outward forces that can enlarge giant abdominal wall defects over time.
Biologic mesh creates a scaffold for epithelialization but defers rather than solves the abdominal domain problem.
Component separation achieved fascial closure in most children with giant defects, even in neonates as young as seven days.

Giant Omphalocele and Gastroschisis: Lessons from Two Decades of Management

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Pulmonary hypertension is a late threat, not just an early one

Giant omphalocele — defined as five centimeters or greater or liver in the sac — carries well-known respiratory risks 0:36. A two-center study of 97 survivors over 20 years confirmed the expected: longer time to full feeds, more TPN dependence, more chromosomal anomalies, and higher rates of respiratory insufficiency 0:36. But the pulmonary hypertension pattern was unexpected. Of 56 patients identified with pulmonary hypertension, most were diagnosed within the first week of life 1:14. Five patients, however, had normal echocardiograms in the first seven days and then developed severe pulmonary hypertension later — all associated with sepsis episodes 1:14. Two of those five died; one required pulmonary vasodilators for more than a year 1:14. The lesson: even patients without early respiratory compromise remain at risk when sepsis occurs. The faster you achieve definitive closure, the less exposure to that risk.

Hydrocolloid dressing enables rapid active reduction

Traditional management options for giant omphalocele include painting the sac, removing the sac and placing a silo with passive or active reduction, keeping the sac with active reduction, or immediate definitive closure 2:28. The hydrocolloid dressing technique — pioneered in Chile — achieved closure in 97% of 40 patients within 30 days and 92% within 15 days 3:54. The technique depends on timing: the dressing must be placed within the first 24 hours before the sac stiffens, and it keeps the sac smooth and hydrated 4:26. Patients are kept in the ICU, ventilated and completely paralyzed during reduction 4:20. Even ruptured omphaloceles can be managed this way — the sac can be sutured and then the hydrocolloid dressing applied 4:45. This approach collapses the timeline from months to weeks, reducing sepsis exposure.

Non-rotation does not mean safe anatomy

Omphalocele patients have increased risk of midgut volvulus compared to gastroschisis patients 5:17. The finding matters because these patients have non-rotation or mal-rotation, and non-rotation does not exclude unfavorable anatomy — a narrow mesenteric base with the two ends fairly close together can still exist 5:17. If you are exposing the intestines during definitive closure, a Ladd procedure is worthwhile 5:17. The teaching point: non-rotation is a descriptive term, not a guarantee of safe mesenteric geometry.

Component separation works across the age spectrum

For massive defects where primary closure is impossible, component separation creates space by separating tissue at the external oblique about one centimeter beyond the rectus sheath bilaterally, then dissecting between the external and internal oblique 10:26. An incision on the anterior rectus sheath can provide an additional centimeter 10:26. A Texas series of nine children aged 7 days to 10 years — mostly giant omphaloceles — achieved fascial closure in the vast majority 10:26. The technique is not reserved for older children; it is applicable from the neonatal period forward. Spring-loaded silos create outward forces that enlarge the defect over time in giant defects 8:49; component separation moves in the opposite direction.

Sutureless gastroschisis closure reduces infectious morbidity

Complex gastroschisis has worse outcomes than simple gastroschisis in every measure: hospital length of stay, requirement for further operations, and sepsis rates 12:25. For simple gastroschisis, sutureless closure — placing a silo or tucking the bowel in with an occlusive dressing changed at five days — showed no difference from sutured closure in time to full feeds, TPN use, or hospital stay duration 12:25. But sutureless closure resulted in fewer anesthetics, less frequent antibiotic use, and fewer infections and septic events 12:25. A randomized trial of over 50 patients found no difference between immediate closure and silo placement 12:25, which validated the move toward sutureless management. The advantage is not in feeding outcomes — it is in avoiding intubation and reducing antibiotic pressure.

The discussants emphasized that the faster you achieve closure in giant omphalocele, the less sepsis risk you carry. That principle — minimize the window of vulnerability — runs through every decision in abdominal wall defect management.

Takeaways from this story

Pulmonary hypertension can develop late in giant omphalocele when sepsis occurs, even after normal early echocardiograms
Hydrocolloid dressing applied within 24 hours achieves 92% closure within 15 days with patients kept ventilated and paralyzed
Non-rotation in omphalocele does not exclude narrow mesenteric base anatomy; consider Ladd procedure during definitive closure
Component separation works from 7 days to 10 years of age for giant defects, creating space without mesh in most cases
Sutureless gastroschisis closure reduces anesthetics and infections without changing feeding outcomes compared to sutured closure

Giant Omphalocele Management: From Pulmonary Hypertension to Definitive Closure

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Pulmonary hypertension is not just an early problem

The teaching begins with what most of us were taught incorrectly: that pulmonary hypoplasia drives respiratory morbidity in giant omphalocele, while pulmonary hypertension belongs to CDH. A two-center retrospective of 97 giant omphalocele survivors found that 56 patients developed pulmonary hypertension, most within the first week 1:14. The critical finding: five patients had normal echocardiograms in the first seven days but later developed severe pulmonary hypertension, all triggered by sepsis episodes 1:14. Two died; one required pulmonary vasodilators for over a year 1:14. The lesson is operational — even patients without early respiratory compromise remain at high risk when sepsis occurs later, and this risk persists throughout the reduction period.

Hydrocolloid dressing achieves rapid closure if applied early

The hydrocolloid technique inverts the traditional painted-sac timeline. Applied within 24 hours before the sac stiffens, the dressing keeps the sac smooth and hydrated 4:26. Patients remain intubated, ventilated, and completely paralyzed during active reduction 4:20. In 40 patients, this achieved closure in 92% within 15 days and 97% within 30 days 3:54. The technique works even for ruptured omphalocele — suture the sac first, then apply the dressing 4:45. The advantage over painting is speed: definitive closure in weeks rather than months reduces the window for septic complications that trigger late pulmonary hypertension.

Non-rotation does not protect against volvulus

Omphalocele patients have non-rotation or malrotation, but non-rotation does not exclude unfavorable anatomy 5:17. The mesenteric base can still be narrow with the two ends close together, creating volvulus risk despite the expected non-rotated configuration. A comparative study found higher midgut volvulus rates in omphalocele than in gastroschisis 5:17. The practical implication: if you are exposing the intestines for definitive closure, perform a Ladd procedure 5:17. The anatomy may look reassuringly non-rotated, but that appearance does not guarantee a safe mesenteric base.

Giant defects require strategies that do not expand the defect

When the defect is massive — liver eviscerated, no amnion, no tissue to sew — spring-loaded silos create outward forces that enlarge the defect over time 8:49. The discussants offered three alternatives. Proline mesh stays in place indefinitely, allowing serial reduction with the bowel protected inside a plastic bag 8:18. Biologic mesh creates a scaffold that adheres to bowel and permits skin epithelialization 9:14. For coverage, foreskin from circumcision can serve as a skin graft 9:14. The unifying principle: avoid techniques that apply lateral tension when you have no fascia to resist it.

Component separation works from the neonatal period through childhood

For the massive ventral hernia that results after staged closure, component separation creates space by separating tissue at the external oblique one centimeter beyond the rectus sheath bilaterally, then dissecting between external and internal oblique 10:26. An anterior rectus sheath incision adds another centimeter 10:26. A Texas series of nine children aged seven days to ten years — mostly giant omphaloceles — achieved fascial closure in nearly all, with some requiring bridging mesh 10:26. The technique is not reserved for older children; it applies whenever you need domain and have run out of other options.

Sutureless gastroschisis closure reduces anesthetics and infections without compromising outcomes

The final teaching point addresses gastroschisis, where sutureless closure — placing a silo or tucking bowel with occlusive dressing changed at five days — showed no difference from sutured closure in time to feeds, TPN duration, or hospital stay 12:25. But sutureless closure resulted in fewer anesthetics, less frequent antibiotic use, and fewer infections and septic events 12:25. A randomized trial of over 50 patients found no difference between immediate closure and silo placement 12:25, establishing that sutureless closure is a valid path. The discussants emphasized that the infection reduction occurred despite less antibiotic use, suggesting we are likely too aggressive with antibiotics in gastroschisis regardless of closure method. The advantage of sutureless closure is avoiding intubation and anesthetic exposure, not the closure technique itself.

Takeaways from this story

Normal early echo does not exclude late severe pulmonary hypertension triggered by sepsis in giant omphalocele patients
Hydrocolloid dressing applied within 24 hours achieves 92% closure within 15 days with active reduction under paralysis
Non-rotation in omphalocele does not exclude narrow mesenteric base anatomy; perform Ladd if exposing intestines
Spring-loaded silos enlarge giant defects over time; use proline or biologic mesh that does not create outward forces
Sutureless gastroschisis closure reduces anesthetics and infections without compromising feeding or hospital outcomes

Topic overview

A discussion of omphalocele and gastroschisis management covering giant omphalocele outcomes, closure techniques, and gastroschisis treatment strategies. Key clinical findings include pulmonary hypertension risk in giant omphalocele patients (especially post-sepsis), a hydrocolloid dressing technique achieving 92% closure within 15 days, increased midgut volvulus risk in omphalocele warranting Ladd procedure consideration, and evidence that sutureless gastroschisis closure reduces anesthesia exposure and infection rates without compromising outcomes. The discussion also addresses management of massive abdominal wall defects using biologic mesh scaffolding and component separation techniques.

Key takeaways

Screen giant omphalocele patients for late pulmonary hypertension during sepsis—5 developed severe PH post-sepsis, 2 died. (1:14)
Hydrocolloid dressing achieves 92% giant omphalocele closure within 15 days; apply <24h before sac stiffens. (3:54)
Consider Ladd procedure in omphalocele repair—patients have higher midgut volvulus risk despite non-rotation. (5:17)
Sutureless gastroschisis closure reduces anesthesia exposure and infection rates without delaying feeds or discharge. (12:25)
Biologic mesh scaffolding allows skin epithelialization over giant defects; component separation achieves fascial closure. (9:14)

Keywords

giant omphalocele gastroschisis pulmonary hypertension pulmonary hypoplasia respiratory insufficiency sepsis non-rotation mal-rotation midgut volvulus adhesive bowel obstruction ruptured omphalocele ventral hernia complex gastroschisis chromosomal anomalies silo placement

Hashtags

#PediatricSurgery #NeonatalSurgery #AbdominalWallDefects #CongenitalAnomalies

Transcript

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Hey, this is Rod Girardo, research resident at Cincinnati Children's Hospital. Today I'm joined by my future replacement. Hey, this is Ellen Sisko, another research resident at Cincinnati Children's Hospital. Ellen, what are we talking about today? Today we're talking about emballous healing gastroschisis. But we're not just going to talk about it. We're going to hear from some experts from the 2020 update course. So we are going to start with an omphalocele case, and we're going to start by just talking about some of the general physiologic principles that I think are underreported in literature, and then we'll go to management. That's Dr. Sean St. Peter, surgeon-in-chief at Children's Mercy Kansas City. And we started out talking about a case of giant omphalocele. Typically defined as five centimeters or greater or liver in the sac. And so to talk about that a little bit, we'd put together a two-center retrospective study that encompassed 20 years, and we had 97 survivors. All right, Ellen, so what did they find in that study? They found that patients with giant omphalocele had a greater time to full feeds, required more TPN, had more chromosomal anomalies, and they had a higher incidence of respiratory insufficiency. Wow. Okay. Well, that is interesting. We typically, at least I was taught in fellowship, think of these as pulmonary hypoplasia as being the main problem, that pulmonary hypertension is a problem in CDH, but pulmonary hypoplasia is the problem when you have an omphalocele. But what we found was that 56 patients of those 97 were identified as having pulmonary hypertension. Now, most of those were diagnosed within the first week of life. But interestingly, we had five patients out of those 56 that had no signs of pulmonary hypertension in their first echo within the first seven days of life. And then they subsequently went on to have pulmonary hypertension later. And this was severe pulmonary hypertension where two of the patients ended up dying, and one was on a pulmonary vasodilator for more than a year. And all of these were associated with an episode of sepsis. So what that tells us is that even in the patient who doesn't have signs of respiratory compromise early, sepsis later put these patients at high risk. So Ellen, when you have this giant omphalocele he's talking about, what options do we have for treatment? So the options are we paint the sack, we remove the sack and place a silo and either passively or actively reduce, we keep the sack and actively reduce, or we just definitively close right now. Okay, let me say this again. So we either paint it, meaning we just paint it and leave it is what I can guess what I mean there. You either paint it, remove the sack and the silo for a passive reduction, I guess you just let it fall in on its own, remove the sack and then active reduction, meaning that we're going to actively push it. Yeah, we're going to push it in. Or you just keep the sack and then you try and reduce it, you try to push it in. And then he added another one, which was closed right now. There's multiple mechanisms that have been described for keep the sack and active reduction, because the time to definitive closure does not have to be more than a year. And with that risk of sepsis, there's the theoretical advantage of the quicker you can get to closure, then the better off you are. And it's a very easy and very smooth technique. As you see, you have to do a hydrocolloid dressing to do a silo without removing the sack. That was Dr. Miguel Guilfant. He's the chief of neonatal surgery at Gonzalez Cortez Children's Hospital in Santiago, Chile. So Ellen, Dr. Guilfant is out in Chile. His team does something different. What do they do for their giant emphalocele? So they use a hydrocolloid dressing to make a silo. And then once that's on, they start reducing from there. And in this 40 patient, we get to close 97% of them within 30 days, and 92% within 15 days. So actually, we have done very well. All these patients keep in ICU ventilated and completely paralyzed. So do we have to paint the sack before we place this dressing? You don't paint it at all. Actually, you have to put it hopefully within the first 24 hours, so the sack doesn't get, you know, very stiff. And the hydrocolloid, it gets the sack very smooth, very hydrate. And what about if we have a ruptured emphalocele? What should we do then? We have three patients that were born with a ruptured emphalocele that we suture the emphalocele and then put this dressing. Todd was convinced. Mark, you want to try it with me on Monday? We'll FaceTime Miguel. So the next part to think about is definitive closure. But Dr. St. Peter had another concern, right? What was that? Yeah. So his concern was that these patients with emphalocele can have non-rotation. And so the question is, should we do a LAD procedure at the time of definitive closure if we are in the abdomen already? Cool. All right. What'd they say? And what we found was that there was an increased risk of adhesive bowel obstruction, of course, with gastroschisis, but the risk of midgut volvulus was higher in patients with emphalocele. And that supported the claim that if you're exposing the intestines, then it's worthwhile doing a LAD procedure at the time because you know these patients have non-rotation or mal-rotation. And non-rotation does not exclude you from having the possibility of having anatomy that's not favorable with the narrow base of mesentery and the two ends being fairly close together. It's not universal, but that's what we found is that it does happen. Well, so what's the whole punchline here? They found that patients with emphalocele are at greater risk of midgut volvulus than patients with gastroschisis. And so doing a LAD procedure is something to consider. Okay. So I'd say we learned three key points there. First, we learned that patients with giant emphalocele have more respiratory compromise and they can even develop pulmonary hypertension, especially after they have an episode with sepsis. Second, we talked about a novel technique for closing emphalocele with hydrocollide dressing like duoderm as the silo. And last, we learned that patients with emphalocele are at greater risk for having non-rotation. So if you're already in the abdomen for definitive closure, consider doing a LAD procedure. So next we heard about an interesting case from Dr. Salim Islam, who's the chief of pediatric surgery at the University of Florida College of Medicine. It was an infant born with a very large abdominal wall defect. A lot of abdominal contents were eviscerated, including the stomach, the intestine, and the liver. There was no sac covering everything. So they placed a silo. Ellen, I'm looking at this and I have to ask, what is this? If you're using the Stay Current app, take a look at the photo at the bottom of the page. Well, the problem we had, so it's basically in terms of the next management. Yeah, we got the silo on. We have that all done. So we call this a ruptured emphalocele. And the rationale for calling this a ruptured emphalocele was that the defect was very large and the entire liver was out. In a gastroschisis, you don't expect the liver to be out. And when you have almost no abdominal domain, it becomes really challenging to try to do anything in place. So here are the choices. You either leave the silo in place and start squeezing down on that. You can create a separate silastic silo that you sew to either the fascia or the skin. You can create a silo with PTFE mesh or with biologic mesh, which is the next choice. And sew both those to the fascial edges. Or you can do and take a long vacation that you always wanted to. And so you're faced this situation where there simply is nothing to sew. There's no amni on at all. What do you do in that situation? And so here we heard from a few different people. First from Dr. Gilfand. In this huge, whatever gastrochisis or phallocyl that I don't have a place to put the hydrocolloid, we have used the same technique for the last 15 years, because I know it's going to be a long, long run to reduce all things. And the only thing that has been okay with us is put a proline mesh, because it stays forever until we can close the case. And we protect that within a plastic bag within the bowel. Then we heard from Todd. I'm just going to call it abdominal wall defect. I don't need to know that. But when I have a giant abdominal wall defect, and I put a Bentec silo, a spring loaded silo, and I push down, the forces go out. And I find that it actually makes your defect much bigger over time. And I used to tease people that would do the old fashioned sewing. But I actually think, in these cases, it may pretend a better outcome. So Dr. Islam and his team used biologic mesh as a scaffold. So Todd, you mentioned that it sticks to the bowel. Yeah, it does. And it does create a scaffold. And that's what you want it to do, to allow the skin to epithelialize, which it did. We then did a circumcision, use that skin to kind of also create a graft and put that on. Wait a second, did he just say to use the foreskin as a graft? Yeah, you heard that right. Okay, that just making sure, carry on. And then the plastic surgeons came and put tissue expanders in, we got flaps, and we managed to finally get coverage. And then we created some domain by before the mesh got incorporated, is we just serially resected it, and then just reduced it and get the upper parts of the mesh and stretch the fascia a bit. So now the question becomes, he's four years old, he managed to get all that skin coverage, he survived. And now what do you do? Now you've got just a gigantic ventral hernia, it looks like he's, he's about, the guts are about to fall out of his belly every time he walks. Wow. Okay, so what do we do with that? So there are a couple of different options we can consider for closing such a big abdominal well defect. The first is using tissue expanders either in the abdomen or in the subcutaneous space to help increase the abdominal domain. A second option is using component separation. This is separating the tissue at the external oblique and just beyond, about a centimeter beyond the rectus sheet. And then that creates a lot of space. And you do this on both sides. And then of course you have to dissect between the external oblique and the internal oblique. And then that creates a lot of room. You can also make an incision on top of the rectus sheet, the anterior rectus sheet to give you another centimeter or so. And remember this is on both sides. So you can create a lot of room to, to get space. And in a, in a report from Texas, they reported the use of this in nine kids and they use it in every age from seven days to about 10 years of age. A majority of them were on falloceles and giant defects. And they were able to close almost every single one of them. They did use some mesh in some cases to help them bridge defects, but they were again, able to get fascial closure in a vast majority of them, which was pretty good. Again, separation of components technique, which our adult colleagues use all the time is something to always remember. And, and they again felt that they could use it even in babies, uh, where they could get good, good results. Okay. So to summarize, uh, we learned about an infant with a very large abdominal wall defect. We weren't really sure if it was in fallocel or gastroschisis initially. Uh, and in infancy, we can use something like either biologic or proline mesh to scaffold and help us close the defect. Then a few years later, when they're older, they'll have a very large ventral hernia. And to close this, we can use again, different techniques like tissue expanders and abdominal component separation. All right. So at the end of this discussion, they went over some key points. The first one being from Dr. Islam about complex gastroschisis. Complex gastroschisis is really a different disease almost to the simple variety of this condition. Um, everything is worse. Their, their, the hospital length of stay, the requirement for further operations, their, um, sepsis rates, everything is just worse. Another important point about gastroschisis is how to manage it. First sutured versus sutureless closure. For those who don't practice it, what the sutureless closure means is you put the silo on, or you just tuck the bowel in, and then you put an occlusive dressing on there. Usually you change it at five days. And then the next change it's the, it's mostly closed at that point. Um, you can go to simple dressings. Um, but what we found was that there was no difference in time into full feeds, TPN use, or duration of hospital stay, but there were fewer anesthetics and the patients who were being managed with, with the sutureless closure got antibiotics less frequently, and they ended up with less infections also. So they had, they had fewer infections and septic events, despite having less antibiotics. And that's probably provider specific, but just the same, what we took away from it is that we probably shouldn't be so aggressive with antibiotics after, uh, babies are born with gastroschisis, regardless of how we manage them. And if we're going to do sutureless closure, um, try to avoid an intubation and an anesthetic, and then that's becomes the advantage that they have. And then what about silo placement versus immediate closure? We had done a randomized trial. We ended up randomizing over 50 patients and found that there was, um, no difference between immediate closure and silo. And the conclusion of that was that this paves the way for sutureless closure, because if we went from silo to sutureless, and we never answered the question, does just tucking it all in and closing the defect initially do better, then we wouldn't go down the sutureless path. But once we saw that there was no difference between silo and immediate closure, then we could study sutured versus sutureless closure. Okay. So that's gastroschisis. First, we reviewed that complex gastroschisis is overall a different beast. Second, we reviewed the management of gastroschisis. We reviewed that when we studied sutured versus sutureless closure. We learned that giving patients fewer antibiotics is overall a good thing. And we learned that with sutureless closure, we need less anesthesia. And last, we reviewed using a silo versus just closing immediately and found that the outcomes are overall similar. Thanks for listening to this Rewind podcast on unphalosyal and gastroschisis. Don't forget to mark your calendars for the update course coming up on August 27th. It's going to be virtual and very interactive. In the meantime, keep listening to our podcast or look for update courses posted on our website. Or wait for the real deal. Our update course for 2021 is August 27th. Mark the calendar. Have a great rest of your week. And remember, knowledge should be free.

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