Staged Closure of Gastroschisis with Spring-loaded Silo

Thank you for joining us at University Children's Hospital UCI Medical Center for this educational video. Gastroschisis is a full thickness abdominal wall defect that typically occurs to the right of the umbilicus. Although the anomaly has a reported incidence of 1 in 6000 to 1 in 10,000, it is much more common in many parts of the US, including here in Southern California. In our pediatric surgery practice at 2 neonatal intensive care units, we take care of 30 to 40 patients a year with gastroschisis. This makes it second only to ingrown hernias as a congenital anomaly requiring surgical correction. Pediatric surgeons have traditionally treated gastroschisis by attempting immediate closure. Stage closure was performed only if primary closure was impossible or poorly tolerated by the infant. This involves suturing an elastic silo to the fascial edges and progressive reduction with risks of silo disruption, fascial dehesis, and infectious complications. The advent of the spring loaded silo manufactured by Bentek Medical significantly simplified stage closure of gastroschisis. It allows for a fast, pain-free, sutureless silo placement without need for a formal operation. The silo is made of silastic material attached to a firm but compressible metal reinforced ring. Once the silo is inserted into the defect, it immediately regains its spherical configuration, staying in position for the duration of its use. The transparent silelastic sheeting allows visualization of the bowel contents throughout the course of the stage reduction. Doctor James Fisher and his colleagues from Loma Linda University were the first to publish a series of patients to undergo routine silo placement at the bedside. Their results emphasized the simplicity and ease of the procedure and prompted many pediatric surgeons to convert to routine stage closure of gastroschisis with the Bentek spring loaded silo. Although a prospective randomized study comparing primary to stage closure of gastroschisis is in progress, we do not yet have the results. However, several retrospective studies from large centers in the US have all reported favorable results with the spring loaded silo staged closure compared to controls who underwent primary closure. In these studies, patients who underwent routine silolacement with delayed closure manifested one or more of the following advantages decreased airway pressures, earlier extubation. Decreased incidence of necrotizing enterocolitis, decreased infectious complications, more rapid return of bowel function, decreased length of stay, decreased hospital charges. For the last 5 years on the UCI pediatric surgery service, we have routinely placed spring loaded silos for patients with gastroschisis with excellent results. Our extensive experience has also taught us important lessons in optimizing the outcomes of this technique, as well as its potential complications. In this video, we will accomplish the following objectives. Describe the technique of spring loaded silo placement and subsequent reduction of the eviscerated abdominal contents. Describe the technique of delayed faccial closure. Review critical points to be observed in placement and maintenance of the silo. Describe other surgical situations where use of the spring loaded silo presents a therapeutic option. At our centers, most women carrying a fetus with gastroschisis are seen by the pediatric surgeon prior to delivery. We then work very closely with our perinatologists in following these fetuses prior to delivery. Most babies are delivered vaginally after spontaneous onset of labor. We do not perform routine cesarean section, nor do we induce early labor. After delivery, the baby is resuscitated, and the eviscerated gastroschisis contents are wrapped in sterile, moist gauze or a bowel bag. The baby is then transported to the NICU. And sedated with fentanyl and midazolam drips, the baby is intubated, and a single dose of vicurronium is given for the procedure. While placement of the silo is certainly feasible without sedation, intubation, or paralysis, we believe these interventions create optimal conditions and a well-controlled situation. The first step in successful deployment of the spring loaded silo is choosing an appropriate size. The Bentex silo is defined by the diameter of the reinforced ring. It is available in 7 sizes from 3 centimeters to 15 centimeters. The diameter of the ring also determines the volume of this elastic cylinder that will house the intestines. We typically choose a ring that is 2 centimeters larger than the diameter of the defect. Since most defects are 2 to 3 centimeters in diameter, 4 and 5 centimeter silos are the most common ones used. However, a larger silo may be chosen if the bowel is more distended or edematous or there is significant peel. Gastroschisis that involve an atresia typically contain severely distended bowel and often require a 7.5 centimeter silo. The following examples illustrate the choice of silo. The defect in both of these cases was approximately 2 centimeters. We chose a 6 centimeter silo for the case on the right since there was a severe evisceration with significant distention, edema, and peel. The case on the left, however, was quite mild and was nicely housed in a 4 centimeter silo. Now we will display placement of the silo. The baby is now in the NICU sedated and intubated. The bowel bag is cut and removed, revealing the gastroschisis. Opening a present It is typical to find a distal colon severely distended with meconium. This is a good indication of the probable absence of a proximal atresia or stenosis. However, evacuation of the colon is important as it will significantly decrease the size of the colon and allow for faster reduction. Likewise, a distended stomach or bladder should be decompressed prior to siloplacement. Gloves are changed and the abdominal wall around the defect is prepped with betadine solution. The chance And draped in a sterile field. The assistant holds the bowel perpendicular to the baby, assuring no mesenteric torsion or kinking. The eviscerated contents are then carefully examined for atresia, stenosis, ischemic or necrotic segments, and perforation. Although atresia and stenosis may not be apparent on first examination, at least a preliminary impression may be gained. If an obstruction exists without perforation, our policy is to proceed with silo placement and closure, followed by exploration 4 to 6 weeks later. In this case, the right fallopian tube and part of the uterus were reduced prior to silo placement. We frequently encounter a testicle which we typically place at the deep ring in a boy. The mesentery is placed in its correct orientation without torsion. The silo is then filled with saline to open it fully and overcome the adherence of its surfaces to each other. This saline is then used to wash the bowel. The bowel is then gradually placed into the silo distal to proximal. The mesentery acts as the axis, and care is taken not to create any torsion or damage to the mesentery or any of the bowel loops. The under surface of the fascia is checked circumferentially to confirm the absence of any adhesions or bands. If any are found, they are ligated and divided. Can you show me doing this maneuver, right? watch it. Color all the time. So it's very difficult to work with. You know, like of color The spring reinforced ring is then squeezed into an oval and slipped under the fascial edge. Upward retraction of the facial edge aids this maneuver. Once one part of the ring is under the fascia, the retractor and ring then rotate until the entire ring is placed under the fascia. have. The ring is then palpated to confirm the absence of any bowel loops between the ring and the fascia. The impression of the ring can be seen. The silo is then suspended from the patient's bed. It is important to maintain the suspension so that the ring is just palpable under the fascia but not elevating the abdominal wall, which would lead to abdominal wall congestion and complicate the final closure. On the other hand, if the ring is too lax and allowed to sink in the abdomen, it may cause necrosis of the underlying duodenum or small bowel, especially if the silo is left in position for a prolonged period. The silo is now tied at the apex of the bowel mass, essentially performing the first reduction. As the umbilical tape is tied, the bowel is pushed inferiorly into the abdomen. OK. As you tighten it pushes the. The baby has remained stable in her bed throughout the procedure, which lasted 18 minutes. During the duration of the silo, it is important to frequently evaluate bowel appearance as well as tension on the ring and any kinking or twisting. The baby is maintained on sedation and mechanical ventilation but not paralyzed. Over the ensuing days, resolution of bowel edema, accommodation by the abdominal cavity, and gravity result in gradual spontaneous reduction. This process is aided by once or twice daily active reduction. Umbilical tape is used to slowly ligate the silo with simultaneous reduction of its contents. Care must be taken not to trap a loop of intestine during the reduction process. This picture shows a gastroschisis which achieved near complete silo reduction in 6 days. The ring should always be palpable just under the abdominal wall. Too much traction on the ring will cause abdominal wall congestion and edema, complicating the closure later on. Too little traction will allow the ring to exert constant pressure on the abdominal contents, most notably the duodenum, with a risk of pressure necrosis. We perform final closure when the silo contents is within 2 centimeters of the abdominal wall. While we do not have a predetermined duration for the silo, we'll leave the silo in place for the shortest time possible. Unnecessary prolongation of the silo duration has no advantages, may make closure more involved by slowly enlarging the defect, and may increase infectious and other potential complications. This is a different case that was reduced in 4 days. Notice the complete containment of the bowel and peritoneal fluid by the silo, essentially creating a closed system. We will now demonstrate the technique of final fascial closure. Yeah, I Right The baby is now 6 days old and final fascial closure is being performed in the operating room. OK Notice the near complete reduction that has taken place. The excess silo has been cut, and the remainder is prepped into the field. The silo is removed. Notice the healthy appearance of the bowel. 9, 10, OK, kid. The surgeon's outer gloves are then discarded and the operation continued. The abdominal wall is stretched to aid in a ten-free closure. This often produces some minor postoperative congestion of the abdominal wall. I. Their residual eviscerated bowel is very easily reduced. OK, now let's have some irrigation, please. The abdomen is irrigated with sterile saline. Wet gauze is used to cover and protect the bow. In this case, a thrombosed umbilical vein is removed prior to fascial mobilization. The umbilical stump, however, is preserved. A skin and subcutaneous tissue flap is raised circumferentially in order to mobilize the fascia for closure. This is easiest to start opposite the umbilicus. The cutting mode of the cautery is used and discrete small bleeders are coagulated. The blunt cautery tip acts as a perfect dissecting instrument, releasing the skin from the fascia. William. A 1 centimeter fascial edge is mobilized in both directions to the border of the umbilical stump. It is important to stay in the correct plane in order not to compromise the fascia or skin. A 20 PDS per string suture is started adjacent to the umbilical stump. The tail is tagged with a mosquito. This is continued circumferentially around the fascial edge with alternating bites inside out. And Outside in. The neck suture? You love. Yeah, I don't know. Nobody knows that. I Cafeteria OK. Closing it in a round manner. We don't do that very much in surgery. We almost always close everything either longitudinally or transversely, but. It's a very good cosmetic result. Belly button. Until the opposite border of the umbilical stump is reached. The suture then jumps to the opposite side. The purse string suture is completed, taking the last bite from outside in in order to bury the knot. The purse string suture is tightened by gently and gradually pulling on both ends. While an assistant relieves the tension by compressing the abdominal wall. The suture is then tied. 1 or 2 interrupted PDS sutures are used to approximate any remaining defect. That I can see. A final fascial stitch is placed on the borders of the umbilical stump to eliminate a future umbilical hernia. Oh I see. The wound is irrigated with sterile saline. The skin closure is now started. A 4-0 monocryl on a cutting needle is anchored in the fascia and taken from inside out, approximately 3 millimeters from the skin edge. The edge is often slightly ischemic, and bites exactly in the skin edge are likely to cause skin necrosis and possible wound infection. This is continued over and over as a running stitch. No, she got in the, she got in the. They This will purse string the skin edge, resulting in a neo umbilicus. Once the opposite end of the umbilical stump is reached, the suture is re-anchored in the fashion. The suture is tightened in a manner similar to the fascial suture. And tied. One or two final sutures are placed to optimize the blicating effect and long-term cosmesis. So that picture like that. I I know and objective. Then the small pieces there for him. is there any uh disadvantages like increases Tension-free closure has now been accomplished. The baby has remained stable without any increase in airway pressures. The procedure was completed in under 25 minutes. These pictures show the appearance of the wound immediately after the operation. And at the 1st clinic visit, 6 weeks after closure. These pictures show the appearance of the umbilicus in several different patients treated with this technique, one month. 3 months. And 6 months after closure. We would now like to summarize the essential factors that result in the optimal outcome of this technique. First, appropriate choice of silo size. Second, avoiding mesenteric torsion. Third, final closure when near complete reduction is achieved and not prolonging the duration of the silo. Fourth, close observation of the silo configuration and contents. 5th, purse string closure of the fascia and skin, and finally, preservation of the umbilical stump. The next few slides will show examples of other unique situations where the benic silo provides a reasonable therapeutic alternative. This patient's gastroschisis included a bowel segment with tenuous blood supply. He went on to develop gangrene of that segment while in the silo. After bowel resection and anastomosis, a new silo was placed, and the defect was closed 5 days later. There were no anastomotic complications. The Bente silo can also be used for staged reduction of omphalocele after excision of the sac. The liver can be gradually reduced along with the bowel and delayed final closure accomplished. The Bente silo can also be used as a bridge to coverage of the bowel in giant defects. This baby had an abdominal wall agenesis with herniation of the entire abdominal contents, including a very large congested liver. A 10 centimeter silo was used and about 70% reduction accomplished over two weeks. In this circumstance, where a large silo is required for a prolonged period, a few corner stitches between the silo ring and the abdominal wall prevent premature dislodgement of the silo. At 2 weeks of age, the defect was covered with human acellular dermis, and a wound vacuum assisted closure device was applied. Finally, the silo can also be used in cases of neonatal abdominal compartment syndrome, such as in this baby with severe diffuse necrotizing enterocolitis. In conclusion, the spring loaded silo provides an excellent alternative for the treatment of babies with abdominal wall defects, particularly gastroschisis. At the University of California Irvine, we continue to apply this method to all patients with gastroschisis, and we also selectively use it in other situations where abdominal wall closure is not possible.