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Abdominal Wall Defects

Video Published 2018-11-10 Updated 2026-08-01

Timestops (8)

Prenatal Gastroschisis Management and Delivery

Newborn Gastroschisis: Primary Closure vs Silo

Managing Intestinal Atresia in Gastroschisis

Feeding Intolerance After Gastroschisis Repair

Large Abdominal Wall Defects: Repair Options

Topical Agents for Wound Management

Intra-abdominal Pressure Monitoring Techniques

Complex Ventral Hernia Repair Strategies

Topic Overview

A panel discussion on the management of abdominal wall defects, primarily gastroschisis and omphalocele, covering prenatal delivery planning, immediate postnatal closure strategies, management of associated intestinal atresia, feeding intolerance, and repair of large chronic defects. The faculty debate early versus spontaneous delivery for gastroschisis, primary versus staged closure techniques, the role of silos, and the use of various monitoring parameters to prevent abdominal compartment syndrome. A key clinical point is that gastroschisis with narrow defects and significant bowel outside the abdomen requires staged expansion of the abdominal cavity rather than aggressive early reduction.

Key Takeaways

Deliver gastroschisis at 37 weeks—earlier trades bowel damage for prematurity, later increases intestinal injury risk. (2:45)
Pre-formed silos enable bedside reduction in ~1/3 of cases, avoiding OR trauma from forceps manipulation. (8:27)
Wait for 10% body weight loss before reducing gastroschisis to allow bowel edema resolution and safer closure. (9:14)
Umbilical stoma placement avoids extra scars and simplifies appliance management compared to lateral sites. (17:19)
Monitor CBC if using silver sulfadiazine in first month—can suppress white blood count and requires surveillance. (26:58)

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

Jack — guest
Speaker 2 — host
Speaker 3 — guest
Speaker 4 — guest
Dan — guest
Speaker 6 — guest

Chapters

0:01Prenatal Management and Delivery Planning for Gastroschisis — Discussion of optimal delivery timing, location, and mode for fetal gastroschisis, including debate over early induction at 37 weeks versus spontaneous labor and the role of cesarean section.
5:16Immediate Postnatal Closure Strategies for Gastroschisis — Faculty debate primary surgical closure versus bedside reduction techniques (Bianchi approach), use of pre-formed silos, sedation versus general anesthesia, and methods to minimize bowel trauma during reduction.
13:02Management of Gastroschisis with Intestinal Atresia — Discussion of whether to repair atresia primarily, drop bowel back and wait 6 weeks, or create a stoma, with consideration of bowel quality and location of atresia. Includes technique of bringing stoma out through umbilicus.
17:25Feeding Intolerance After Gastroschisis Repair — Debate over management of persistent feeding intolerance at one month post-repair, including when to wait versus when to re-explore for mechanical obstruction, and the role of prokinetic agents.
21:12Management of Large Omphalocele — Discussion of paint-and-wait versus staged surgical closure for large omphaloceles, including use of mesh, component separation, and various topical agents (silver sulfadiazine, betadine, Xerform).
27:19Monitoring for Abdominal Compartment Syndrome — Faculty discuss methods to assess safe closure tension including ventilator parameters, bladder pressure, intragastric pressure, and CVP, with debate over reliability of each method.
32:02Repair of Chronic Untreated Omphalocele — Case discussion of 3-year-old with epithelialized omphalocele and narrow fascial defect, emphasizing staged approach with fascial enlargement and gradual reduction rather than aggressive primary closure, with potential role for plastic surgery involvement.

Key claims

2:45Most damage to the intestine in gastroschisis occurs in the last few weeks of pregnancy based on animal and clinical studies — Jack
3:14Delivering gastroschisis at 37 weeks results in better neonatal outcomes compared to later delivery — Jack
3:22Delivering gastroschisis too early (34-35 weeks) trades bowel problems for problems of prematurity — Jack
3:44The age at spontaneous onset of labor for gastroschisis pregnancy is 3 weeks earlier than the general population — Jack
3:56About half of gastroschisis pregnancies go into labor spontaneously before 37 weeks — Jack
4:37No perinatal center in Canada performs routine cesarean sections for gastroschisis — Jack
4:49Routine cesarean section for gastroschisis was standard of care 15-20 years ago but has gone out of favor — Jack
8:27Using a pre-formed silo allows gentle reduction of bowel without trauma from forceps manipulation — Jack
8:47Approximately one-third of gastroschisis cases can be reduced at bedside using the Bianchi technique with silo assistance — Jack
9:14Waiting for 10% body weight loss before reducing gastroschisis allows bowel edema to resolve — Speaker 4
9:41Leaving a silo on for more than one day causes the fascial defect to enlarge significantly — Jack
15:58There are two types of intestinal atresia in gastroschisis: early-developing atresia without bowel thickening, and late-occurring atresia from small defect with matted bowel — Jack
17:19Bringing a stoma out through the umbilicus avoids creating an additional abdominal scar — Jack
17:41Umbilical stoma placement provides an easy location for appliance placement compared to lateral positions — Jack
26:58Silver sulfadiazine use in the first month of life can cause white blood count suppression and requires monitoring — Jack
30:02Intragastric pressure of 20 is suggested as the threshold for safe abdominal closure — Jack
36:51In older children with chronic omphalocele, the abdomen does not expand as rapidly as in newborns and requires more time for staged reduction — Jack

Cases discussed

0:0124-year-old mother with fetal gastroschisis diagnosed at 18 weeks
5:1637-week newborn with gastroschisis and minimal bowel damage
13:02Newborn with gastroschisis and obvious intestinal atresia
18:05One-month-old infant with persistent feeding intolerance after gastroschisis repair
21:12Term neonate with large omphalocele and no other anomalies
32:023-year-old from Africa with untreated epithelialized omphalocele

Points of disagreement

1:36Optimal delivery timing for gastroschisis
- Jack: Induce labor at 37 weeks based on evidence that most intestinal damage occurs in final weeks of pregnancy
- Dan: Wait for spontaneous labor without early induction
7:00Sedation level for bedside gastroschisis reduction
- Speaker 2: Intubate with general anesthesia in NICU for bedside reduction attempts
- Dan: Use sedation without intubation or paralysis for bedside reduction
- Jack: Use pre-formed silo with sedation but no intubation, allowing gentle reduction
9:14Timing of silo reduction in gastroschisis
- Speaker 4: Wait for 10% body weight loss (1-2 days) before tightening silo to allow edema resolution
- Jack: Reduce within first day to prevent fascial defect enlargement
13:59Management of gastroschisis with intestinal atresia
- Dan: Bring distal atresia out as ostomy; drop proximal atresia in and wait
- Speaker 3: Primary repair if bowel looks healthy; drop in and wait if edematous
- Jack: Use bowel quality as guide - repair if minimal damage, drop in if nasty/matted
19:37Management of feeding intolerance at one month post-gastroschisis repair
- Dan: Lower threshold for re-exploration after being burned by delayed diagnosis of mechanical stricture
- Speaker 3: Wait longer as 4 weeks may not be enough time for bowel recovery
28:00Preferred method for monitoring safe abdominal closure
- Speaker 3: Ventilatory parameters most reliable as measurable number
- Dan: Ventilatory parameters and perfusion measures (urine output); bladder pressure measured but not fully trusted
- Jack: Intragastric pressure via NG tube transduction provides easy intraoperative monitoring

Open questions

What is the optimal timing for re-exploration in gastroschisis patients with persistent feeding intolerance?
Which monitoring parameter (bladder pressure, intragastric pressure, ventilatory parameters, CVP) most reliably predicts abdominal compartment syndrome?
Does early delivery at 37 weeks for gastroschisis improve outcomes enough to justify routine induction versus waiting for spontaneous labor?
What is the role of tissue expanders and plastic surgery techniques in management of large chronic omphaloceles?
Can Botox injection into abdominal wall muscles facilitate closure of large abdominal wall defects 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:

Staged Reduction of Chronic Omphalocele in a Three-Year-Old: When Newborn Principles Fail

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

Presentation

A three-year-old girl arrived from Africa with an untreated omphalocele that had epithelialized over time 36:51. Most of her liver and bowel remained outside the abdominal cavity, contained within a narrow fascial defect relative to the volume of herniated viscera 36:51. The family had been told at birth that she would not survive; instead, the defect had simply healed over, leaving her with a massive ventral hernia 36:51.

The Decision Point

The surgical team faced a deceptively familiar problem with unfamiliar constraints 36:51. In a newborn with omphalocele, the abdomen expands rapidly during staged reduction — the fascial ring stretches, the peritoneal cavity accommodates, and reduction proceeds over days to weeks 36:51. But this patient was three years old 36:51. Her abdominal wall had spent three years adapting to the absence of its contents 36:51. The question was not whether to reduce the omphalocele, but how quickly that reduction could safely proceed without precipitating abdominal compartment syndrome 36:51.

One discussant had already learned this lesson the hard way: an attempt at relatively rapid reduction in a similar older child had resulted in abdominal compartment syndrome and death 36:51. The memory shaped the approach to this case 36:51.

Management and Reasoning

The team elected to enlarge the fascial defect inferiorly before attempting any reduction, deliberately avoiding the superior margin where hepatic veins posed a risk with so much liver herniated 36:51. The reduction itself would be staged across multiple operations, allowing the abdominal cavity time to expand between procedures 36:51.

The critical insight was recognizing that an older child's abdomen does not behave like a newborn's 36:51. In the newborn, the fascial ring and peritoneal cavity are still developing; gentle sustained pressure produces rapid accommodation 36:51. In a three-year-old, the abdominal wall has matured into a fixed structure 36:51. Forcing viscera back into a cavity that has contracted over years does not stretch the fascia — it compresses the contents 36:51. The result is elevated intra-abdominal pressure, compromised venous return, restricted diaphragmatic excursion, and ultimately organ failure 36:51.

The discussant who had lost a patient to this error emphasized the lesson explicitly: "In an older kid, it's not like a newborn. It doesn't just expand so rapidly and you have to give it time" 36:51.

Outcome

The outcome of this specific case was not discussed 36:51. The focus remained on the strategic approach and the cautionary experience that informed it 36:51.

What the Case Changes

This case illustrates a broader principle in pediatric surgery: techniques that work reliably in neonates may fail catastrophically when applied to older children with congenital anomalies 36:51. The newborn's physiologic plasticity — the reason we can reduce gastroschisis at the bedside or close large omphaloceles primarily — is time-limited 36:51. After months or years, that plasticity is gone 36:51.

When managing chronic omphalocele in an older child, the safe approach is serial staged reduction with adequate time between operations for abdominal wall adaptation 36:51. Enlarging the fascial defect before beginning reduction reduces the risk of strangulation at the ring 36:51. Avoiding the superior margin protects hepatic venous drainage when the liver is herniated 36:51. And most importantly, accepting that the process will take longer than it would in a newborn may prevent the single worst outcome: abdominal compartment syndrome in a child who survived years with an untreated defect 36:51.

The death that taught this lesson was not a technical failure 36:51. It was a failure to recognize that the patient's age fundamentally changed the problem 36:51.

Takeaways from this story

Older children with chronic omphalocele require slower staged reduction than newborns; their abdominal walls lack neonatal plasticity.
Enlarging the fascial defect inferiorly before reduction avoids hepatic vein injury when the liver is herniated superiorly.
Abdominal compartment syndrome from overly aggressive reduction has caused death in older children with chronic omphalocele.

Delivery Timing in Gastroschisis: Induction at 37 Weeks vs. Expectant Management

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Clinical Question

Should gastroschisis pregnancies be routinely induced at 37 weeks, or should clinicians wait for spontaneous labor 2:45 3:14? The question turns on when intestinal damage occurs and whether early delivery improves neonatal outcomes without introducing complications of prematurity 3:14 3:22.

The Case for Induction at 37 Weeks

One discussant presents evidence that most damage to the intestine in gastroschisis occurs in the last few weeks of pregnancy, based on animal and clinical studies 2:45. Following this reasoning, delivering at 37 weeks results in better neonatal outcomes compared to later delivery 3:14. The approach acknowledges a boundary: delivering too early — at 34 to 35 weeks — trades bowel problems for problems of prematurity 3:22.

The timing is not arbitrary 3:44 3:56. The age at spontaneous onset of labor for gastroschisis pregnancy is three weeks earlier than the general population 3:44, and about half of these pregnancies go into labor spontaneously before 37 weeks 3:56. Induction at 37 weeks therefore captures a window where the fetus is mature enough to avoid prematurity complications but early enough to limit progressive intestinal injury 2:45 3:14 3:22. The discussant notes that concerns about failed induction leading to high cesarean rates have not materialized in practice, given the tendency toward earlier spontaneous labor in this population 3:44 3:56.

The Case for Expectant Management

Another discussant follows a different protocol: routine ultrasound surveillance without planned early delivery 5:10. The approach relies on imaging to detect changes in bowel condition rather than assuming progressive damage occurs on a predictable timeline 5:10. This position does not dispute that intestinal injury can worsen late in pregnancy 2:45, but questions whether routine induction improves outcomes enough to justify intervention in all cases.

The expectant approach accepts that many of these pregnancies will deliver spontaneously before term anyway 3:44 3:56, and reserves intervention for cases where imaging suggests deterioration or other obstetric indications arise 5:10. It avoids committing every gastroschisis pregnancy to induction, which — even at 37 weeks — represents an intervention with its own risks and resource requirements.

Where They Agree

Both approaches reject routine cesarean section for gastroschisis 4:37 4:49. No perinatal center in Canada performs routine cesarean sections for this indication 4:37, and routine cesarean section was standard of care 15 to 20 years ago but has gone out of favor 4:49. When delivery does occur, vaginal delivery is the preferred route unless obstetric factors dictate otherwise 4:37 4:49.

Both also agree that delivering too early creates problems 3:22. The 34- to 35-week range is recognized as too premature, introducing respiratory, feeding, and thermoregulation complications that may outweigh any bowel benefit 3:22. The disagreement is not about whether timing matters, but about where the optimal window lies and whether active management improves on natural history 2:45 3:14 5:10.

What Would Resolve It

The discussant advocating for 37-week induction cites published data suggesting better neonatal outcomes with this approach 3:14. The expectant management advocate does not dispute the data directly but maintains a different practice pattern 5:10, suggesting either the evidence has not been compelling enough to change established protocols or that local experience and resources favor surveillance over routine induction.

A definitive answer would require a randomized trial comparing planned delivery at 37 weeks to expectant management with close surveillance, measuring not only immediate neonatal outcomes but also long-term bowel function, time to full feeds, length of stay, and maternal outcomes including cesarean rates and complications 3:14 5:10. The natural experiment created by different institutional practices may provide observational data, but selection bias and confounding by indication limit what can be concluded 3:14 5:10. Until such evidence exists, both approaches remain defensible based on different interpretations of the available literature and different weightings of intervention risk versus disease progression risk 2:45 3:14 5:10.

Takeaways from this story

Gastroschisis labor occurs 3 weeks earlier than general population; half deliver spontaneously before 37 weeks
37-week induction aims to prevent late intestinal damage without introducing prematurity complications seen at 34-35 weeks
Routine cesarean section for gastroschisis has been abandoned across Canadian perinatal centers

Timing, Technique, and Judgment in Abdominal Wall Defect 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

Delivery timing balances bowel damage against prematurity

The case for early delivery in gastroschisis rests on when intestinal injury occurs. Most damage to the bowel happens in the final weeks of pregnancy, supported by both animal models and clinical observation 2:45. Delivering at 37 weeks produces better neonatal outcomes than waiting longer 3:14, but pushing earlier—to 34 or 35 weeks—trades bowel problems for the complications of prematurity 3:22. The biology of gastroschisis pregnancy itself argues for the 37-week threshold: spontaneous labor begins three weeks earlier than in the general population 3:44, and about half of these pregnancies enter labor before 37 weeks without intervention 3:56. The old standard of routine cesarean section has been abandoned; no perinatal center in Canada performs it routinely for gastroschisis 4:37, a practice that was universal 15 to 20 years ago 4:49.

Silo-assisted bedside reduction protects the bowel

The pre-formed silo changes what bedside closure can accomplish 8:27. Rather than forcing edematous bowel back through a tight defect with forceps—risking direct trauma—placing a silo first allows the bowel to be guided in gently 8:27. In approximately one-third of cases, this technique permits complete reduction at the bedside without intubation, using only sedation 8:47. The alternative approach—leaving the silo in place and waiting for body weight loss—allows bowel edema to resolve before reduction 9:14, but carries a cost: each day the silo remains, the fascial defect enlarges significantly 9:41. That enlargement matters if you intend to avoid a formal operative closure, since a larger defect takes substantially longer to contract and epithelialize spontaneously 9:41.

Intestinal atresia in gastroschisis comes in two forms

Not all atresias associated with gastroschisis are the same pathologic process 15:58. Early-developing atresia occurs without significant bowel thickening or matting—a developmental anomaly rather than an acquired injury 15:58. Late-occurring atresia results from a small abdominal wall defect causing vascular compromise, and presents with matted, thickened bowel 15:58. The distinction matters for surgical planning: the early type may tolerate primary repair if the bowel quality is good, while the late type often requires staged management 15:58. When an ostomy is necessary, bringing it out through the umbilicus avoids creating an additional abdominal scar 17:19 and provides a favorable location for appliance placement compared to lateral positions 17:41.

Pressure monitoring guides closure but clinical judgment prevails

Intragastric pressure measurement offers an objective threshold for safe closure 30:02. The technique is straightforward—fill the nasogastric tube with saline and connect it to a pressure transducer—and the literature suggests 20 mmHg as the upper limit 30:02. But the number is not absolute 30:02. If the pressure reads slightly above threshold and the infant's ventilation parameters remain acceptable and perfusion is maintained, the closure may still be safe 30:02. The converse also holds: a pressure below threshold in an infant who looks poorly perfused or requires escalating ventilator support is not safe 30:02. The measurement informs the decision; it does not make it 30:02.

Chronic omphalocele in older children requires patience

The abdomen of an older child does not behave like a newborn's 36:51. In chronic omphalocele with a narrow neck, aggressive reduction can cause abdominal compartment syndrome—a lesson learned through fatal outcome 36:51. The safer approach enlarges the fascial defect without forcing reduction, then allows spontaneous settling over multiple stages 36:51. Each stage closes skin over progressively more viscera until fascial closure becomes possible without component separation or mesh 36:51. The timeline extends over months, not days, because the older abdomen expands slowly 36:51. Attempting to compress that timeline by force courts disaster 36:51.

The most emphasized point: match technique to tissue quality

The discussants returned repeatedly to one principle: what you do depends on what you find. Minimal bowel damage permits bedside closure with silo assistance 8:27 8:47. Matted bowel with late atresia requires staged reduction and often ostomy 15:58. Chronic omphalocele in an older child demands patience and serial procedures rather than single-stage heroics 36:51. The error is not in choosing one technique over another—it is in applying a technique without regard for the tissue in front of you.

Takeaways from this story

Deliver gastroschisis at 37 weeks—most bowel damage occurs in the final weeks, and half enter labor spontaneously before that.
Use a pre-formed silo to guide bowel reduction gently; about one-third can be reduced at bedside without intubation.
Distinguish early atresia (no bowel damage) from late atresia (matted bowel from small defect)—they require different approaches.
Intragastric pressure of 20 mmHg guides closure, but clinical assessment of ventilation and perfusion overrides the number.
In older children with chronic omphalocele, enlarge the defect and allow staged reduction over months—the abdomen expands slowly.

Keywords

gastroschisis omphalocele intestinal atresia abdominal compartment syndrome pulmonary hypoplasia feeding intolerance ventral hernia umbilical hernia primary surgical closure Bianchi technique silo placement plastic closure component separation Schuster repair tissue expansion

Hashtags

#Gastroschisis #FetalSurgery #NeonatalCare #PediatricSurgery

Transcript

OK, so the first case is a, is a prenatal case. This is a 24 year old mom and do I, I can advance them now from here? Yes, the little arrows there. OK, that's a great picture. Yeah, that's, that's Photoshopped. Viral video. Yeah, right, right. So this is, um, so this is um a young mom with a Fetal gastroschisis, uh, that's diagnosed at 18 weeks. So the question is, what's the most appropriate delivery plan? You wait for the onset of spontaneous labor and then vaginal delivery at your local community hospital. So what these questions are getting at are the issues of where you're gonna deliver, whether you're gonna deliver early or not, and whether you're gonna do a cesarean section or not. So, it's basically all the combinations of those. So you wait for spontaneous labor and then vaginal delivery at a perinatal center. Do you induce labor early, either at the local community hospital or at the perinatal center, or do you do a planned cesarean section? Let's check. So let's take it through, is it? Let's take it through the, uh, faculty here. Uh, um. Sorry, Jim, hold on one second. Um, let's, let's go through this. So we put Jonah, can you put the pole up here? So who here, what, what would be your thoughts, Dan, on this patient? I know you and I were just talking, I'm sorry I may have missed some of the details. So basically, it's basically, are you going to deliver early? Are you going to induce labor early? Are you going to deliver at a, at a perinatal center or at the local hospital or are you going to, the last one is a planned cesarean section. So our, our bias would be to deliver, uh, since we don't have a delivery service in our hospital to deliver close to our hospital and we would not advocate early delivery. So you just let them go into spontaneous labor and make sure they deliver at your perinatal. Yeah, I believe that that's what we do. I mean, I'm not part of our fetal, uh, group, so I don't see these or have to make these, uh, recommendations anymore, uh, too often, but, um, you know, I, I, I, I thought we, um, folks had advocated, uh, spontaneous vaginal delivery whenever it's reasonable and as close to the, uh, center, the surgical center as possible. We have an on-site delivery unit, so we can have the patient deliver there. Is there anybody that doesn't do that? Anybody that does early delivery or cesarean section? We just follow up with a routine ultrasound to make sure there's no change in the bowel. All right. Well, we have, I mean, we just published a paper, uh, that, because our approach is to deliver at 37 weeks, because there's, there's evidence from animal studies and also from, uh, clinical studies that most of the damage to the intestine occurs in the last few weeks of the pregnancy. So, we bring them in at 37 weeks. If they haven't already gone into spontaneous labor, uh, by 37 weeks, then we induce labor. So, we do deliver them by, by vaginal delivery. We don't do routine cesarean section. Have you noticed a change? Well, we, the data that we just published would suggest that the that the neonatal outcomes are better if you deliver them a little bit early. But you have to be careful not to deliver them too early, because some people have delivered them at 34 weeks, 35 weeks, and then you start treating the bowel problems. For the problems of prematurity, can you do that for whether they're prime or multis, yeah, and what we've, you know, a maternally might be a little different. Well, a lot of times, a lot of people have said, you know, you're trying to induce labor at 37 weeks, there's no way you're going to be doing a lot of sections. But in fact, the, the age at spontaneous onset of labor for gastroschisis pregnancy is 3 weeks earlier than the general population, and we also published a paper that showed that, so. In fact, about half of them end up going into labor spontaneously before that 37 week mark. Let me make one comment to the audience. Um, as you all probably noticed, we're an hour behind schedule here and um, I am OK with that. Um, I I planned this out thinking we could do everything in 45 minutes and that was, I, I'm, I'm making that as an under judgment. I think that having this faculty here and these discussions are so valuable that I'd rather us be a little bit over and, and get through everything, um, and so I am not going to hurry anything. I'm going to keep things going. I apologize that we're going to be over schedule, um, but I, I, I, that's next time we'll make it an hour for each segment. So keep going, Jack. Um, it was interesting. We did a, um, we did a poll of all of the perinatal centers in Canada because we have, we're lucky in Canada we have kind of population-based, uh, groups, and there was no center that was doing routine cesarean sections. Um, so I think that the, um, that, that choice has gone out of favor, um, because, you know, 15 or 20 years ago, that was pretty much the standard of care. Do other centers deliver them specifically at 37 weeks, we have a few that do and most of them just let them go into spontaneous. So I'll just move ahead because this is. Uh This, it'd be more interesting to talk about postnatal stuff. So, this is a 37 week newborn with gastroschisis with minimal bowel damage. And the question is, uh, how do you manage this, uh, early on? Uh, the, the choices are primary surgical closure, so you take him to the operating room and try and push it all back in under general anesthesia. Do you close it at the bedside without a general anesthetic using the, the Bianchi approach? You place a, uh, pre-formed silo, a Bente silo or one of those, uh, pre-formed silos and gradually reduce it until you get it in and then take them to the operating room and close it under general anesthetic, or do you put a silo on at the bedside and then gradually reduce it until it's all in and then just take the silo off and stick a dressing on it. Can I clarify the question? Um, so I'll just start with me then. Uh, um, I think it depends on, uh, I don't use, I guess if you're asking, do we put a routine silo on even if it's not necessary? Is that what you're asking? In other words, if I can easily reduce the bowel in and there's no increased peak pressures and Uh, I don't feel that there's a lot of tension in the abdomen. I'll put it in primarily. If I feel that there's any question that it would be of any compromise to the child to put all the bowel back in, I will do D. Uh, I, I, I do, and it's not the Bianchi because that's a sutured repair. I do the sutureless repair where I will, if the baby can tolerate it, I'll intubate in the NICU, put the bowel back in. Um, and use the umbilical cord as a covering and, and tape on top. If, uh, if I cannot get it safely in, I don't even try hard. I just put a silo on and then do the. So you're, so you're essentially attempting a Bianchi in every baby at the bedside. Are you doing it with forceps or your fingers or try to use my, I have the, I get a little minor tray there with forceps and retractors. The retractors are the more important instrument, not, not so much, and the retractors sometimes I'll squish out some of the meconium if that helps. And I use my fingers and a little bit of the uh. Factor of the forceps, but I try not to, and you're doing this under general like a heavy sedation in the NICU intubated with intubated, OK, because the Bianchi approach is, is not intubated. That's what I'm saying it's not the Bianchi so you're clarifying that basically I think what you're doing is a you're, you're you take away the in the OR but you're, you're doing attempting a primary reduction under general anesthesia, correct. And then, and of course the backup plan if it's too tight is always to always to put a silent. Yeah, I would say my approach is similar, except that without the intubation and I mean I always try to reduce it, as Aaron will tell you, I always try to reduce them in the NICU and if I can get it all the way in, then I'll just close them. If not, then I put a silo on. But then subsequent to that, I take them, but we take them to the operating room and close. So, I'm willing to, so that's, I want to learn, so you do it without sedation. Yeah, it's, I'll try it. It's, I wouldn't say without sedation. We do it without intubating. OK. So, it's not without paralysis. OK. And that's what, that's what I do. I, I, I actually tried this technique of pushing it in at the bedside with, with my fingers and with forceps and retractors, and I had a couple where I think I really hurt the bowel. So what I actually do now is I always put a, a pre-formed silo on and then I try and push it all back in. And a lot of times you can just swish it back in. You're not harming the bowel. It just slithers back in and you take the silo right off, stick the umbilical cord on top of it, and, uh, put a dressing on. I think that's genius. Yeah, so it's I love that technique for just getting the bowel back in. So it's essentially a Bianchi technique with no, no intubation, some, you know, narcotics for sedation, and I, and I think in my practice it's probably a third of them that, that you can do that. I've never thought of that, and that's what I'm gonna switch to, yeah, I like that. Um how about the same technique, but wait, uh, because what I do is I put the silo on routinely and then I wait till they lose their 1st 10% of body weight. They, they, all this edema that's in the bowel, they pee it off, and then, uh, I'll, I'll reduce it. Uh, in fact, I usually don't even tighten the silo for the first couple of days, If you don't do it, you just suspend it, you, it's amazing how in within one or two days, half of the bowel goes in doing nothing. It's just much less edematous, and then it's comparatively very easy. I've taken him to the OR afterwards to formally close it, but now I'm going to try to reduce it like a toothpaste to. I find the problem with, uh, leaving the silo on for more than a day is that the defect gets much bigger. Um. So, if you, if you don't want to go to the operating room to surgically close it, once you take the silo off, you've got a much bigger defect there. It takes a lot longer for it to, to all contract down and heal. Well, I'm a dinosaur. I do a. That's all I've ever done. Um, I've trained with Rafensberger. We, that group, we closed 80% of them primarily. My number's now down probably to a third to half that I closed, and the rest have put aside on. So, so you do a sutured repair of the fasci. I just take him to surgery and close it or put a silo on. I want to make sure we clarify that and that's why I was saying that's what A is, I think, right, in the OR. A is a take them up to surgery and close at subway either primarily or with a silo. Well, I mean it's hard. You, you'd need probably 15 choices to have all the different combination. I didn't know what you were you're getting at whether people do a suture repair or a Tape and weight, uh, repair that I think that's a question that I think we're also getting out of this besides, do you do general anesthesia or not? And do you use a silo or not. So there's different questions, right? And so that's what I'm getting at between C and D is one is you do a surgical closure once you have everything in, and the other one is you just stick a dressing on it and let it close by itself, what we call a plastic closure because you're sticking a piece of plastic. OK, right, exactly. So did, did, uh, do you want to see what everybody, yeah, do we have those polls? Oh yeah, here, sorry. So the majority were a. And my guess is the majority were probably sutured repair, um, is my guess. Um, the next one was C, placement of a pre-formed silo with gradual reduction. So it sounds like the majority of the audience does a surgical stitch repair, whether it's delayed or immediate, is, is a difference, right? And I guess that's one of the things I wanted to highlight with this question is, is that using this so-called plastic closure, the non-surgical closure. Uh, you get extremely good results. You, you often end up with a little umbilical hernia, but the vast majority of those will close by age 2. And, um, the advantage of it is that you don't have to go to the operating room. Right. And, uh, and in fact, if, if you're successful getting it all in without intubating, uh, you, you can get them closed without even a general anesthetic. Can I ask you a question? In your patients that you do with just sedation, if you can't get them in, will you then intubate and do a paralysis? Or will you just put a silo. We just put a silo, OK. And, and just to clarify, if I can get it all in, I put a stitch in the fascia to close it. So, yeah, a stitch or two or whatever it takes to close the, the defect. So it's the skin basically it's the operative repair in the NICU in the NICU. you're, you're on 15 17 now just so I. While they're awake. Yeah, are you causing the fascia or the skin, Doctor Fascia fascia. You're mean. Nikki, NICU here won't even let us put on silos without intubating and sedating them, so they wouldn't. Is that true? Yeah, they're very, um, against the silo and, uh, pushing it down. At least that's what I've seen in the short time we've been here. I think, I think you have to sedate them. You have to give them something, but. Yeah. But we usually don't have to intubate them. So, I think we'll move on to the next case. Um, another gastroschisis case. This is a newborn with gastroschisis and an obvious intestinal atrusion. So there are only 3 choices on this one. Assuming that there's not that much bowel damage and you can get everything back in, um, are you gonna do, are you gonna repair the atresia and then stick everything back in? Are you gonna drop everything back in and wait? Or are you going to do a stoma? And while, while we're waiting for these polls to come up, I would encourage all of this group of faculty to look at the chat questions because we're so behind, I don't have time to address them all. So if you could answer some of these chat questions, um, that would be helpful. Some questions about using the Alexis. There's questions about why, uh, the time is the reason why do we do silos? Why those kind of questions. So, let's see, do we have, what are, so Dan, um, what do you, how do you manage intestinal atresia? Uh, it depends on where the atresia is. If it's a very distal atresia, I would bring that out as an ostomy. Brad Warner once accused me of transposing the, uh, defect from the midline to the right. But um but yeah, if it's distal, then I would do that. I would not do a primary repair because I'm concerned about the pressure you then put on the bowel as you cram it back in there. Right, so you addressed A and C, but what's your thoughts on B? So dropping it in and just waiting 6 weeks. That's if I, if it's a higher atresia, then I would drop it in and wait, but a lower atresia, you would, I would bring it up. I'm sorry, OK. I think if the bowel looked as good as um looked healthy, sometimes they, they don't look that bad. I think I, I might try a primary repair, it might be the wrong thing to do, but, uh, but if it's really edematous, I probably would just drop it back in and come back in a few weeks, 6 weeks, 4 to 6 weeks. Yeah, I mean, I, I, I Use the status of the bowel as a as a guide. So if the bowel doesn't look that damaged, then I, I've repaired them and stick them back in. And, uh, and so far I've never regretted doing that. If the bowel looks nasty, then I, uh, then I push it, I put it back in and come back in 6 weeks. I almost never have done a stoma. 65% do what, what, what I do, which is drop it back in and wait 6 weeks. I, I haven't done the stratification the way you do it, but I, I would consider that. But I, I don't know. It seems like it's matted most of the time, and I haven't seen nice beautiful little like that picture you had is not always the case, especially when you have an intrisia. And what if you have anothertris. Beyond your anastomosis. Yeah, then you're going to have a blowout. If the bowel, right, if the bowel is matted, that's, so you're talking about perfect. So, so I'm, uh, yeah, so what I said is if the bowel is really matted and nasty, then I dropped it. I put, I either drop it in or in, in most of those cases, you'd have to put it in gradually with a, with a silent. I think there's two kinds of intestinal atresia and gastroschisis. There's, there's some that is an early, an early developing atresia, which isn't always associated with bowel thickening and matting. And then there are the ones that occur late because of a very small abdominal wall defect. Um-hum. And I think they're different. I think you have to kind of think of them differently. Well, so, um, I've done all three of these. Um, a lot of things that have been discussed, but, One thing I just wanted to bring out was if, if I've done an ostomy, I've brought it out through the umbilicus, uh, so, so you don't, so Brad Warner doesn't accuse you of transposing it and so you just sew it to the umbilicus as the ostomy site. And when you come back in, usually the adjacent bowel is right next to it. You do a little local exploration, free it up, do the anastomosis, drop back in and close the umbilicus. So, does any, I mean, that's great. Does anyone have a problem with that? I think it's a good idea. I think it's a great idea. I probably would switch to that now. We, we did. I bet I've done that 3 or 4 times. What's that, Aaron? We did that once and the stoma never worked. Like the bowel never functioned well because they had gastroschisis bowel modal, and so we had the stoma that we never had the benefit from. Interesting. But that also works well if you've got a perforation or something like that and you, you need to do an ostomy for sure. Just bring it out through the umbilicus. That's great. OK. Well, actually, I usually bring my stomach out through the umbilicus. Do you? OK. OK, any other questions or discussion about that? What you mean routinely, like for a necrotizing enterocolitis? That's a common place for you to, in babies. That's because then you don't have, uh, a scar afterwards because it's, uh, it's the umbilicus. So it just, it looks like an umbilicus rather than looking like a scar somewhere else on the abdomen. It's also a good, an easy place to put a, um, an, an appliance because it's right on the front of the abdomen, so you don't end up with problems because you're off lateral and you've got the hip and the leg and that sort of thing. We've, uh, we've published that, in fact, Gord Cameron, from who I took over from in Hamilton in the 1980s is the first one that actually described umbilical stones. OK, case 4. So this is now a, a, a baby who had gastroschisis. It's been repaired and it's one month later, and he's still not tolerating feeds. Um, you do a follow through to see if there may be a, an atresia that you missed, and it shows dilated bowel and very slow transit, but ultimately, the contrast appears in the colon, so you at least don't, you know you don't have a, a complete atresia. So the question is, What's your next step? Are you going to wait longer? Are you gonna start a prokinetic agent? And we would normally use intravenous metoclopramide because it's intravenous and then you, you bypass the problem of, of the non-functioning bowel. Would you start cisapride if you have access to it, uh, or would you, uh, do a laparotomy? So again, while we're waiting for this one more instruction, so half of our audience is in one platform, and half of it is in Adobe. So for the faculty, there's a lot of questions coming in on both GlobalC's website and the Adobe website. So check both of those and Mark, if you can transpose one into the other so everyone can see all the questions. Uh, and now we have Jason Fisher on the phone. Jason, can you hear us? I hear you. Perfect. So I don't know how long you've been there, but, uh, I don't know if you want to take this question or if that's just, that's just mean to you because you just came in. Maybe we'll give you. That's very mean. We'll we'll let you wait and get comfortable, uh. Dan, do you want us to start with this? You know, we're often colored by our, our last experience, and I had a child with exactly this recently, and I kept saying, we'll just wait, just wait, we'll wait, and I'm not going to operate on them. And when I did operate on the child, she had a mechanical stricture which I fixed, and she was on full feeds like 2 weeks, about 1 week and a half later. So, um, I guess my threshold is lower for taking them back to the operating room, making sure it's not a mechanical obstruction. I've had the opposite experience. I've waited and they did great. Yeah, yeah, exactly. So it's, well, I think in this scenario, it's only been 4 weeks. I think I'd probably wait, uh, just because I, I don't know if that's long enough for the bowel to recover and it may still be dilated because of the motility disorder. I don't know, but I think I'd probably wait. I don't know if I, I'm not, I'm sopride used to be a great drug, but we don't have, we don't have that available anymore, but I'm not, I'm not a big fan of Reglan, so I'd probably just wait. Anyone else in the gallery have a comment to make about these patients? Everyone says just wait I would wait. All right, so what about 2 months? Let's, let's make it 2 months. I repeat the upper GI, yeah, I think that's a reason, which is reasonable, but, but you already know that there isn't at least a complete aresion. You don't know that there isn't a narrow spot, and it's likely gonna show you the same thing. Yeah, I think if it's 8 weeks and they're still feeding intolerance, I'd probably, uh, explore. So 60% say wait another 3 to 4 weeks. 28% metoclopramide, 9% laparotomy. All right, let's keep going. OK. So we'll move to omphalocele. This is a, uh, term neonate with a large omphalocele and no other associated anomalies or other problems. So the question is how do you manage this? Do you, uh, attempt to reduce it and close the fascia and close the skin? Do you attempt just, just skin coverage without fascial closure? Uh, do you attempt patch closure of the fascia with skin coverage over top of that? Or do you use a, a selastic silo and try and stage it over a week or so? Or do you just, uh, apply a dressing to the, and wait for it to granulate and epithelium? This is a, a full term baby with no other medical problems. Was there a bunch of an abdomen on that picture? I don't know. You showed it. That you could, yeah, if you want to go back to the picture again, so this is a large, this is a large umphal seal. So, um, I'll start off, I paint and wait. OK. I would agree. I, you know, I think I've gotten into trouble by taking the sack off and then not being able to get it together and then you end up putting a prosthetic patch of some sort. There are lots of different options. I've even closed the sac that was partially ruptured and painted it and it worked. OK. Use it as a, you know, autogenous silent. OK. Our group tends to use more of a Schuster type of repair with the, Uh, with, with a mesh and a gradual closure and then a primary closure, stop. So you leave the sack intact and then put a mesh on top of mesh to the fascia and then, uh, gradually, um, close it, close it over the sack and then eventually it's close enough, it's, uh, um, oftentimes close enough eventually to do a primary repair, like a gortex. Yeah, Gore-Tex or, um, yeah, the reinforced vortex. Uh-huh. OK. Jack, what do you do? Um, if, if the baby's otherwise fine and full term, I usually try and stage it like that. Um, often you can't get a fascial repair and, uh, and I don't push so hard that I'm going to. Right. Cause problems, but I think you're better off with a patch covered by skin or just a skin coverage than the, than the paint and weight, which takes months and months and, uh. When you try to bring the together, do you do a component separation laterally at all? Do you separate? Do you do a flap from the skin? Do you do a lateral component separation because you'll get a much easier time of bringing the edges together if you do some sort of component separation. Uh, well, we haven't done muscle component separations. We've been too worried about the thinness of the abdominal wall, uh, but we do raise skin flaps. Aaron, you paint, right? Uh, anyone else. Two variations on this where, where you can, uh, put an antibiotic ointment on the sac to keep it supple and then take a stack of 4x4s, put it on top and use an Ace wrap to try to push it in. And, and I've also had some success using the, the, uh, sac as a silo, twisting it and then putting a, uh, an umbilical tie on it to get some purchase. So, If I do that thing where I put the 4x4s on and wrap it with the, wrap the abdomen with the ACE wrap, then you can tighten that as it as it goes in, but you have to keep the sac moist and it has to be a tough sack. Doc Doctor, um, Abello, who I just want to mention here, who presented two years ago at our first tricks of the trade symposium, is commenting here. He's got a lot of great ideas and good experience with these. This is his major focus, and he takes. Uh, Duoderm and wraps it around and then tightens the Duoderm on top each day, and he has a great video that shows that it just gets it down. So, so no suture or anything, just a wrap on top of it. And I know he's talked about Botox and all these other kind of, uh, ideas to try to loosen the muscle. Um, I can tell you that Mike Rosen is an adult hernia ventral hernia surgeon and he has had very good experience with Botox, uh, for these large massive ventral hernia repairs. It relaxes the muscle. He's able to get things together. So that's just something to consider. Yeah, there, there are many, many reports out there of all kinds of really interesting ideas for how to, how to deal with this problem. Uh, OK, so, The next one I think I know what most people's answer is going to, do you want to, what did most people say there for the uh it was, uh, 68% is E, the pain and the paint and epithelialization, yeah, and everything else is kind of small numbers. So the next one is basically, uh, oh, here, let's go to the next one and then I'll ask what happened there. That's our cool effect. There we go. So the next one is, uh, is basically the same kind of phalocele but in a child who's premature and has pulmonary hypoplasia. And, uh, I, I don't think we need to spend a lot of time on that because I think most people would be painting and waiting on that. And what, what do people paint it with because we, you know, we use silver sulfasalazine, but, uh, other people have used other things. I've tried everything, uh, that's what I use. I, I use, uh, actually er form now. That's all I use. I'll tell you what I would not recommend that I was a disaster for me is I tried applied Aquacel on top of it. I thought it would, it would harden. It would just, it would just. It was a mess because it never really came off easily and it was a big disaster. So I would not recommend using Aquaccell. But I've used everything else. I'm the only thing that matters. But yeah, Silvadene and Silvadene I use Betadine, just the, the dilute betadine and then at the beginning and then zero form afterwards only, or, and actually, actually after that just Vaseline gauze. Do you monitor iodine levels when you're using the betadine? That's why I've only done it in the beginning for a few days and then after that switched. Yeah, our pharmacy gives us some trouble with silver sulfadiazine in the first month. Because of the interaction with the sulfa. Yeah, in the babies when we first started using it, we were measuring levels, uh, you know, white count and which is the main thing that happens, you know, we didn't have any cases where it was a problem, so, but the crits were really low folic, the folic acid. So I wanna go, I'm gonna go back to the, to the follow-up question on the first one, which is, um, which is in a baby, and this could be for gastrosthesis or for othalocele, if you are trying to close an abdominal wall defect, um, how do you measure how tight it is and, and what kind of parameters do you use to decide how far to go? And the options I gave you, and there may be other options um are ventilator parameters, um, entitled CO2, bladder pressure using the Foley, stomach pressure using the NG tube or the CVP and it could be a combination of these as well. Let's not keep starting with Dan. Pete. Well, I, I, I feel like I've been burned using any of these, uh, you know, uh, there really isn't, I don't, I don't think any good, good one, ventilatory parameters, I think, uh, for me are probably, I feel like the most reliable just because I feel like I can, it's a number I can measure and, and, and, uh, believe in, but, um. I'm not sure there really is a good way that abdominal compartment syndrome is, uh, is something I really fear because you can't, uh, I don't think you can really get a good sense for it, uh, clinically. So anyway, I guess I'm, I'm punting on this one because I don't know, um, I'd take A in the OR mostly and C, post-op trending that out in the NICU is probably what I would use, but obviously it's a combination. So have you found success with measuring? Bladder pressures in tiny newborns. In fact, we're in Cincinnati, it's standard. We actually have to measure it and document it for at least 24 hours. No, actually I'm not a big fan. I, uh, I. I think sometimes it works, sometimes it doesn't, but what that means is you can't trust it. Right. So, what do you use? I, I you Monitor their ventilatory parameters and then post-op, it's things like urine output and, you know, other measures of perfusion. Um, but we do as a routine, we measure and document bladder pressures on everybody. OK. Yeah, for me, being in a place where we close so many of them, um, I'm really sensitive now. It's they got to look good when they leave the OR, I just put a silo on them. I mean, I've been burned a couple times with put, putting too much pressure in the abdomen and having to go back. So, I use the ventilatory parameters, how the abdomen feels and then how the baby looks. So, uh, Pablo or Joy or Jason, any of you at your institutions do anything different or pretty much the same as what you've heard? OK, we'll assume that means the same. So, go ahead. Uh, there's, I use intragastric pressure in, in the, in the operating room just because it's so easy. Just, uh, they all have an NG tube already. You just fill it up with saline, hook it up to the central line pressure monitor, and, and it's a, it's a general, there's no absolute number, although the literature would suggest that 20 is the, is the number. But if it's 22 and the baby looks fine and the, you know, the ventilation pressures aren't that high, I'll accept that. I just, so first of all, there must be a Toronto thing because Tony Sandler taught me the same thing. I, I don't understand it though, exactly how to do it. First of all, are you risking your, your, how much volume are you putting in the stomach? Um, I don't put any volume. You don't, you don't put in. You just put the full, the balloon in and blow it up. How do you measure the gastric pressures? You have your nasal gastric tube and you just, and you just transduce it, just transduce it. You don't have to have a column of, of, yeah, you put, you put saline in the tube. Like put 5 cc's or 10 cc's in the tube and then doesn't it just run right out? Well, not once you when you put the the transducer on the end of it, it doesn't. OK. Yeah, I've heard. I just, I've never conceptualized it, but OK. It just makes me feel more comfortable and, and, you know, on both ends of it. So if the, if my gastric pressure is 12 and the baby looks fine, then I feel really comfortable that that that closure is OK. But if it's 35 or 40, yeah, then I'm, even if the baby looks OK, then I'm nervous. My, my only caution would be the physics of it, because even an air bubble in the stomach is gonna just like when you hold a syringe that has saline in air, it's. Spongy, but the, the pressure, it doesn't, that's not a good reflection of the actual pressure in there, but, uh. So, I've thought about how to do this practically, and the only thing I can think of is to use that little blue Christmas tree adapter because it has a lure lock, so it'll fit onto the art line setting and then you can push that very tightly into the clear port of the NG tube, and then you can actually flush it. You can run a column of water down there to get rid of the, Get rid of the air without having this problem where there's, you break the vacuum and now Now you've got air in the system. Let's keep going. OK. So this is actually the last case. So this, this is a 3 year old, uh, who came to us from Africa with an untreated omphalocele. So this was an omphalocele that was just, they, they put her in the corner. They thought she was gonna die and she didn't, and it ended up epithelializing and she had the big ventral hernia. And pretty much all of her liver and bowel were out in this phalocele, um, and the abdominal wall defect was relatively narrow compared to all the stuff that was out. And here's a, it's a picture of the CT scan that shows you that same thing. So the question here is, uh, how do you deal with that? Do you attempt primary reduction with fascial closure? Do you try and stage it with a silo? Do you go in, enlarge the fascial defect, and then try and attempt primary closure? Do you go in and enlarge the fascial defect and then do some kind of staged closure using a silo, or do you go in and enlarge the fascial defect and attempt some kind of staged closure just closing the skin over the top? I, I would do a combination of D and E, which, um, I would, I would first think you have to open up that, that defect. It's interesting to see what happens after three years. We don't get to see that very often. So, it really does start to close down. Um, and I'm very curious how that patient ended up making it over to your hospital also. Uh, we have a fund called the Herbie Fund that pays for kids from the developing world to come. That's great. And get managed at our hospitals. Um, so I would do, I would almost start over. So I would enlarge the defect. Now you're faced with what you were, uh, what would be for us after a year when I have them, and I would, I would probably save most of that skin, but I would save some of that skin, but most of it would be excised, and I would go back to that thing we were talking about before, which sort of a stage vortex, which I've done and slowly start tightening it over time until I can get everything in. I would think you would be able to preserve enough skin from that big thing. There's lots of, there's lots of skin in skin, so I would, I would open a defect and close the skin and stage it. I'm sorry. So let me clarify, you would use skin to, you would open up the defect. I agree that, you have enough skin to close the skin defect, but how would you get, so then you have all this stuff that you're going to put in, you're going to have this huge defect now that you're not going to be able to get closed now because all the liver and everything is back inside the abdomen. So now you have this huge defect. How are you going to close that defect? Um, I think it depends on how, I mean, there's a lot of abdominal wall there that wasn't there before, so you could either potentially do a component separation to pull the fascia together. It's unlikely you're gonna get it all in, uh, and I would then potentially just close the skin, leave a leave a hernia, and then go back and continue to reduce it. If it was too tight and you thought the skin wasn't gonna heal, then you'd have to put some sort of, uh, right, and I, you know what, I know I. I might engage my plastic surgery colleagues for something like this and consider tissue expanders and see if I can uh buy some time and some extra tissue and then come back and I need to do a component, you know, Ramirez uh component separation or. Uh, some other stage closure if it needed to be that way. I think that's an important point that I wanted to bring up at this point is the, uh, involvement of, of plastic surgery because they do this kind of stuff all the time. And you mentioned though, some of the different options that the plastic surgeons will use for this sort of situation, including tissue expanders and component separation. Um, the other point I wanted to make on this case is that thalloseals come in essentially two varieties. One is with a narrow opening and a lot of stuff out. The other one is a big opening and a lot of stuff out. And the ones that we paint and wait where the opening is very big, what you find over 6 months to a year is that most of it goes back in by itself, and that operation to close it is usually not a big deal. The ones with the narrow opening, they're like this. So what I've done, I've had two of these now just like this, and what I've done is is just go in and just open the, the, make the opening bigger and not even really push much in. And what happens is over time it starts to settle back in and in 2 or 3 stages you can go back that's just closing the skin over the top and eventually get fascial closure without a patch and without component separation or anything. You just leave the fascia open then, yeah, you don't put a tex over it or anything. No. The way you photographed it, I thought you were going to say that you use the skin as a side. cinched down. Well, you could. I mean, you could, you could, but the problem is you need time for that abdomen to expand. And this is not like a, like a baby. I learned that lesson with, with one of these where I tried to push it in fairly quickly and, uh, and the child got abdominal compartment syndrome and actually died. So, I learned a very important lesson from that. In an older kid, it's not like a newborn. It doesn't just expand so rapidly and you have to give it time. When you open the fascial vein, did you open it, uh, inferiorly or, uh, because I worry about the hepatic veins up at the top if you have all this liver out and encountering those. Yes, good point, and I did. I, I just opened it inferiorly. Inferiorly. So, why don't we, I think, unless there's any other last point you want to get across. We're going to. Uh, we're going to add, those are the summary questions which. Um, any, any, why don't you just say, uh, without going through the question, what is the major point of those two summary questions? What's the point of them? Uh, they were sort of a hodgepodge of, uh, OK, all right, so, so I, I think we should, uh, probably move on. All right, good. So let's move on. Uh, next is, uh, Doctor von Alman who is going to be talking to us about Hirschrung's disease, and, uh, Dan, um, who has been, uh, done these shows.

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