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 the, 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, so, so I think we should, uh, good. So let's move on.
