Gabello is submitting a video on the management of giant um file seals, but he submitted a video years ago, and I want to show that first, briefly. We'll just show that for a little bit, and then we'll go on to his updated video. I want to show the old umfoul seal video. We're pulling that up now. And I'm very curious to see if anyone else is doing this technique and want to get some idea from the faculty after this on how everyone here manages giant umphal seals. Um, while we're waiting for this to load, I'll just say that I know that I use escharization. I, I paint them and then treat them, I let them epithelialize. I'm wondering how you manage giant phallo seals, Jack. Yeah, I guess it depends on what you mean by giant. I mean, my first choice. In a child without pulmonary hypoplasia, without a bad heart problem, my first choice is to try and get coverage, uh, early on, uh, because I think it's just quicker and, and easier. But for those patients with pulmonary hypoplasia or bad hearts or prematurity. Uh, or where the fallacy is just too big and there isn't enough skin to get over, um, I do the escharotic technique just like you do, and we're trying, we've been using silver sulfa, silver sulfasalazine, no silver, silvadene, yeah, we call in Canada we call it flamazine. It's a great name, much better name, but it's perfect for burns. I love it. Uh, we've, we've been using that for many years because that's what Sigy Ein taught us, but we have a plastic surgeon now who, uh, is helping us to, uh, develop some easier, um, equally effective or perhaps even more effective ways of addressing them. There's these silver impregnated, um, sponges that you can use now that, uh, basically offer the same advantage of the Silvadene, but. Um, you don't have to paint it. It's not as messy. Um, so let me, so I've tried using a silver impregnated material Aqua cell, and I don't know if it's the same thing. OK, because that was a disaster. Uh, I, I laid the Aqua cell on the silver Aqua cell and it stuck to the, uh, sack and it became incorporated. And could not get it off. So that was, that did not work well because usually aqua cell is supposed to fall off once it hardens underneath, but it did not do that. I've tried bacitracin. I've tried and zero form. I'm sure I'm curious, silver nitrate liquid I've used, um, I'm closer to nothing, um, at this stage. They just, they, they, they harden and close and retract on no dressing open to the, I've used because you can't do that and then they have to have something on there or else they all go, but I really like the what we'll get to is the. You know, aiding that along with maybe some compression or piece, right, which is, and I don't know, Mark, are we able to pull that video up or is it not loading? It's ready to go. Let's watch this video and then we can open the discussion up to the rest of the faculty. Now this is the old video that was submitted to us a couple of years ago and here's the This is the giant haloseal um with the liver you can see. And we're going to, we're not going to play the whole video, but I just want to show what was shown. And I'm so curious to see what everyone does here. OK, so Duoderm, uh, he cuts this T-shaped Duoderms, and I have actually not tried this yet, um. It's work intensive. I mean, that's for sure. You put on the these uh and you fasten these, these uh duoderms. Come up here. And I apologize to the faculty who are seeing this in a small video pod. Thank you. Yeah, I see. And those look like tongue depressors, uh. And little by little, just now he's got a silo formed on the outside with the Duoderm and little by little keeps compressing it down just like you would a gastroschisis until it gets flat, um. And I don't remember how long, uh, Cristobal, I don't remember how long it was, but I think he was, I think it was like 1 week or 2 weeks, maybe 10 days, I don't remember. And he gets it all compressed in. There you go. So, uh, there's there's more to the video. It shows how he then resects the sack and then closes it, but that is an interesting technique. Mark, let's go ahead and pull up the next, uh, Uh, video, which is now the more recent video, his next submission. Uh, for this year. I love that and, and, and I just, I, I mean it takes a lot of work, you got to go up every day and keep adjusting it, but I think it's uh The problem is if you have a patient with pulmonary hyperplasia or a bad heart where you really can't safely increase the intraabdominal pressure, and those are the ones really that we're talking about. Right, those are, those are the ones that are the most difficult cases. Right. Um, so I agree if they have, if you can't physiologically compress them, you can't do it, but in those that you can, that's where I think the question is, do you paint it? I still paint them, but maybe I'll do this. Um, is that video ready? There's the new video. Let's play the new video. I. Again, I apologize to the faculty of how small the videos and High Complexity clinic North in Barranquilla, Colombia presentallo, separation of components and closure of the abdominal wall by Dr. Cristobalabelello, Dr. Ricardo Cre. And Dr. Osodium. Our objectives are to minimize postoperative risk of abdominal hypertension and abdominal compartment syndrome, to increase the abdominal capacity at the time of closure, to facilitate the most anatomically definitive midline closure regarding the rectus muscles, and to limit eventation, evisceration, and incisional hernias. This is a 28 week gestation 1.130 g premature female product of cesarean born with a giant omphalocele which included the liver. It was identified by prenatal ultrasound. With the Abeo protocol and a duoderm silo, the inversion of the sac and approximation until complete closure was realized. She is then taken to surgery for abdominal wall closure. This is the peritoneal sac. After 10 days of manipulation with the duoderm silo still covered, thick, and manageable. The maneuver to free viscera from the sac. Tolerance is confirmed. In this schematic you can see the omphalocele, the amniotic sac, the peritoneum. In purple. Laterally you can see the semiunar line and the level of dissection 0.5 to 1 centimeter outside of the semiluar line. We began this procedure with a 2 centimeter incision outside the amn cutaneous edges, opening and resecting the sac. However, since there was too much tension for closure, we decided to proceed by performing a component separation as described by Ramirez and Diaz. In this illustration you can see how the incision and the semi-unar line are parallel and the direction of the dissection of the lateral fascia towards the major oblique. By dissecting the fascia in this way until the mid axillary line, you can gain between 2 and 4 centimeters. Mhm It's. As you can see, we resect the amnioes, preserving the cord, which is mobilized caudally. The rectus muscles are joined centrally, and the cord is moved to where it will become the future umbilicus. In this way, you suture caudally until constricting the umbilical cord. Hm. We are reporting this case as the probable smallest patient with lowest weight and giant omphalocele treated with a Baylo method and component separation for definitive anatomic closure without eventation. Thank you. OK, so let's get talking here. Uh, first of all, I just want to make a comment. I know Dr. Abelo, uh, we're having some audio issues with you, but let me just make a comment about Dr. Abelo. He's, he's one of these minds that you meet and, and he thinks so creatively, so he's so innovative, and every time I watch his videos, Um, I just am fascinated. I know he's talked in the past about maybe using Botox to uh help relax the abdominal wall, just a fascinating mind, and I love watching this video. I have tried doing component separations in little babies, and it is not that easy all the time, especially if it's been on a silo for a long period of time and it's all scarred together. I'm wondering, uh, let's first start off in the studio and then we're going to move it out into the virtual virtual faculty, and I, I also want to get to some of the questions from the audience. Comments on the video and what you've done and what you have to say about what he's done here. I'm, I'm impressed with the component is what's that abdominal wall like when that person is 20 years old? You know, are they gonna be able to function normally? Will they be able to do the things with their abdominal wall that that they should be able to do? Um, what I've done instead is I just used, um, some kind of patch, usually some kind of, um, absorbable patch. We used Sergisis for a long time, but we had a lot of recurrences, and now we're using Stratus, which, uh, we seem to have better, uh, results with. And I think the advantage of that is that you leave their abdominal wall mus musculature intact, and as the child grows, the patch becomes a smaller and smaller percentage of the, of the area of that abdominal wall. So. Um, I, I personally feel until we know the long term outcomes from component separation, I'd rather use a patch. The other issue is that many of these on falseals, the defect goes right up to the costal margin. And I'm not sure how even with component separation, you can, you can close that hole right along the costal margin. So I often find myself closing primarily the lower part of the defect, but having to put a patch in along the costal margin. It is, it does bring it together up top from, I mean, but it, but it probably because you bring most of it together from below and then you can get the edges together up top, but you're a good point. The data would suggest though that component separation works and as a long term follow up. But I agree with you. The question is when you're dealing with a child that's 1.3 kg, you know, what are you really going to get to? I think part of the key point in the discussion though was his dissection was to the mid-axillary line. I mean you have to go. Way out to find what you need and to do it adequately and pull it together. I've gone back more to what you do. I'm still with the surgess, but the new six-ply stuff they have, I find, is at least in the ones that work better. I think you get 22 tension lines in that. You get the tension on the patch, and then you can bring the uh metal together, and it seems to work. But I have a lot of comments, but I wanna, I want to hear what they say. And then Holly Williams wrote a comment about how she does it. So Holly, if you can call in, we'll put that phone number up if you're looking on the And on our Global cast site, you can see the phone number to call in, but Mark, can you put that in Adobe as well? Um, any of the faculty have a comment about what you've seen here? Todd, can you hear me? Yes, says that he has not had any long-term follow-up with the separation component of components, but he has had long-term follow up with the first technique that he described, and they have all healed well without any problems. The first technique being just just getting the Duoderm, right? You dooderm, but that just Duoderm gets the sack down, but almost this was I saw this video, maybe I misinterpreted this is sort of the second stage either you just do a primary closure, and I guess the point of this video was, so in the first video he probably just did primary closure of all of them, right? And I think that, but the Duoderm is giving you, it's, it's a silo. You're, you're getting tissue, it's a tissue expander technique again, and it helps, uh, David, you were going to say something. Well, I was wondering why should you do this technically highly complicated procedure, which, uh, with a huge surgical area in such a small child, when in most cases, uh, like has been explained before, Even putting just fatty gauzes on them until its and then wait until they're 67 months and just do your delayed primary closure. OK, so it's technically very nice, but it's very demanding, and if you have a complication, you immediately have very big complications. So why take the risk? Great question. The question is, is there a benefit? And maybe Deb, if we can ask Dr. Abello, what is the advantage of early closure? Why not? Is there a disadvantage in Doing escherization and and letting it close over time and then doing a delayed closure when they're may be a year of age and they're much larger and then get their abdominal close. So I'm just curious if anyone, yeah, Bob, yeah, because I, I'm much more in the camp of just waiting, you know, we forget where we, we were, where we've come from sometimes, you know, we look at those great old pictures and, you know, of skin covered in phallos, which still didn't have great techniques to fix them, which we do have now. You can just get out of the way. Let the kid, they go home, they're playing, they're active regular kids. They epithelialize the whole thing and then fix it when they're older with some of these maybe component separation type techniques. Let's pull the audience um in a in a giant foul seal. Um, Mark, maybe put that question, uh, do you, would you try early closure or delayed closure? Um, and I'm just curious, any of the other, uh, faculty there, uh, Kathy, Sharif or Suad have any comments about how they manage these? And for me, actually, what I use is the usual ones is the painting and then allow it to to allow the kids to grow and then close it with a delayed primary closure, and most of these kids actually I manage to close them when they are older without using the patch. and I had to use only once actually a patch in one of the patients, and so far things are OK. I like the idea of the Duoderm to put like a silo to put it down the sac that maybe ease the things and finish it too quickly, but the the separation component, I don't know. I'm not, I'm not convinced 100% at this low age of birth. OK, can I ask a question and then I want to You know, and Todd, this is Holly Williams. I called in. Hey, so I tried after I saw that wonderful video before about the Duoderm, I tried it and I've had a success, um, on two kids that were giant halo seals with the liver out, um, uh, and I was able to do it over a longer period of time, uh, you know, I wasn't in a rush. Um, I found that, um, I was able to do it with, uh, just keeping them on nasal cannula and just giving a little morphine when I did it, and I, they didn't have to get intubated until I actually was ready for the repair. Um, but what I did find was, um, is that I just did, um, I had to do the Duoderm patch. I, I applied it, this is the, the, the, uh, silo. I would apply it and only redo it only about every 3 days. So I was. Making very gradual progress. Holly, let me ask you, so yeah, let me, what did you find? I'm assuming before, I'm assuming before you did this you were painting and waiting. What is the advantage of the question that's been posed of doing this technique with the Duoderm of getting early closure? Why, why did you switch? Well, I actually haven't been. I haven't been much of a painter except for a short period of time, and then I've been more of a, um, where I get some sort of a closure with a patch with the plan that it will be multiple stages of an of operations over a couple of years, but having some kind of a. Of a closure that's done. That's what I had done. And so in these cases what I liked about it was that in the babies they're so compliant that you can really get, you know, a lot with those Duoderm pulling and you leave the amnios, just push the amniose in. And, uh, the Duoderm, when you get to that stage where you can cut it into diamonds, you know, and then you can actually be pulling on the, the, uh, rectus out laterally, and it, and it, and it works extremely well so that you can get to the point where you can close primarily at at least the edges so that the defect that you have to bridge with the patch is much smaller. And I just use, um, the, uh, Alloderm. And then, um, and leave the amnios also and so then you've basically got like this, uh, nice protective layer and I'm just watching these kids to see if they're actually going to need any kind of revision at all. Yeah, you know, this is, uh, go ahead on the line, uh, yeah. Go ahead, Doctor Abe. When. The suspense is killing me. I can't wait to hear what he said. So what, what did he say, Deb? He's, um, I couldn't understand him. He's talking very muffled with the microphone. He's trying to say it again and This method that we have designedness of the human um uh tissue. OK, I, I think the and in our first approach. We found that in just relaxing the patient and sedating the patient, we were able to get the stretching that was necessary for primary closure. OK, let me stop for one second. So I just, I want to even the patient, let's say you wait, you, uh, paint and wait, you wait till they're, and I thought that Holly's comment about maybe when they're younger they're more pliable. That's interesting. But I, I do wait till they're a year of age. And I've had one, I don't know if you remember, uh, that it was so massive and he had only a muscle at the very lateral edge. So we did even, even painting and waiting, we still had to do some sort of closure technique. So we did a combination of lateral component separation. And actually, and then we attached Gore-Tex, and we went back every few days. Uh, and it took 3 times and we stretched him almost like a Whitman patch, and we brought the edges together and then we were able to get the edges closed together. So that's an extreme example of someone who has pretty much no abdominal wall at all. You could put a patch in and just leave it, um, but I wanted to use just muscle if I could. Yeah. Well, I think the trick with a patch too is that, um, I mean you can't, at least that I'm aware of, I don't know, you may know some where you can bridge with a patch. You got to have. You got to have something together over a patch unless somebody's found a patch. Yes, I have a question for you. Here's my question. So the cardiac, we can't use patch. A biologic dressing is not meant to be bridged, right? A biologic dressing will turn into liquid, right? It's only a temporary thing. It won't turn into muscle. Unless it's permanent and it stays as a well, go ahead. Where are you taking it? OK, but the cardiac surgeons, they were, they were saying, wait, when you put these biologic patches in the heart and the VSD closure, it actually turns into cardiac muscle. But for us, they say, absolutely do not think of using, uh, you know, like surgicist that it's going to turn into muscle. It, it is not meant to be a bridge, but I I think that in babies who are still developing their tissue, I had a kid that it did turn into muscle. OK, I put a little patch muscle, maybe not muscle or scar. I'll go with that. I'll go with that Todd, yeah, yeah, Todd, this is Holly Williams. So you know, I haven't, I didn't have any good experience with er when I was using it long ago for diaphragms, but Ah, the, ah, Alloderm has worked well, I think, for these abdominal wall and using it as a bridge and what the idea is you try to, to, you try to minimize the size of the patch that you're going to do, and I like the Duoderm method because it really you do get a significantly smaller defect when you're ready to close it, and you can they're very compliant in the neonatal period. And, uh, if you leave the amniose, that's usually stuck to the liver, right in the center anyway, you leave that and then you have the alloderm over that and then get close the skin. And what I think it ends up turning into over time is, is sort of some thick fascia. You know, I'm not necessarily convinced that it's muscle, but you end up with a relatively small central defect. Uh, that's fascia that's thick, so it's almost like a rectus diastasis, and then it seems like the benefit is that the muscle edges don't. Continue to get farther and farther apart. That's the problem I see with painting and then waiting is they don't, your, your, your muscle stays way out laterally and over time it's almost like they have a bigger defect. So I think that's a great point and Bob wants to make a point. And then I want to let Dr. Abello make a final comment and we're going to go to his last video and both of you go ahead, yeah. One of the most challenging situations. That I've come up with is not the huge defects, but the smaller defects with everything out, the whole liver out, because those ones actually don't go back in when you're painting and waiting and I, I'm wondering if uh Doctor Abeo has had any of those and whether the Duoderm technique successfully gets those reduced. I'm guessing that it doesn't because it's almost like the liver's locked out. And in those cases, you, you actually have to go and enlarge the fascial defect in order to get things to go back in. It would be interesting to see cause those livers, they often have a, I mean they're actually built into the I mean they change and have a shape that's like a big mushroom it's like a it's like a I showed you that yeah it's like a sacrococcygeal terra, you know, that's coming at you know, it's doing a dumbbell thing right they're very difficult to as soon as you start seeing that memories of three months ago came back when you talk about that. But I wonder if Dr. Abeo can just comment whether the Duoderm technique works for that situation. So, so two questions, uh, first, uh, Deb and Dr. Abeo, I want. Dr. Abeo to answer, but please give us very short answers so that Deb has time to translate just brief sentences and let her translate. So, if you can address Dr. Langer's comment about that the mushroom affected liver with a small defect, and then I also see that you said that you wrote none of that is necessary. I, I think you're talking about patches, about using, uh, uh, patches. So can you address both of those, and then we'll move on to your last video. ground. I wouldn't, uh, there is an algorithm for the procedure for the proper treatment of the patients with giant phalocele, OK. The first that I do is a test of relaxation. OK. Lets me know how much um where the patient will how much is the patient need me that. and then I can figure out how much of the silo I need by using the size and that tissue to the primary closure. It's when I was younger and I'm. the process. The uh, the patient is able to be manipulated in this way, uh, actually quite easily and the process itself is uh fairly simple. OK, you tell me no no professor. I am able to finish this um by uh checking in the first place whether the patient will be able to tolerate the primary closure. I know that I have two alternatives if I can't do primary closure. I go to separation of components and if the pressure is too high, do you guys. The first is something called you. If after separation of components, the pressure and the intraabdominal pressure is still too high or too critical, I can put a um. A mesh, got it. OK. So I think first of all I If during some kind Yes. I don't know that pressure is too high or the pulmonary pressure or pulmonary hypertension occurs at any moment I can abort the process and go with the traditional painting and waiting. if the patient does not tolerate the above stated procedure, I can abort this and go to the traditional method. So let me, let me stop here and take two comments. First of all, we're going to.
