Thank you for joining us at University Children's Hospital, UCI University. Thank you for joining us at University of Illinois Medical Center for this educational video. Gastroschisis is a full thickness abdominal wall defect that typically occurs to the right of the umbilicus. Although the anomaly has a reported incidence of 1 in 6,000 to 1 in 10,000, it is much more common in many parts of the U.S., including here in Southern California. In our pediatric surgery practice at two neonatal intensive care units, we take care of 30 to 40 patients a year with gastroschisis. This makes it second only to inguinal hernias as a congenital anomaly requiring surgical correction. Pediatric surgeons have traditionally treated gastroschisis by attempting immediate closure. Stage closure was performed only if primary closure was impossible or poorly tolerated by the infant. This involves suturing a silastic silo to the fascial edges and progressive reduction, with risks of silo disruption, fascial dehiscence, and infectious complications. The advent of the spring-loaded silo manufactured by Bentec Medical significantly simplified stage closure of gastroschisis. It allows for a fast, pain-free, suture-less silo placement without need for a formal operation. The silo is made of silastic material attached to a firm but compressible metal reinforced ring. Once the silo is inserted into the defect, it immediately regains its spherical configuration, staying in position for the duration of its use. The transparent silastic sheeting allows visualization of the bowel contents throughout the course of the stage reduction. Dr. James Fisher and his colleagues from Loma Linda University were the first to publish a series of patients to undergo routine silo placement at the bedside. Their results emphasized the simplicity and ease of the procedure and prompted many pediatric surgeons to convert to routine stage closure of gastroschisis with the Bentec spring-loaded silo. Although a prospective randomized study comparing primary to stage closure of gastroschisis is in progress, we do not yet have the results. However, several retrospective studies from large centers in the U.S. have all reported favorable results with the spring-loaded silo staged closure compared to controls who underwent primary closure. In these studies, patients who underwent routine silo placement with delayed closure manifested one or more of the following advantages. Decreased airway pressures, earlier extubation, decreased incidence of necrotizing enterocolitis, decreased infectious complications, more rapid return of bowel function, decreased length of stay, decreased hospital charges. For the last five years on the UCI pediatric surgery service, we have routinely placed spring-loaded silos for patients with gastroschisis with excellent results. Our extensive experience has also taught us important lessons in optimizing the outcomes of this technique as well as its potential complications. In this video, we will accomplish the following objectives. Describe the technique of spring-loaded silo placement and subsequent reduction of the eviscerated abdominal contents. Describe the technique of delayed fascial closure. Review critical points to be observed in placement and maintenance of the silo. Describe other surgical situations where use of the spring-loaded silo presents a therapeutic option. At our centers, most women carrying a fetus with gastroschisis are seen by the pediatric surgeon prior to delivery. We then work very closely with our perinatologists in following these fetuses prior to delivery. Most babies are delivered vaginally after spontaneous onset of labor. We do not perform routine cesarean section, nor do we induce early labor. After delivery, the baby is resuscitated, and the eviscerated gastroschisis contents are wrapped in sterile moist gauze or a bowel bag. The baby is then transported to the NICU and sedated with fentanyl and midazolam drips. The baby is intubated, and a single dose of Vecuronium is given for the procedure. While placement of the silo is certainly feasible without sedation, intubation, or paralysis, we believe these interventions create optimal conditions and a well-controlled situation. The first step in successful deployment of the spring-loaded silo is choosing an appropriate size. The Bentex silo is defined by the diameter of the reinforced ring. It is available in seven sizes, from 3 cm to 15 cm. The diameter of the ring also determines the volume of this elastic cylinder that will house the intestines. We typically choose a ring that is 2 cm larger than the diameter of the defect. Since most defects are 2 to 3 cm in diameter, 4 and 5 cm silos are the most common ones used. However, a larger silo may be chosen if the bowel is more distended or edematous, or there is significant peel. Gastroschisis that involve an atresia typically contain severely distended bowel and often require a 7.5 cm silo. The following examples illustrate the choice of silo. The defect in both of these cases was approximately 2 cm. We chose a 6 cm silo for the case on the right since there was a severe evisceration with significant distension, edema, and peel. The case on the left, however, was quite mild and was nicely housed in a 4 cm silo. Now, we will display placement of the silo. The baby is now in the NICU, sedated and intubated. The bowel bag is cut and removed, revealing the gastroschisis. It is typical to find a distal colon severely distended with meconium. This is a good indication of the probable absence of a proximal atresia or stenosis. However, evacuation of the colon is important as it will significantly decrease the size of the colon and allow for faster reduction. Likewise, a distended stomach or bladder should be decompressed prior to silo placement. Gloves are changed and the abdominal wall around the defect is prepped with betadine solution and draped in a sterile field. The assistant holds the bowel perpendicular to the baby, assuring no mesenteric torsion or kinking. The eviscerated contents are then carefully examined for atresia, stenosis, ischemic or necrotic segments, and perforation. Although atresias and stenosis may not be apparent on first examination, at least a preliminary impression may be gained. If an obstruction exists without perforation, our policy is to proceed with silo placement and closure, followed by exploration four to six weeks later. In this case, the right fallopian tube and part of the uterus were reduced prior to silo placement. We frequently encounter a testicle, which we typically place at the deep ring in a buoy. The mesentery is placed in its correct orientation without torsion. The silo is then filled with saline to open it fully and overcome the adherence of its surfaces to each other. This saline is then used to wash the bowel. The bowel is then gradually placed into the silo distal to proximal. The mesentery acts as the axis and care is taken not to create any torsion or damage to the mesentery or any of the bowel loops. The undersurface of the fascia is checked circumferentially to confirm the absence of any adhesions or bands. If any are found, they are ligated and divided. the the the the the the the the the the The spring reinforced ring. The spring is then squeezed into an oval and slipped under the fascial edge. Upward retraction of the fascial edge aids this maneuver. Once one part of the ring is under the fascia, the retractor end ring then rotate until the entire ring is placed under the fascia. The ring is then palpated to confirm the absence of any bowel loops between the ring and the fascia. Compression of the ring can be seen. The silo is then suspended from the patient's bed. It is important to maintain the suspension so that the ring is just palpable under the fascia but not elevating the abdominal wall, which would lead to abdominal wall congestion and complicate the final closure. On the other hand, if the ring is too lax and allowed to sink in the abdomen, it may cause necrosis of the underlying duodenum or small bowel, especially if the silo is left in position for a prolonged period. The silo is now tied at the apex of the bowel mass, essentially performing the first reduction. As the umbilical tape is tied, the bowel is pushed inferiorly into the abdomen. The baby has remained stable in her NICU bed throughout the procedure, which lasted 18 minutes. During the duration of the silo, it is important to frequently evaluate bowel appearance as well as tension on the ring and any kinking or twisting. The baby is maintained on sedation and mechanical ventilation but not paralyzed. Over the ensuing days, resolution of bowel edema, accommodation by the abdominal cavity, and gravity result in gradual spontaneous reduction. This process is aided by once or twice daily active reduction. Umbilical tape is used to slowly ligate the silo with simultaneous reduction of its contents. The ring should be palpable. The ring should always be palpable just under the abdominal wall. Too much traction on the ring will cause abdominal wall congestion and edema, complicating the closure later on. Too little traction will allow the ring to exert constant pressure on the abdominal contents, most notably the duodenum, with the risk of pressure necrosis. We perform final closure when the silo contents is within 2 cm of the abdominal wall. While we do not have a predetermined duration for the silo, we will leave the silo in place for the shortest time possible. Unnecessary prolongation of the silo duration has no advantages, may make closure more involved by slowly enlarging the defect, and may increase infectious and other potential complications. This is a different case that was reduced in 4 days. Notice the complete containment of the bowel and peritoneal fluid by the silo, essentially creating a closed system. We will now demonstrate the technique of final fascial closure. The baby is now 6 days old and final fascial closure is being performed in the operating room. Notice the near complete reduction that has taken place. The excess silo has been cut and the remainder is prepped into the field. The silo is removed. Notice the healthy appearance of the bowel. The surgeon's outer gloves are then discarded and the operation continued. The abdominal wall is stretched to aid in a tension-free closure. This often produces some minor post-operative congestion of the abdominal wall. The residual eviscerated bowel is very easily reduced. The abdomen is irrigated with sterile saline. The ulcerative gauze is used to cover and protect the bowel. In this case, a thrombosed umbilical vein is removed prior to fascial mobilization. The umbilical stump, however, is preserved. The skin and subcutaneous tissue flap is raised circumferentially in order to mobilize the fascia for closure. This is easiest to start opposite the umbilicus. The cutting mode of the cautery is used and discrete small bleeders are coagulated. The blunt cautery tip acts as a perfect dissecting instrument, releasing the skin from the fascia. of the lax. of the and the the the the the the fascial edge is mobilized in both directions to the border of the umbilical stump. It is important to stay in the correct plane in order not to compromise the fascia or skin. A 2.0 PDS purse string suture is started adjacent to the umbilical stump. The tail is tagged with a mosquito. This is continued circumferentially around the fascial edge with alternating bites. Inside out and outside in. What is the next suture? Uh, probably use the 4.0 monitor. Okay. I don't know. The way over. Okay. Yeah. I do. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. One or two interrupted PDS sutures are used to approximate any remaining defect. A final fascial stitch is placed on the borders of the umbilical stump to eliminate a future umbilical hernia. The wound is irrigated with sterile saline. The skin closure is now started. A 4-O monocryl on a cutting needle is anchored in the fascia and taken from inside out approximately three millimeters from the skin edge. The edge is often slightly ischemic and bites exactly in the skin edge are likely to cause skin necrosis and possible wound infection. This is continued over and over as a running stitch. This will purse string the skin edge. Resulting in a neo-umbulicus. This will purse string the skin edge resulting in a neo-umbulicus. Once the opposite end of the umbilical stump is reached, the suture is re-anchored in the fascia. The suture is tightened in a manner similar to the fascial suture and tied. One or two final sutures are placed to optimize the umbilical effect and long-term cosmesis. One or two final sutures are placed to optimize the fascia. One or two final sutures are placed to optimize the fascia. Then there's more pieces of ear form, 2 by 2 and up, right? Is there any other pieces of hand like increase of small bowel? Do you like this? No. It's not worked that way. Yeah. Tension-free closure has now been accomplished. The baby has remained stable without any increase in airway pressures. The procedure was completed in under 25 minutes. These pictures show the appearance of the wound immediately after the operation and at the first clinic visit 6 weeks after closure. These pictures show the appearance of the umbilicus in several different patients treated with this technique 1 month, 3 months, and 6 months after closure. We would now like to summarize the essential factors that result in optimal outcome of this technique. First, appropriate choice of silo size. Second, avoiding mesenteric torsion. Third, final closure when near-complete reduction is achieved and not prolonging the duration of the silo. Fourth, close observation of the silo configuration and contents. Fifth, per-string closure of the fascia and skin. And finally, preservation of the umbilical stump. The next few slides will show examples of other unique situations where the Bentec silo provides a reasonable therapeutic alternative. This patient's gastroschisis included a bowel segment with tenuous blood supply. He went on to develop gangrene of that segment while in the silo. After bowel resection and anastomosis, a new silo was placed and the defect was closed 5 days later. There were no anastomotic complications. The Bentec silo can also be used for staged reduction of omphalocele after excision of the sac. The liver can be gradually reduced along with the bowel and delayed final closure accomplished. The Bentec silo can also be used as a bridge to coverage of the bowel and giant defects. This baby had an abdominal wall agenesis with herniation of the entire abdominal contents, including a very large congested liver. A 10 cm silo was used and about 70% reduction accomplished over two weeks. In this circumstance, where a large silo is required for a prolonged period, a few corner stitches between the silo ring and the abdominal wall prevent premature dislodgement of the silo. At two weeks of age, the defect was covered with human acellular dermis and a wound vacuum-assisted closure device was applied. Finally, the silo can also be used in cases of neonatal abdominal compartment syndrome, such as in this baby with severe diffuse necrotizing enterocolitis. In conclusion, the spring-loaded silo provides an excellent alternative for the treatment of babies with abdominal wall defects, particularly gastroschisis. At the University of California, Irvine, we continue to apply this method to all patients with gastroschisis, and we also selectively use it in other situations where abdominal wall closure is not possible. you
