Staged Closure of Gastroschisis with Spring-loaded Silo
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
At this pediatric surgery practice serving two neonatal intensive care units, 30 to 40 patients per year are treated for gastroschisis, making it second only to inguinal hernias as a congenital anomaly requiring surgical correction.
For the last five years on the UCI pediatric surgery service, spring-loaded silos have been routinely placed for patients with gastroschisis with excellent results.
At these centers, most women carrying a fetus with gastroschisis are seen by the pediatric surgeon prior to delivery, with close collaboration with perinatologists.
Most babies are delivered vaginally after spontaneous onset of labor; routine cesarean section is not performed, nor is early labor induced.
The baby is sedated with fentanyl and midazolam drips, intubated, and given a single dose of Vecuronium for the silo placement procedure.
While silo placement is feasible without sedation, intubation, or paralysis, these interventions create optimal conditions and a well-controlled situation.
A ring that is 2 cm larger than the diameter of the defect is typically chosen.
Since most defects are 2 to 3 cm in diameter, 4 and 5 cm silos are the most commonly used.
A larger silo may be chosen if the bowel is more distended or edematous, or there is significant peel.
Gastroschisis cases involving an atresia typically contain severely distended bowel and often require a 7.5 cm silo.
A severely distended distal colon with meconium is a good indication of the probable absence of a proximal atresia or stenosis.
Evacuation of the colon is important as it will significantly decrease the size of the colon and allow for faster reduction.
If an obstruction exists without perforation, the institutional policy is to proceed with silo placement and closure, followed by exploration four to six weeks later.
The ring should be maintained just palpable under the fascia but not elevating the abdominal wall, which would lead to abdominal wall congestion and complicate final closure.
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.
Over the ensuing days, resolution of bowel edema, accommodation by the abdominal cavity, and gravity result in gradual spontaneous reduction, aided by once or twice daily active reduction.
Final closure is performed when the silo contents are within 2 cm of the abdominal wall.
The silo is left in place for the shortest time possible; unnecessary prolongation has no advantages, may slowly enlarge the defect making closure more involved, and may increase infectious and other potential complications.
The abdominal wall is stretched to aid in a tension-free closure, which often produces some minor post-operative congestion of the abdominal wall.
It is important to stay in the correct plane during fascial mobilization in order not to compromise the fascia or skin.
Skin closure suture is 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.
Essential factors for optimal outcome include appropriate choice of silo size, avoiding mesenteric torsion, final closure when near-complete reduction is achieved and not prolonging silo duration, close observation of silo configuration and contents, purse-string closure of fascia and skin, and preservation of the umbilical stump.
The Bentec silo can be used for staged reduction of omphalocele after excision of the sac, with gradual reduction of liver along with bowel.
When 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.
Gastroschisis has a reported incidence of 1 in 6,000 to 1 in 10,000, but is much more common in many parts of the U.S., including Southern California.
Traditional staged closure with sutured silastic silo carries risks of silo disruption, fascial dehiscence, and infectious complications.
The spring-loaded silo allows for fast, pain-free, suture-less silo placement without need for a formal operation.
Dr. James Fisher and colleagues from Loma Linda University were the first to publish a series of patients undergoing routine bedside silo placement.
Several retrospective studies from large U.S. centers reported that routine silo placement with delayed closure showed one or more advantages: decreased airway pressures, earlier extubation, decreased incidence of necrotizing enterocolitis, decreased infectious complications, more rapid return of bowel function, decreased length of stay, and decreased hospital charges.
The Bentec silo is available in seven sizes, from 3 cm to 15 cm diameter, with the ring diameter determining the volume of the silastic cylinder.