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Sutureless Closure of Gastroschisis - APSA Practice Gaps 2019

Video Published 2020-03-03 Updated 2025-03-20

Topic Overview

A discussion of sutureless versus sutured gastroschisis closure techniques, examining evidence from retrospective studies and one randomized trial. The speakers debate whether sutureless repair reduces time to feeding and length of stay, with conflicting data from multiple studies. Key clinical points include: complications appear similar between techniques, fascial closure may not be necessary for all cases, and approximately 13% of sutureless repairs require later umbilical hernia repair. The group identifies the need for prospective multi-center trials that account for patient heterogeneity and standardized feeding protocols.

Key Takeaways

Sutureless gastroschisis repair shows similar complication rates to sutured closure, though outcomes vary across studies. (2:27)
Approximately 13% of sutureless repairs require umbilical hernia repair at 4-5 years, higher than fascial closure. (6:00)
Fascial closure may be unnecessary regardless of defect size; skin closure alone appears adequate for gastroschisis. (19:40)
Standardized gastroschisis protocols avoiding general anesthesia reduced antibiotic use, intubation, and opioids without affecting LOS. (16:02)
Selection bias favoring easier cases for sutureless repair may confound outcome comparisons in retrospective studies. (7:58)

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

Salim — guest
Speaker 2 — host
Speaker 3 — guest
Todd — guest
Speaker 5 — guest
Mac — guest

Chapters

0:00Case presentation and sutureless repair origins — Introduction of a full-term gastroschisis case and polling on repair techniques. Discussion of how sutureless repair originated serendipitously with Tony Sandler at Iowa, followed by review of conflicting evidence from retrospective studies versus the Brisoni randomized trial.
6:19Study heterogeneity and umbilical hernia outcomes — Analysis of why multiple studies disagree, with emphasis on practice pattern variations and feeding protocols. Discussion of umbilical hernia rates (13% requiring repair at 5 years) and mechanisms of fascial closure in sutureless repairs.
10:40Anesthesia considerations and technique variations — Debate over intubation necessity for gastroschisis closure, review of animal versus human data on anesthetic neurotoxicity, and discussion of patient heterogeneity affecting outcomes. Introduction of 'minimally invasive surgery as a concept' applied to gastroschisis.
15:06Standardized protocols and complicated cases — Presentation of UCLA's UC fetal consortium standardized care pathway showing reduced antibiotic use, intubation days, and opioid use without decreased length of stay. Discussion of management approaches for complicated gastroschisis with atresia or thick peel.

Key claims

2:27Complications are similar between sutureless and standard sutured gastroschisis repair — Salim
3:00Tony Sandler at Iowa originated sutureless repair when a large gastroschisis wound closed spontaneously after covering with umbilical cord and tachyderm — Salim
4:20Multiple retrospective studies reported sutureless repair patients eat quicker, go home faster, and are cheaper to manage — Salim
4:50The Brisoni randomized study from Stanford found sutureless repair patients took longer to eat and had longer hospital length of stay — Salim
5:30A subsequent 98-patient study from UCSF showed benefit for sutureless repair, conflicting with the Brisoni randomized trial — Salim
6:00Approximately 13% of sutureless repair patients require umbilical hernia repair at 4-5 years of age, higher than fascial closure patients — Salim
6:19Robert Baird's study from McGill showed everything was better about tape closure and had a lower umbilical hernia rate — Todd
7:20Fear of feeding after sutureless closure may drive increased length of stay due to hesitation about bowel distension and evisceration — Todd
7:58Natural selection bias may favor sutureless closure for easier cases, confounding outcome comparisons — Salim
9:45The UCSF study with 98 patients and 5-year follow-up found 13% required hernia repair when compared to historical sutured controls — Salim
10:40Patients with attempted fascial closure without silo have higher incidence of umbilical or ventral hernias requiring repair — Salim
11:47All general anesthetic agents in every class cause increased apoptosis and developmental issues in animal studies (rats, mice, sheep) — Salim
12:30The GAS trial and PANDA study with 5-year data show no difference in neurodevelopmental outcome between spinal and general anesthesia in human infants — Salim
15:06Tony Sandler no longer uses the umbilical cord for sutureless closure; it is not as important as once thought — Salim
15:40A silo can be placed, reduced, then followed by tape closure even if immediate reduction is not possible — Salim
16:02UCLA's UC fetal consortium standardized gastroschisis care without general anesthesia or intubation significantly decreased antibiotic use, intubation days, and opioid use, but did not decrease length of stay — Speaker 2
17:34Gastroschisis patients should be delivered vaginally unless there is an obstetric indication for C-section — Salim
18:10The gastroschisis prognostic score (GPS) based on peel degree, bowel distension, and matting did not ultimately matter as much as hoped — Salim
19:00Gastroschisis with very thick peel, very distended bowel, and many loops should not undergo immediate closure; silo reduction is preferred — Salim
19:40There is no real need for fascial closure regardless of gastroschisis defect size; skin closure alone is adequate — Salim

Cases discussed

0:00Full-term 3.4 kg infant with gastroschisis, stable on room air, amenable to immediate reduction and closure

Points of disagreement

10:40Whether to intubate for gastroschisis closure
- Todd: Prefers closing with baby paralyzed and intubated for higher success rate, despite peer pressure to avoid intubation; considers it 'cruel and unusual punishment' to squish bowels in while awake
- Speaker 2: UCLA protocol attempts all closures without general anesthesia, without intubation, with minimal narcotics
2:08Whether to close skin only versus fascia
- Salim: Closes skin only at bedside
- Speaker 3: Performs fascial closure in OR

Open questions

What is the optimal feeding protocol after sutureless gastroschisis closure to balance early nutrition with risk of distension and evisceration?
Does the mechanism of umbilical fascial closure differ in sutureless repairs compared to natural closure, and why do some defects close while others require later repair?
What is the true comparative effectiveness of sutureless versus sutured repair when controlling for patient heterogeneity, feeding protocols, and selection bias?
What is the optimal management sequence for complicated gastroschisis with intestinal atresia: immediate closure followed by delayed atresia repair, or addressing both simultaneously?
Does the gastroschisis prognostic score (GPS) have utility in predicting which patients are candidates for immediate closure versus silo reduction?

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:

Sutureless Gastroschisis Closure: When Skin Alone Is Enough

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

The Case

A full-term 3.4 kg infant with gastroschisis lay stable on room air in the NICU, bowel loops eviscerated but amenable to immediate reduction [case1]. The surgeon stood at the bedside explaining two options to the parents: standard fascial closure in the operating room under general anesthesia, or sutureless closure at the bedside using the umbilical cord to cover the defect [case1]. The question was not whether closure was possible — it clearly was — but whether avoiding the operating room, the anesthesia, and the fascial sutures would help or harm this infant.

The Decision Point

The choice hinged on conflicting evidence. Multiple retrospective studies had reported that sutureless repair patients ate faster, went home sooner, and cost less to manage 4:20. The technique itself arose by accident when Tony Sandler at Iowa faced a gastroschisis defect too large to close after reduction; he covered the wound with umbilical cord and tegaderm, planning to return later, and found the wound closing spontaneously 3:00. The appeal was obvious: no transport, no intubation, no operating room time.

But a randomized trial from Stanford told a different story. The Brisoni study found that sutureless repair patients took longer to reach full feeds and had longer hospital stays 4:50. A subsequent 98-patient study from UCSF contradicted this, showing benefit for sutureless closure 5:30. One discussant proposed that the difference might not be in the patients but in the practice patterns — that fear of feeding after sutureless closure, driven by concern about bowel distension and evisceration without fascial support, was artificially prolonging length of stay 7:20. Another pointed out the selection bias inherent in retrospective series: easier cases naturally gravitate toward bedside closure, confounding any outcome comparison 7:58.

The hernia question added another layer. Approximately 13% of sutureless repair patients required umbilical hernia repair at 4-5 years of age, a higher rate than in fascial closure patients 6:00. One study from McGill reported better outcomes with tape closure and paradoxically lower hernia rates 6:19. Conversely, patients who underwent attempted fascial closure without silo placement had higher rates of umbilical or ventral hernias requiring repair 10:40.

What Was Done

The discussants did not state which approach was chosen for this specific infant. The conversation instead centered on what the accumulated evidence permits. Salim noted that Tony Sandler no longer considers the umbilical cord essential — it can be omitted 15:06. A silo can be placed, the bowel reduced over days, and then tape closure performed even when immediate reduction is not possible 15:40. The UCLA fetal consortium standardized gastroschisis care without general anesthesia or intubation, significantly decreasing antibiotic use, intubation days, and opioid exposure, though length of stay remained unchanged 16:02.

The consensus that emerged was conditional. For gastroschisis with very thick peel, very distended bowel, and many loops, immediate closure should not be attempted; silo reduction is preferred 19:00. But for straightforward cases, there is no real need for fascial closure regardless of defect size — skin closure alone is adequate 19:40.

What the Case Changes

The central insight is not that sutureless closure is universally superior, but that the old mandate to close the fascia in all gastroschisis cases is probably wrong 19:40. Complications are similar between sutureless and standard sutured repair 2:27. The heterogeneity of the gastroschisis population — from minimal evisceration to thick peel with matting — makes any single protocol suspect. The gastroschisis prognostic score, which attempted to stratify cases by peel degree, bowel distension, and matting, did not ultimately matter as much as hoped 18:10.

What remains unresolved is whether the differences in feeding and length of stay reported in various studies reflect real physiologic differences or simply the hesitations of the teams managing these infants. The question is not yet answerable from single-center retrospective series. One discussant called for a prospective multicenter trial comparing apples to apples — same feeding protocols, same selection criteria, same outcome measures. Until then, the choice between sutureless and sutured closure rests more on institutional culture and individual case characteristics than on definitive evidence. The infant in this case could reasonably be managed either way.

Takeaways from this story

Complications are similar between sutureless and standard sutured gastroschisis repair; the choice is not about safety.
Fascial closure is not required for gastroschisis regardless of defect size; skin closure alone is adequate.
Fear of feeding after sutureless closure may artificially prolong length of stay more than the technique itself.
About 13% of sutureless repair patients require umbilical hernia repair at 4-5 years, higher than fascial closure patients.

Sutureless Gastroschisis Closure: What the Conflicting Evidence Actually Teaches

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

The serendipitous origin matters less than the principle it revealed

Tony Sandler at Iowa faced a gastroschisis defect too large to close immediately. He covered the eviscerated bowel with umbilical cord and tachyderm, planning to return to the operating room days later — but found the wound had spontaneously closed to half its original size 3:00. He subsequently reported a series of ten patients managed this way, launching what became sutureless repair. The technique's origin story is less important than what it demonstrated: that fascial closure may not be necessary for safe gastroschisis management, regardless of defect size 19:40.

Retrospective enthusiasm collided with prospective reality

Multiple retrospective studies reported that sutureless repair patients ate faster, went home sooner, and cost less to manage 4:20. The narrative was compelling: avoid the operating room, avoid general anesthesia, improve outcomes. Then the Brisoni randomized trial from Stanford found the opposite — sutureless patients took longer to reach full feeds and had longer hospital stays 4:50. A subsequent 98-patient study from UCSF with five-year follow-up showed benefit for sutureless repair, directly contradicting the randomized data 5:30. When well-designed studies disagree this sharply, the answer is not in the technique itself but in what surrounds it.

Practice patterns confound technique comparisons more than patient selection

The natural assumption when outcomes diverge is selection bias — surgeons choose sutureless closure for easier cases, skewing results 7:58. But the more insidious confounder is practice pattern. If a team hesitates to advance feeds after sutureless closure because they fear bowel distension will cause evisceration through unsutured fascia, that hesitation — not the closure technique — drives increased length of stay 7:20. When a study introduces a feeding protocol simultaneously with a new closure technique, you cannot separate which intervention changed the outcome. The lesson: compare equivalent patient populations *and* equivalent postoperative management. Otherwise you are measuring your own anxiety, not the surgery.

The umbilical hernia rate is real but the clinical burden is low

Approximately 13% of sutureless repair patients require umbilical hernia repair at four to five years of age, higher than those who received fascial closure 6:00. One study from McGill reported a *lower* hernia rate with tape closure, which surprised everyone 6:19. Patients who undergo attempted immediate fascial closure without a silo also have higher rates of umbilical or ventral hernias requiring repair 10:40. The pattern suggests that tension on the abdominal wall — whether from forced fascial approximation or from leaving fascia open — matters more than whether you place sutures. An umbilical hernia repair at age four is a straightforward operation; the question is whether avoiding it justifies the morbidity of early fascial dissection in a newborn.

Anesthetic neurotoxicity in animals does not predict human outcomes

Every general anesthetic agent across every class — volatile gases, intravenous agents, NMDA receptor blockers — causes increased apoptosis and developmental issues in rats, mice, and sheep 11:47. The animal data is unambiguous and alarming. The human data is equally unambiguous and reassuring: the GAS trial and PANDA study with five-year follow-up show no difference in neurodevelopmental outcomes between spinal and general anesthesia in infants 12:30. This does not mean the animal findings are irrelevant — it means the dose, duration, and developmental context in human infants differ enough that extrapolation fails. The clinical implication: avoiding general anesthesia for gastroschisis closure is reasonable for logistical and cost reasons, but neurotoxicity should not be the primary justification.

Heterogeneity in gastroschisis severity demands flexibility, not dogma

Some gastroschisis defects close easily at the bedside with minimal analgesia — one or two loops of bowel, minimal peel, small defect. Others present with thick peel, severe distension, and extensive matting, requiring silo placement and staged reduction 19:00. A silo can be placed, reduced over days, and then followed by tape closure even when immediate reduction is impossible 15:40. Sandler no longer considers the umbilical cord essential to sutureless closure 15:06. The gastroschisis prognostic score — quantifying peel thickness, bowel distension, and matting — was developed to stratify severity but ultimately did not predict outcomes as reliably as hoped 18:10. The teaching point: match your technique to the case in front of you, not to a protocol. Sutureless closure is a concept, not a mandate.

Takeaways from this story

Conflicting study results often reflect practice pattern differences (feeding protocols, anesthesia hesitation) rather than technique superiority.
Fascial closure is not required for any gastroschisis defect size; skin closure alone is adequate with 13% later hernia repair rate.
Animal studies show anesthetic neurotoxicity, but human trials (GAS, PANDA) find no neurodevelopmental difference at 5 years.
Severe gastroschisis (thick peel, distension, matting) should not undergo immediate closure; silo reduction followed by tape closure works.

Sutureless Gastroschisis Closure: What Serendipity Taught Us About Fascial Dogma

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 specialists · Teaching arc · AI-written, human-reviewed

The Accidental Discovery That Challenged Orthodoxy

Sutureless gastroschisis repair began not as a planned innovation but as necessity meeting observation. Tony Sandler at Iowa faced a defect too large to close primarily — so much bowel exteriorized that immediate reduction seemed impossible. He covered the viscera with umbilical cord and tachyderm, planning to return for delayed closure. Days later the wound had spontaneously closed to half its original size 3:00. That serendipitous case became a 10-patient series and launched a technique that would force the field to reconsider whether fascial closure was ever necessary.

The retrospective enthusiasm met prospective reality. Multiple single-center retrospective studies reported that sutureless patients fed faster, went home sooner, and cost less to manage 4:20. The narrative was compelling: avoid the OR, skip general anesthesia, reduce iatrogenic harm. Then the Brisoni randomized trial from Stanford inverted those findings — sutureless patients took *longer* to feed and had *longer* hospital stays 4:50. A subsequent 98-patient study from UCSF with 5-year follow-up contradicted Stanford again, showing benefit for sutureless repair 5:30. The conflict is unresolved, but it exposes something more important than which technique wins: practice patterns, not physiology, may be driving the differences.

Fear of feeding after sutureless closure may be the real variable. When the fascia remains open, clinicians hesitate to advance feeds aggressively — worried about distension, worried about evisceration 7:20. That hesitation extends length of stay regardless of whether the bowel itself would tolerate feeds. Institutions that introduced feeding protocols alongside sutureless closure saw improved outcomes, but then attributed the improvement to the closure technique rather than the protocol. The lesson: if you change two variables simultaneously, you cannot isolate which one mattered. Any prospective trial must standardize feeding advancement, antibiotic duration, and narcotic use across both arms, or the comparison remains contaminated.

Selection bias confounds every retrospective comparison. Surgeons naturally choose sutureless closure for easier cases — minimal peel, easily reducible bowel, small defects 7:58. The difficult cases — thick peel, distended loops, extensive matting — go to the OR for silo placement and staged reduction 19:00. Comparing outcomes between these groups is comparing different diseases. The gastroschisis prognostic score attempted to quantify peel thickness, distension, and matting to stratify cases, but ultimately did not predict outcomes as reliably as hoped 18:10. The heterogeneity of the condition means that any trial must either randomize at birth before the surgeon assesses reducibility, or stratify by objective criteria and power the study to detect differences within each stratum.

The umbilical cord is not essential; the concept is. Sandler no longer uses the umbilical cord for coverage — it is not as important as once thought 15:06. A silo can be placed, reduced over days, then followed by tape closure even if immediate reduction was not possible 15:40. The UCLA UC fetal consortium standardized gastroschisis care without general anesthesia or intubation and significantly decreased antibiotic use, intubation days, and opioid use — though length of stay did not change 16:02. The real insight is that minimally invasive surgery is a concept, not a technique. The principle of "less is more" applies here: avoid fascial dissection, avoid prolonged anesthesia, avoid creating iatrogenic hernias by forcing primary fascial closure under tension.

The hernia rate is the price of avoiding fascial closure. Approximately 13% of sutureless patients require umbilical hernia repair at 4-5 years of age, higher than those who received fascial closure 6:00. But umbilical hernia repair at age four is a straightforward outpatient operation. The alternative — attempting primary fascial closure without a silo — produces higher rates of ventral hernias requiring repair anyway 10:40. The choice is not between hernia and no hernia; it is between a predictable small umbilical defect versus an unpredictable ventral hernia from forcing closure under tension.

What remains settled: there is no real need for fascial closure regardless of defect size; skin closure alone is adequate 19:40. What remains unsettled: whether sutureless closure genuinely improves time to feeds and length of stay, or whether those outcomes reflect practice patterns rather than physiology. The field needs a multicenter prospective trial with standardized feeding protocols, objective criteria for technique selection, and long-term hernia follow-up. Until then, the most honest answer is that complications are similar between approaches 2:27 — and the choice of technique should rest on what the surgeon can execute safely, not on retrospective data comparing incomparable patients.

Takeaways from this story

Practice patterns, not physiology, may drive length-of-stay differences — fear of feeding after sutureless closure extends hospitalization.
Selection bias confounds retrospective studies: surgeons choose sutureless closure for easier cases, making outcome comparisons invalid.
Fascial closure is unnecessary regardless of defect size; skin closure alone is adequate, accepting 13% hernia repair rate at age 4-5.
Attempting primary fascial closure without silo produces higher ventral hernia rates than accepting umbilical hernia after skin-only closure.
Complications are similar between sutureless and sutured repair; technique choice should rest on surgeon capability, not retrospective data.

Keywords

gastroschisis umbilical hernia ventral hernia atresia bowel perforation sutureless gastroschisis closure fascial closure skin closure silo placement umbilical hernia repair laparoscopy thoracoscopic TEF repair Tylenol opioids antibiotics

Transcript

All right, so this case is that of a full-term 3.4 kilo infant who has gastroschisis. Baby's on room air, is stable, you're at the bedside, and you believe that the patient can probably tolerate a reduction and closure immediately. You go ahead and inform the family and the NICU team of your decision, and as you're just talking with the parents, you tell the family that you can either go ahead and repair it in the OR via what you call a standard suture technique with fascial closure, or you can just simply attempt closure at the bedside without sutures, utilizing the umbilical cord partially to close that effect. So, as you're talking with them and you're discussing the questions and issues, which of the following is correct regarding the sutureless gastroschisis closure? A, you have to intubate them. B, by doing sutureless repair, your time to full feeding is reduced. B, you cannot do sutureless repair. C, if a silo has been used. D, complications are fairly similar to a standard repair. Or E, there is an increased length of stay when you do a sutureless repair. So, let's discuss while we're waiting. Who here uses a sutureless repair? Puts tape on it. One, two, three, who, four, five. Who does a sutured repair? Go to the operating room. Baby's born with gastroschisis, you go to the operating room. So, you have to define what you mean by sutured repair. So, sutured repair, is it fascia closure, or is it you're just suturing the skin together in a purse string fashion? Because that can also be a sutured repair-ish. But really, when you talk about sutured repair, you're talking about fascial closure. Fascial closure. Are you closing the fascia or not? Well, does anyone just close skin? Yeah, I just close skin. Ah, interesting. I didn't know that. Okay. So, you do that at the bedside? No. You can do it at the bedside. Oh, yeah. Or you can just take the OR. Fascial closure. Anyone go for fascial closure one? Okay. So, it's pretty split here between B and D. Yep. So, the answers here right now on the poll, most people chose B, in which that if you do a suture-less repair, the time to full feeding would be reduced, versus D, that the complications are similar to a standard repair. And the answer is, in fact, that the complications are similar to standard repair. And so, when we look at the suture-less repair, the whole idea of suture-less repair in the fashion that is being done now, came about, like most things in pediatric surgery, by serendipity. I think it was Tony Sandler was in Iowa at the time, and he had a baby who came with the intestines, just so much of it out, he couldn't figure out what to do. It took him a while to get everything back in. And once he got everything back in, the wound was so big, he just couldn't close it. And so, he figured he'd just flop the umbilical cord over it and put a tachyderm on top of it and said, we'll come back and fight another day. And when he came back to fight in a few more days, in fact, the wound was closing. It was half the size, and then he let it go, and then it just closed up on his own. So, he was quite surprised with that. And then a couple of years later, he actually reported a series of these patients. The first series had about 10 patients in it, and it was his experience from Iowa. And he reported, basically, he didn't need to take them to the OR. They just closed on their own. So, that's how the whole idea got born. The thoughts are that, well, obviously, you don't have a need for anesthesia. You can do this at the bedside. You don't need the anesthesia. You don't need the transport to the OR. There's a chance to improve other outcomes as well. In fact, the data is somewhat conflicting. And so, there's been multiple retrospective studies on this, which have reported that, yeah, they just, they're way better. They eat quicker. They go home better. They don't need to go to the OR. And therefore, it's probably cheaper to manage them this way, too. And so, it was great. But when there was a randomized study that was done, so this was a randomized study that was done about two or three years ago that was published in the Journal of American College of Surgeons by Brisoni and their group from Stanford. And they randomized babies at birth to either have sutureless repair, which could be done with or without the silo, or to sutured repair, where they close the fascia. And what they found was kind of strange. What they found was that they found they took longer to eat. They had a longer hospital length of stay in some cases. And so, it was conflicting data because it conflicted with all the retrospective studies and even a subsequent one, which was done with 98 patients from their partners in San Francisco at UCSF, which showed a benefit for all of those things. So, I think the jury's still out as to where sutureless repair lies. The take-home message, as the slide says, is that what it's taught us, perhaps, is that the old adage that you must close the fascia for all these babies is probably not true. You can just simply do some kind of version of a skin closure, and that's okay. You leave an umbilical hernia. The data over five years shows that about 13% of them will need an umbilical hernia repair performed, which is higher than babies who got a fascial repair. But umbilical hernia repairs at about four or five years of age is usually a very straightforward operation. So, on that last point, so I love how you phrased all this because there have been, and I'm sure Witt can attest to this, there have been a lot of papers in JPS over the last couple of years because I know we've done a lot of reviews on them looking at these two groups. And you said it perfectly. They all disagree with each other. The study by Robert Baird when he was at McGill showed everything was better about the tape closure versus... In fact, in his paper, they had a lower umbilical hernia rate, which was really surprising. But then you have the Brouzoni study, which disagreed. I think it's time for the Midwest Pediatric Surgical Consortium to do this the right way. We need to get multiple centers together, not single center. It has to be prospectively evaluated. I think one of the things that... So we looked at our own data recently and found that obviously our length of stay had gone up since we'd started doing more suture-less closures. And one of the things that we think is driving it is a fear of feeding, right? Okay, the kid doesn't have a primary closure of their fascia, so we're hesitant to feed them because we don't want them to get super distended and evisceree, right? And so that's sort of been our thoughts. We actually just recently with our NICU instituted a feeding protocol. And so we have some more objective things. If the repugal output is less than 20 per kilo, it comes out. If the kid is tolerating, you go up by 20 per kilo each day and trying to see if we can push ourselves along to having normal things. I think it's really hard in these studies to know what's driving your difference in feeding or your difference in length of stay. Is it practice patterns because of our own hesitations or is it really a difference in the patients? It's totally, you're absolutely right. Practice patterns. And so in some of those studies, they simultaneously introduced a feeding protocol. And then they said, oh, they introduced a feeding protocol. And so the key thing here is, as Todd mentioned, if you're going to do a prospective trial is to make sure you compare apples versus apples. Because there will be a natural selection bias that, oh, this one is easy. And so, and is more amenable to a sutured repair. I mean, a sutureless closure. And so those are the ones that are going to have a better kind of easier, slower, quicker outcome anyway. So it's careful, have to be careful that you're not selecting out patients who are going to be better, if you will, right off the bat. So you have to make sure that you put equal emphasis on that. So, Salim, I was interested in your figure of around 13%, 15% of patients who I think I understood eventually needed an umbilical hernia repair as opposed to actually who had an umbilical hernia but never underwent a repair. So my question has to do with the mechanism of closure of the umbilical fascia. So I think we all think that there's some contracting mechanism that happens at birth that we don't really understand that allows the umbilical hernias to close. The teaching used to be that that didn't really happen if you had an abdominal wall defect because somehow you interrupted that contracting mechanism. So is there any more information about how or why the umbilical fascial defect actually closes in these babies who undergo the sutureless repair? I think so. I think it's uh, each study that mentioned it, the last one was the uh one from UCSF with 98 patients which was published in uh JAMA Surgery, I think last year or earlier this year. And basically they they found they're the ones who studied them for over five years. So they had five years of data and they the older ones were acquiring hernia repair, 13% is what they found when they compared it to the sutured group that was historical control. And so um, they didn't comment much on that um, but yeah, that's an interesting uh thing that maybe need to be looked at. There's other studies which have shown that when you attempt a fascial closure and try to bring it all together um uh without a silo, so an immediate repair, those patients tend to have a higher incidence of umbilical hernias or ventral hernias, whatever you want to call it, requiring repair. So, so you know an interesting thing you get sometimes get pushed by your peers. So I, I uh, really loved closing these with the baby paralyzed. Um, I been pushed by my peers saying why are you still intubating these patients? No one else does that. And so now I've been pushed by my peers where I do it that way. And I still think it's uncruel and unusual punishment to the kid who, who does not love having their bowels squished in while they're awake. I do it. I, my, I'm wondering about risk reward on that. I think my success rate's higher when um, when I do it with them paralyzed. But I know that the, that the, the recommendations are to do this with them wide awake. So I, I, when I do my, and I do a variation of it, like I said, I do a suture, I suture the skin closed with a monocle stitch and just purse string it around the umbilicus. Um, and I don't close the fascia. Uh, so I don't require them to be paralyzed, but they are asleep. And, um, and so they do get intubated from that standpoint. That brings to the question of whether we believe that a general anesthesia in this age group, in fact, is, uh, has a problem or not. And I think animal studies say yes. Animal studies say that every single general anesthetic agent in every class that has been studied, whether it's a volatile gas, whether it's an IV, whether it's ketamine or an NMDA receptor block, it doesn't matter. All of them in rat studies and mice studies and sheep studies have shown, uh, that, um, they all cause increased apoptosis and, and pervasive developmental issues. When you look at humans, though, they've been now two or three very well done trials, including the GAS trial and the PANDA study. The GAS trial now has five-year data showing no difference in neurodevelopmental outcome in babies randomized together, either, you know, the spinal, uh, their ingrown or near-paired under, spinal or general anesthesia, arguably using the dumber gender males, um, as their, as their higher population and comparing them to females. Mac? Just to make an obvious comment that we all understand, but I'm not sure we said it out loud. You, you hinted at it, Salim, and that is the heterogeneity of this population makes a huge difference in the results we're talking about now. There are some where the, the, uh, flap closure works easily. Little Tylenol in the bottom and shove the one or two loops back in. But then you've got these complicated cases that need a silo and need to go to the OR and need other things. So right now we have one prospective randomized trial. Correct. Where they didn't take into consideration the heterogeneity. All those other trials are biased by this one I can do this way, but that one is really hard. And so we just, as we go forward, we need to figure out how to sort that out. That's all. Absolutely. One size certainly does not fit all. No. And, and there has to be, um, horses for courses. Mark Wilkin. So I was going to say recently, uh, one of my fellows talked me into taking a larger defect and we couldn't, wouldn't close it with the umbilical cord all the way across. And we just spiral it around. And even that works. I mean, it's, uh, you just love, as long as you have enough cord. So, you know, I mean, it's interesting. I think that, I think the technique is still evolving. And, you know, again, to Max's point, we're not sure what patients this is going to work best in and which ones it's not. You know, but one of the things that is a theme been, you know, through this, all of these presentations this morning is that less is more. And, you know, one of the things that, you know, I always say, you know, you know, way back when this course used to be all about, you know, how to do a thoracoscopic TEF or a lobe. And it was all about MIS. And, you know, I'll say that minimally invasive surgery is a concept, not a technique. And, you know, this is just taking that concept to gastroschisis. And, you know, I do think that as we think about things, that we do a lot of things that cause more harm. And, you know, whether it's interfering with the abdominal wall's ability to close up that umbilical hernia or not by messing with it, who knows. Maybe Salim has the answer where you just close the skin. I don't know. I don't like that, actually. But there's a lot of, you know, I think there's a lot of questions still to be answered. So a couple things. Tony Sandler says that he, I think, I think I'm right about this, he does not even use the umbilicus anymore, the umbilical cord anymore. Or he don't need it. You could just, that's not as important as we once thought. I think it just sort of sits there. So that's number one. Number two, some people will put a silo on, reduce it with the silo, and then put the tape. So even if you can't get it back in, it doesn't mean you need to immediately tape the kid. We have just, and before we get to Steve, so Maria Varela from Argentina says that they currently take them all to the operating room for a general anesthesia for fascial closure. Number one, she says they see umbilical hernias in this population. And she's very intrigued by this discussion, and maybe try the other way. Steve? So part of the, at UCLA, we have a UC fetal consortium where we actually standardize the care for gastroschisis. And all of them are attempted without general anesthesia, without intubation, even minimal narcotics. And we've, you know, also identified antibiotic protocols, feeding protocols, and so forth. The, and what we found was very interesting was the fact that the length of stays did not decrease, even with this strict protocol. What we did find was the use of antibiotics, the intubation days, and the opioid use significantly decreased. So one of the partners also was able to even open the defect, reduce everything back down, and still do a skin closure or suture-less closure with that. And that still works very well with great outcomes. Just a question for you. So if you have patients with complicated gastroschisis, so they have a... They're out the door. They don't fit the pathway. So do you, but do you close them initially, or do you take those patients to the OR and address their atresias or... The complicated? Like if you have a patient with an atresia that you can obviously see when they show up. We've closed them and addressed them later on. That's what I do too. Unless it's the only ones that we don't, it would be those that are perforated. I think next year we should do that as a topic, because I know that you, Aaron, taught me some stuff that you do with when you have an atresia. Best way to manage an atresia with gastroschisis. And we've had like five in the last two months, so it would be an interesting thing to discuss. Any other... Here's a question from the audience related to asking about whether some of these different factors will influence what technique you use to close in terms of thickness of the peel on the intestines and whether the baby was born via C-section or vaginal delivery. So rural delivery usually doesn't make a difference, at least in the way I look at it. They should all be, unless there's an obstetric indication or something like that, they should probably all be delivered vaginally, I think. That's pretty much the consensus from studies. So there's that. The other issue is the degree of peel. So the degree of peel was tried, they tried to kind of quantify that using what's called the GPS, the gastroschisis prognosis prognostic index or prognostic score. And the Canadians did that using capsnet. And they assigned a score based on the degree of peel, the degree of bowel distension, matting, and they gave it a score. I forget what the scoring system was on a scale of 1 to 10 or 1 to 5. And they used that as a proxy to see if that would help in kind of telling, these are really bad ones, these are really good ones. The GPS in the long run didn't seem to really matter as much. It was a good idea, but it didn't really end up mattering that much. But most of us would say that if you have one which looks really bad with a very thick peel, very distended, and lots of bowel loops out, then you would probably not want to consider an immediate closure. Those will all go in the silo, and you'll try to reduce them and get them done. At the end of a silo, you can always do a suture-less repair. That's fine. But you wouldn't try to do an immediate closure. So in those studies, what is the rate of conversion from suture-less technique to surgical closure and reasons for the same? Did they discuss that? They didn't. They did talk about how there's been a transition, like Todd mentioned, that basically everybody said, this is the way we're going to do it. And people were dragged kicking in or screaming, or both, into doing it. And so they converted in 2013. Their group converted. And so they just pretty much all do it suture-less. The question when you talk about suture repair, again, you have to talk about what you really mean by that. So if you're just using sutures to close the skin because somehow it's too wide a defect to bring things together, versus you're actually closing the fascia. So I think at this point we've understood that there's no real big need for fascial closure, no matter what the size of these gastroschisis defects. That if you can get skin closure alone in some way, shape, or form, that's probably adequate. So they didn't mention much about that. But again, those which they're unable to close, you can always just bring the skin together. Question from India. They want to know if matted bowel plays into your decision about what to do. For me, it doesn't. I don't usually matted. So if it's really badly matted, then you can't do an immediate closure necessarily. You won't be able to be able to push everything back in. You'll probably end up putting a silo on and using a silo to reduce. And once it's reduced, then it doesn't matter. You're right. You can do a suture-less repair at that point. It's completely fine. You can just cross the skin. Okay. And so that, yep. So matting doesn't really matter. Let's go to break because I think...

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