External Silo Reduction of the Unruptured Giant Omphalocele

By Barbara Barlow, Arthur Cooper, Rajinder Gandhi, and Maria Niemirska New York, N e w York

�9 Construction of an external silo dressing over the intact omphalocele membrane allows complete reduction of the giant omphalocele with enlargement of the abdomi- nal cavity before surgical intervention, so that primary closure of the abdominal wall can be achieved. Three infants with giant omphalocele containing a central liver were successfully managed by this technique avoiding the complications associated with operative silo placement or simple membrane painting. �9 1987 by Grune & Strat ton, Inc.

INDEX WORD: Omphalocele.

T HE GIANT OMPHALOCELE, which contains the liver, cannot be closed primarily. Current

treatment is operative insertion of a prosthetic silo attached to the abdominal wall, followed by gradual reduction of the contents. Infants who are unable to tolerate operative intervention are treated by painting of the membrane, which gradually epithelializes. Both methods are associated with complications: premature silo separation, sepsis, or fistula formation in the former method; and failure of the abdominal cavity to enlarge in the latter method.

Construction of an external silo dressing over the intact omphalocele membrane allows gradual reduc- tion of the omphalocele contents with enlargement of the abdominal cavity. Primary closure of the abdomi-

Fig 2. Partial reduction by second day of life.

nal wall defect can then be achieved avoiding the problems of current management.

This technique has been used successfully on three infants with giant omphaloceles. The abdominal wall defects were 10 cm or greater, and the intact omphalo- cele sacs contained central livers. Two infants had respiratory insufficiency at birth, which improved prior to closure of the abdominal wall; the third infant was normal except for the omphalocele.

MATERIALS AND METHODS

Infants with intact omphalocele treated by this method have a nasogastric tube inserted, which is continuously aspirated to avoid gaseous distention of the bowel. In addition, the infant spontaneously passes meconium, so that at the time of abdominal wall closure the gastrointestinal tract is completely decompressed.

Fig 1. External silo perpendicular to infant's abdomen.

From the Division of Pediatric Surgery, Harlem Hospital Center, Columbia University, College of Physicians and Surgeons, New York.

Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto, Ontario, May 14-17, 1986.

Address reprint requests to Barbara Barlow, MD, Chief of Pediatric Surgery, Harlem Hospital 17103, 136th and Lenox Ave, New York, NY 10037.

�9 1987 by Grune & Stratton, Inc. 0022-3468/87/2201-0019$03.00/0

Journal of Pediatric Surgery, Vo122, No 1 (January), 1987: pp 75-75 75

76 BARLOW ET AL

Fig 3. Complete reduction by fourth day of life. Fig 4. Primary closure on fifth day of life.

The membrane is painted twice daily with povidone-iodine and covered with zeroform gauze to prevent adherence of the external silo dressing to the membrane. The omphalocele is wrapped with an elastic gauze roller bandage forming an external silo (Fig 1). The bandage is passed loosely around the infant's body supporting the omphalocele perpendicular to the infant's abdomen. If the omphalo- cele cannot be supported perpendicular to the abdomen by the dressing alone, umbilical tape is incorporated in the dressing so that the dressing can be suspended by the tape from the isolette. The apex of the omphalocele is wrapped more firmly than the base promoting return of the contents to the abdominal cavity. Pressure provided by the dressing must be limited to the area of the membrane with downward pressure over the defect. Circumferential pressure around the abdomen will interfere with expansion of the abdominal cavity, elevate the diaphragms and produce leg edema. The dressing is changed twice daily and at each dressing change the membrane is inspected. Gradual reduction of the omphalocele contents can be achieved during each dressing change as the abdominal cavity progressively enlarges (Fig 2). Complete reduction of the omphalo- cele contents, so that the dressing was flat on the abdominal wall, was achieved for the three infants in three to five days (Fig 3). After the omphalocele contents have been reduced, a loose circumferential dressing is applied with gauze placed over the zeroform in the defect to hold the membrane at the level of the fascia. When the general condition of the infant allowed operative intervention, primary closure of the abdominal wall was achieved in all three infants with gentle stretching in order to approximate the rectus muscles (Fig 4).

DISCUSSION

Construct ion of an external silo dressing with grad- ual reduction of the omphalocele contents allows pri- mary operative closure of the giant omphalocele at a t ime when the abdominal cavity has enlarged suffi- ciently to hold the bowel and liver present within the omphalocele sac at birth. The sick newborn can recover from respiratory distress or neonatal sepsis before undergoing major operative intervention. The complications associated with surgically placed pros- thetic silos are avoided.

This technique was originally devised for the sick newborn with a giant omphalocele. It has proved to be so successful tha t we plan to use an external silo dressing for all infants with a giant omphalocele and for infants with an intermediate sized defect who would require postoperative respiratory support if pri- mary closure was performed. An operatively placed prosthetic silo can be inserted if membrane rupture occurs during external silo reduction or if the reduction of the omphalocele contents is not progressing satisfac- torily.