7. Intra-operative decision making

The aspired aim is to achieve full reduction of the bowel with muscle and skin closure of the abdominal wall, as cosmetically as possible. Safety of the child and the gut are paramount therefore if a complete primary closure is not possible staged reduction should be considered.

All manipulations should be done in a sterile environment. The authors routinely take all cases to theatre, however bedside procedures are also possible. Central vascular access is secured and a urinary catheter would have been placed during initial resuscitation in all cases.

The authors follow the guideline outlined in Figure 5: cases of simple GS with no obvious viscero-peritoneal disproportion (VPD) will undergo primary closure. If very straightforward, sutureless closure with steri-strip dressings is done. On occasion some cases will require division of bands or strands of omentum adherent to the defect and they go on to have formal sutured closure of the defect. Primary (sutured) closure has excellent cosmetic results (Figures 6 and 7). Sutureless closure is associated with a higher incidence of umbilical hernia [56, 57] Guided by ventilation pressures, cases with moderate VPD will undergo a skin closure with the size of the defect determining if the umbilicus, the skin or a prosthetic patch is needed. Marked VPD and high ventilation pressures call for staged silo closure. The authors fashion surgical silos from sterile intravenous fluid bags (Figure 8a–c). Surgical silos can be made from a variety of materials which are summarized in Box 1. Spring-loaded (pre-formed) silos are ready-made and obviate the need for suturing to the abdominal wall [20, 55]. They come in various sizes to allow for the variability in the GS defect (Figure 9). One may rely on gravity alone, active tucking or a combination of both to reduce the contents into the abdominal cavity. There is weak evidence in favor of the routine use of pre-formed silos instead of primary closure [20, 55, 58].

Complex GS is defined as any case with associated bowel atresia, stenosis, perforation or volvulus. In the presence of atresia, the authors' preference is to plan a delayed repair but a primary resection and anastomosis at the time of abdominal closure is also acceptable if the bowel is healthy and not too edematous. Stoma formation is fraught with high-output stoma complications such as failure to thrive and peri-stoma skin breakdown—therefore is not the surgery of choice in lowresource settings. Closing GS represents a spectrum of disease where the defect has started to narrow down around the prolapsed gut. At its simplest form it can lead to intestinal stenosis but may progress to atresia, gut ischemia up to complete

Figure 4.

120

Figure 3.

Cling film covering the bowel in gastroschisis.

Pediatric Surgery, Flowcharts and Clinical Algorithms

Initial management of gastroschisis. \*

Kinking can be avoided by laying the child on their side or by propping up

the bowel with gauze rolls while the child is supine. \*\*ABC of basic resuscitation. Do not forget blood sugar.

CBC, complete blood count; UEs, urea and electrolytes; LFTs, liver function tests.

disappearance of the prolapsed bowel if the defect closes completely, aka closed GS

associated with worse outcomes compared to simple GS. Narrowing or atresia may

" [61]. Closing GS is challenging even in HICs and is

or

123

Figure 7. Primary Closure.

Figure 6.

Cosmetic result after primary closure.

Management of Gastroschisis

DOI: http://dx.doi.org/10.5772/intechopen.85510

"vanishing gut syndrome

Figure 6. Cosmetic result after primary closure.

disappearance of the prolapsed bowel if the defect closes completely, aka closed GS or "vanishing gut syndrome" [61]. Closing GS is challenging even in HICs and is associated with worse outcomes compared to simple GS. Narrowing or atresia may

Figure 5.

122

Pediatric Surgery, Flowcharts and Clinical Algorithms

Options for closure of gastroschisis. \*Can be done cotside. \*\*Silo material, see Box 2.

VPD,

viscero-peritoneal

disproportion.

\*\*\*Delayed repair is around 6 weeks

post-operatively.

 \*\*\*\*Avoid stoma in a

low-resource

 setting. GS, gastroschisis;

Figure 8. (a–c) Staged silo reduction.

#### Box 1.

Available silo materials [55, 59, 60].

Figure 9. Pre-formed silos http://bentecmed.com/bentec-medical-products/ventral-wall-defect-silo-bags/.

lend themselves to resection and primary anastomosis (either at the time of reduction, or delayed). Necrotic gut will require resection (Figures 10 and 11) and vanished gut will indicate an ultra-short intra-abdominal segment. These cases will require either primary or delayed bowel lengthening procedures [62].

8. Post-operative care

Closing gastroschisis with necrotic bowel.

Figure 11.

125

Figure 10.

Closing gastroschisis with necrotic bowel.

Management of Gastroschisis

DOI: http://dx.doi.org/10.5772/intechopen.85510

The staged reduction process should take between 1 day and 2 weeks and is dependent on the degree of VPD. Enteral feeds are started once the gastro-intestinal system shows signs of resumed function: decreased nasogastric aspirates <20 ml/kg and bowel motions. Ideally expressed maternal breast milk is used [63–65], but formula feeds are acceptable. Elemental feeds may help protect against necrotizing enterocolitis. GS infants fed at around 7 days post closure seem to have the best outcome [66]. If the bowels do not open within 10–14 days a water-soluble contrast

Figure 10. Closing gastroschisis with necrotic bowel.

Figure 11. Closing gastroschisis with necrotic bowel.
