6. Initial management (pre-operative management)

A GS infant is ideally delivered at or near a facility with pediatric surgical support [25]. Conversely, outborn cases have been shown to have worse outcomes such as longer days on parenteral nutrition and longer duration to achieving full feeds [54].

The accepted approach to managing GS is to cover the gut with a sterile bag (Figure 3), nasogastric decompression and fluid resuscitation. Hypothermia is a major risk due to the exposed gut and significant fluid losses [55]. Premature babies are particularly prone to hypothermia because of their high ratio of skin surface to weight and a lower amount of subcutaneous and brown fat. They may also have respiratory issues which impact on their oxygen consumption and heat production [55].

The authors follow the protocol outlined in Figure 4. At the outset doctors and nurses are reminded that the triad of hypovolemia, hypothermia and sepsis are the major threats to this neonate and that resuscitation is directed to mitigating their

or teratogen-induced mesenchymal failure [19]. None of the theories are fully satisfactory [20]. The right-sided occurrence of the defect has been linked to the position of the yolk sac [15, 21] without clear reasoning as to why. Left-sided defects

In high-income countries (HICs) routine antenatal scans may detect more than 97% of cases [23]. A diagnosis can be made as early as 10 weeks of gestation [24] and aids counseling, transfer and delivery [25, 26]. Ultrasound will typically pick up herniated bowel not covered by amnion, to the right of the umbilical cord (Figure 2). In contrast, an exomphalos will be covered by a membrane, lies in the

have also been described [22].

Gastroschisis with prolapsed bowel to the right of the umbilicus.

Pediatric Surgery, Flowcharts and Clinical Algorithms

3. Antenatal diagnosis

Figure 1.

Figure 2.

118

Antenatal scan showing GS.

effects. Almost simultaneously, certainly not sequentially, the baby is positioned lengthwise on a resuscitaire or warmer to facilitate access. Any wires, leads or lines are shifted away from the baby and the bowel. Kinking of the bowel is avoided by laying the child on their side or by propping up the bowel with gauze rolls in the supine position. Probes for temperature and oxygen saturation are connected. ECG leads are placed and connected to a monitor. A urinary catheter is placed with an aseptic technique. Resuscitation follows APLS guidelines of airway, breathing, circulation, rapid initial examination while the bowel is covered with cling film. An appropriately-sized nasogastric tube is placed on free drainage supplemented by 2-hourly active aspiration. Peripheral vascular access is secured and bloods are taken for blood sugar (if not done earlier), a complete blood picture, kidney and liver functions, clotting and cross-match. A fluid bolus is then administered

followed by maintenance according to body weight. Broad-spectrum antibiotics are

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

All manipulations should be done in a sterile environment. The authors routinely

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

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

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

given according to the hospital protocol.

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

Management of Gastroschisis

7. Intra-operative decision making

reduction should be considered.

initial resuscitation in all cases.

instead of primary closure [20, 55, 58].

121

#### Figure 3.

Cling film covering the bowel in gastroschisis.

#### Figure 4.

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.

### Management of Gastroschisis DOI: http://dx.doi.org/10.5772/intechopen.85510

effects. Almost simultaneously, certainly not sequentially, the baby is positioned lengthwise on a resuscitaire or warmer to facilitate access. Any wires, leads or lines are shifted away from the baby and the bowel. Kinking of the bowel is avoided by laying the child on their side or by propping up the bowel with gauze rolls in the supine position. Probes for temperature and oxygen saturation are connected. ECG leads are placed and connected to a monitor. A urinary catheter is placed with an aseptic technique. Resuscitation follows APLS guidelines of airway, breathing, circulation, rapid initial examination while the bowel is covered with cling film. An appropriately-sized nasogastric tube is placed on free drainage supplemented by 2-hourly active aspiration. Peripheral vascular access is secured and bloods are taken for blood sugar (if not done earlier), a complete blood picture, kidney and liver functions, clotting and cross-match. A fluid bolus is then administered followed by maintenance according to body weight. Broad-spectrum antibiotics are given according to the hospital protocol.
