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Abdominal Wall Defects
Chapter 1 of 7 · Acute Management
Delivery planning
Prenatal management and delivery planning for gastroschisis
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
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
Most damage to the intestine in gastroschisis occurs in the last few weeks of pregnancy, supported by animal and clinical studies.
Delivering gastroschisis at 37 weeks results in better neonatal outcomes compared to waiting for spontaneous labor.
The age at spontaneous onset of labor for gastroschisis pregnancy is 3 weeks earlier than the general population.
About half of gastroschisis pregnancies go into labor spontaneously before 37 weeks.
No perinatal center in Canada performs routine cesarean sections for gastroschisis.
Routine cesarean section for gastroschisis was standard of care 15-20 years ago but has gone out of favor.
Using forceps and retractors for bedside reduction can harm the bowel in some cases.
A pre-formed silo allows gentle reduction of gastroschisis contents without harming the bowel, and in about one-third of cases the bowel can be reduced immediately and the silo removed.
Waiting for the neonate to lose 10% of body weight reduces bowel edema and makes reduction easier.
Leaving a silo on for more than one day causes the fascial defect to enlarge significantly.
A larger fascial defect after silo removal takes longer to contract and heal if not surgically closed.
Rafensberger's group closed 80% of gastroschisis cases primarily; current practice has decreased to one-third to one-half primary closures.
Plastic closure (non-surgical closure with dressing) produces extremely good results for gastroschisis, often with a small umbilical hernia that closes by age 2 in the vast majority of cases.
Plastic closure avoids the need for operating room and general anesthesia in successful bedside reductions.
Primary repair of atresia in gastroschisis is appropriate when the bowel does not look damaged.
If the bowel looks nasty or matted, the atresia should be managed by reduction and delayed repair at 6 weeks.
There are two types of intestinal atresia in gastroschisis: early-developing atresia not always associated with bowel thickening, and late atresia due to very small abdominal wall defect.
Bringing an ostomy out through the umbilicus avoids a lateral scar and makes appliance placement easier.
Gord Cameron first described umbilical ostomies in the 1980s.
A mechanical stricture causing feeding intolerance after gastroschisis repair, when fixed surgically, can result in full feeds within 1-2 weeks.
At 4 weeks post-gastroschisis repair with feeding intolerance, waiting longer is reasonable; at 8 weeks, exploration is warranted.
Removing the omphalocele sac and attempting closure can lead to inability to achieve closure and need for prosthetic patch.
A partially ruptured omphalocele sac can be closed and painted, functioning as an autogenous silo.
Schuster-type repair uses mesh sutured to fascia with gradual closure over the intact sac, eventually allowing primary repair.
For large omphalocele in a full-term baby with no other problems, staged closure with patch and skin coverage is preferable to paint-and-wait, which takes months.
Lateral component separation can facilitate bringing fascial edges together in omphalocele closure.
Keeping the omphalocele sac supple with antibiotic ointment, applying stacked 4x4s, and wrapping with Ace wrap can facilitate gradual reduction.
Aquacel applied to omphalocele sac is not recommended as it does not come off easily.
Pharmacy may restrict silver sulfadiazine use in the first month due to sulfa interaction concerns.
Ventilatory parameters are the most reliable measure of safe abdominal closure tension.
Bladder pressure measurement is standard practice at Cincinnati Children's for 24 hours post-closure, though its reliability is questioned.
Intragastric pressure via NG tube is easy to measure intraoperatively and provides a useful guide, with 20 mmHg as a suggested threshold.
Intragastric pressure of 12 mmHg with a stable baby provides reassurance that closure is safe; pressure of 35-40 mmHg raises concern even if the baby appears stable.
Omphaloceles with a big opening and much content externalized often reduce spontaneously over 6-12 months with paint-and-wait, making eventual closure straightforward.
Omphaloceles with a narrow opening require staged enlargement of the defect to allow gradual reduction over 2-3 stages without need for patch or component separation.
In older children with giant omphalocele, rapid reduction can cause abdominal compartment syndrome and death; time must be allowed for abdominal domain expansion.
When enlarging the fascial defect in a giant omphalocele with liver externalized, the inferior direction is safer to avoid hepatic veins superiorly.
Wrapping Duoderm around an omphalocele and tightening daily can achieve gradual reduction without sutures.
Botox has been used successfully in adult ventral hernia repair to relax muscle and facilitate closure.
Silver sulfadiazine is commonly used to paint omphaloceles, though some use Betadine initially or Xerform.