Use of Pledgets
in the Repair By
Gastroschisis;
omphalocele.
I
N THE SURGICAL management of omphalocele and gastroschisis, primary closure,‘,2 skin flap technique,3,4 or silastic silo technique5-’ are all used for the repair of the abdominal wall defect. The choice of procedure is dependent on the local anatomical situation.‘.8 However, none of these techniques can avoid substantial tension at the approximating sites because there is usually a significant disparity between the size of the exteriorized viscera and the capacity of the abdominal cavity.‘.” The sutures used to approximate the fascia, skin, or silastic sheet may tear through tissue causing abdominal wound disruption, evisceration, or subsequent incisional hernia. To avoid these serious complications, we have successfully used Dacron felt pledgets on the sutures to protect the tissue from tearing. The results have been most satisfactory. This article introduces the technique. TECHNIQUE
Primaiy Closure
In patients with little disparity between the volume of the eviscerated abdominal contents and the abdominal cavity, primary closure is indicated as the ideal technique, avoiding multiple staged operations.‘.‘.’ For easier reduction of the eviscerated organs, we use incisions that extend the defect craniocaudally in the midline. Double-armed 3-OTevdek sutures are placed in an interrupted horizontal mattress fashion through the linea alba, with Dacron felt pledgets (3 x 5 mm) on the margins. The sutures are not individually tied. After placing all sutures, the sutures are tied, beginning with the one at the inferior corner. Traction is
From the Department of Surgery, The University of Iowa College of Medicine. Iowa City, LA. Date accepted: June 26,199O. Address reprint requests to Ken Kimura, MD. Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Copyright o I992 by W B. Saunders Company 0022.3468/9212701-0017$03.0010 64
Wall Defects
Ken Kimura and Robert T. Soper lo wa City, lo wa
0 This article describes surgical techniques using Dacron felt pledgets over the sutures to protect tissue against tearing in the procedures used for the closure of the abdominal wall defect in gastroschisis and omphalocele. Copyright o 1992 by W.B. Saunders Company INDEX WORDS:
of Abdominal
placed on the adjacent suture while the first is being tied to reduce tension on the suture being tied. The underlying abdominal viscera should be retracted by a malleable retractor to avoid trapping viscera between the approximated fascial edges. Skin Flap Technique
This technique is used in patients with a large disparity between the size of the eviscerated abdominal organs and the space within the abdominal cavity.4 From the margins of the extended abdominal incisions in the midline between the xyphoid process and the pubic symphysis, the skin with its subcutaneous tissue is detached bilaterally from the underlying anterior sheath of the rectus abdominis and the external oblique aponeurosis as far lateral as the anterior axillary line. Traction sutures placed on the margins of the skin and incised linea alba facilitate this dissection (Fig 1). With traction on the undermined skin flap, the medial edges of the longitudinally incised linea alba are sutured to the undersurface of the skin flap using continuous 4-O Vicryl sutures; this prevents retraction of the fascial edges as well as subsequent herniation of abdominal viscera into the space between the skin and the fascia (Fig 2). The margins of the skin flap are then lifted and approximated in an everting fashion. For this purpose, double-armed 4-O Tevdek sutures are placed in an interrupted horizontal mattress fashion through Dacron felt pledgets (4 x 8 mm). The sutures should
Fig 1.
At creation of the skin flap, traction sutures are placed along of the linea alba.
JolournalofPediatr;ccSurgery, Vol27, No 1 (January), 1992: pp 64-66
REPAIR OF ABDOMINAL
WALL DEFECT
Fig 3. Skin flap technique. The margins of the skin flaps are approximated in everting fashion using horizontal mattress sutures over the Dacron felt pledgets.
back into the abdominal capacity.” During this period of 7 to 14 days, the abdominal cavity rapidly expands and the eviscerated organs reduce in size, finally enabling the margins of the abdominal wall defect to be approximated. In this procedure, persistent tension is produced on the sutures that attach the silastic silo to the fascia of the linea alba, with a possibility
Fig 2. Cross-section of the abdomen. With the skin flaps lifted under moderate traction, the margins of the linea alba are sutured to the undersurface of the skin flaps (arrows) to prevent development of hernia.
be tied relatively loosely to avoid strangulating the skin flaps sandwiched between the pledgets (Fig 3). Two to 3 months later, definitive reconstruction of the abdominal wall is undertaken. The margins of the linea alba are approximated using the same technique described for primary closure. Mastic Silo Technique In patients with a large defect or great disparity between the eviscerated abdominal contents and the size of the abdominal cavity, a silastic silo is created to temporarily accommodate the abdominal viscera.‘-’ Following this procedure, the silastic silo is daily plicated to reduce its capacity, providing substantial pressure to reduce the eviscerated abdominal organs
Fig 4. In silastic silo technique, the silastic sheets are sutured to the margins of the linea albe using the sutures on Dacron felt pledgets in horizontal mattress fashion.
66
KIMURA AND SOPER
that the sutures might tear through the tissue and detach the silo from the abdominal wall. Use of pledgets on the sutures can prevent this complication. A Dacron-reinforced silastic sheet of an appropriate thickness is tailored to match the size of the abdominal wall defect. We use two identical sheets, one for the right-hand side and the other for the left-hand side of the linea alba. The silastic sheet is approximated to the abdominal wall fascial rim using double-armed 3-O Tevdek sutures in an interrupted horizontal mattress fashion, with pledgets on the abdominal wall fascial edge in an everting fashion (Fig 4). The sides and top of the silastic sheets are approximated using continuous stitches of 3-O Tevdek to completely wrap the eviscerated abdominal organs. Seven to 14 days later, when the daily plications of the silo have allowed the herniated viscera to return to the abdominal cavity, the abdominal wall defect is closed by approximating the margins of the linea alba. After resecting the silo, the technique identical to primary closure is used. DISCUSSION
In patients with gastroschisis treated by primary closure of the abdominal wall defect during the early 1970s we experienced serious complications of bowel fistula, which were caused when bowel was lacerated by suture material that bridged between dehisced fascial margins.4 Elevated intraabdominal pressure would thrust the bowel segment against the suture material and contribute to the injury. This experience motivated us to try to improve the suturing techniques used to close the abdominal wall defect. We
knew that in cardiac surgery pledgets were used to safely attach synthetic materials to myocardial tissue without tearing through this constantly moving target. This experience suggested that we might use pledgets to repair abdominal wall defects. In primary closure, it is not necessary to use pledgets in all sutures. In most instances, sutures with pledgets can be placed every three or four stitches as retention sutures, so that the remaining convential interrupted stitches can be secured free of tension.8 In the skin flap technique, water-proof approximation of skin edges is required to prevent infection and evisceration. However, dense and tight approximation of the skin flap margins may cause strangulation and necrotic dehiscence of the skin edges. With relatively loose tying of the sutures placed on pledgets, viability of the skin sandwiched between pledgets is preserved and yet water-proof approximation of the wound is achieved. Patients with gastroschisis have been treated by this technique without complication. In the postoperative management of patients who undergo silastic silo closure, continuous traction with substantial tension is produced by daily reefing of the silastic silo to reduce the protruded organs into the abdominal cavity.” Increased tension remains persistently on the fascia approximated to the silastic sheet, which frequently causes the fascia to fragment and tear resulting in detachment of the silo and herniationl evisceration. Pledgets cushion the interface between suture and fascia and can abort necrosis and dehiscence. This technique allows the silo to function as a substitute abdominal wall for up to 3 weeks if necessary.
REFERENCES 1. Ein SH, Rubin SZ: Gastroschisis: Primary closure or silon pouch. J Pediatr Surg 15549-552, 1980 2. Canty TG, Collins DL: Primary fascial closure in infants with gastroschisis and omphalocele: A superior approach. J Pediatr Surg 18:707-712,1983 3. Thompson J, Fonkalsrud EW: Reappraisal of skin flap closure for neonatal gastroschisis. Arch Surg 111:684-687, 1976 4. Muraji T, Tsugawa E, Nishijima H, et al: Gastroschisis: A 17-year experience. J Pediatr Surg 24:343-345,1989 5. Shermeta DW, Hailer JA: A new preformed transparent silo for the management of gastroschsis. J Pediatr Surg 10:973-975, 1975 6. Rubin SZ, Ein SH: Experience with 55 silon pouches. J Pediatr Surg 11803-807, 1976
7. Aaronson IA, Eckstein HB: The role of the silastic prosthesis in the management of gastroschisis. Arch Surg 112:297-302,1977 8. Luck SR, Sherman JO, Raffensperger JG, et al: Gastroschisis in 106 consecutive newborn infants. Surgery 98:677-683,1985 9. Yaster M, Buck JR, Dudgeon DL, et al: Hemodynamic effects of primary closure of omphalocele/gastroschisis in human newborns. Anesthesiology 69:84-88,1988 10. Wesley JR, Drongowski R, Coran AG: Intragastric pressure measurement: A guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis. J Pediatr Surg 16:264270,198l 11. Shim WKT: Surgical treatment of gastroschisis-Description of a modification of the staged treatment for large defects. Arch Surg 102:524-529, 1971
in the Repair By
Gastroschisis;
omphalocele.
I
N THE SURGICAL management of omphalocele and gastroschisis, primary closure,‘,2 skin flap technique,3,4 or silastic silo technique5-’ are all used for the repair of the abdominal wall defect. The choice of procedure is dependent on the local anatomical situation.‘.8 However, none of these techniques can avoid substantial tension at the approximating sites because there is usually a significant disparity between the size of the exteriorized viscera and the capacity of the abdominal cavity.‘.” The sutures used to approximate the fascia, skin, or silastic sheet may tear through tissue causing abdominal wound disruption, evisceration, or subsequent incisional hernia. To avoid these serious complications, we have successfully used Dacron felt pledgets on the sutures to protect the tissue from tearing. The results have been most satisfactory. This article introduces the technique. TECHNIQUE
Primaiy Closure
In patients with little disparity between the volume of the eviscerated abdominal contents and the abdominal cavity, primary closure is indicated as the ideal technique, avoiding multiple staged operations.‘.‘.’ For easier reduction of the eviscerated organs, we use incisions that extend the defect craniocaudally in the midline. Double-armed 3-OTevdek sutures are placed in an interrupted horizontal mattress fashion through the linea alba, with Dacron felt pledgets (3 x 5 mm) on the margins. The sutures are not individually tied. After placing all sutures, the sutures are tied, beginning with the one at the inferior corner. Traction is
From the Department of Surgery, The University of Iowa College of Medicine. Iowa City, LA. Date accepted: June 26,199O. Address reprint requests to Ken Kimura, MD. Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Copyright o I992 by W B. Saunders Company 0022.3468/9212701-0017$03.0010 64
Wall Defects
Ken Kimura and Robert T. Soper lo wa City, lo wa
0 This article describes surgical techniques using Dacron felt pledgets over the sutures to protect tissue against tearing in the procedures used for the closure of the abdominal wall defect in gastroschisis and omphalocele. Copyright o 1992 by W.B. Saunders Company INDEX WORDS:
of Abdominal
placed on the adjacent suture while the first is being tied to reduce tension on the suture being tied. The underlying abdominal viscera should be retracted by a malleable retractor to avoid trapping viscera between the approximated fascial edges. Skin Flap Technique
This technique is used in patients with a large disparity between the size of the eviscerated abdominal organs and the space within the abdominal cavity.4 From the margins of the extended abdominal incisions in the midline between the xyphoid process and the pubic symphysis, the skin with its subcutaneous tissue is detached bilaterally from the underlying anterior sheath of the rectus abdominis and the external oblique aponeurosis as far lateral as the anterior axillary line. Traction sutures placed on the margins of the skin and incised linea alba facilitate this dissection (Fig 1). With traction on the undermined skin flap, the medial edges of the longitudinally incised linea alba are sutured to the undersurface of the skin flap using continuous 4-O Vicryl sutures; this prevents retraction of the fascial edges as well as subsequent herniation of abdominal viscera into the space between the skin and the fascia (Fig 2). The margins of the skin flap are then lifted and approximated in an everting fashion. For this purpose, double-armed 4-O Tevdek sutures are placed in an interrupted horizontal mattress fashion through Dacron felt pledgets (4 x 8 mm). The sutures should
Fig 1.
At creation of the skin flap, traction sutures are placed along of the linea alba.
JolournalofPediatr;ccSurgery, Vol27, No 1 (January), 1992: pp 64-66
REPAIR OF ABDOMINAL
WALL DEFECT
Fig 3. Skin flap technique. The margins of the skin flaps are approximated in everting fashion using horizontal mattress sutures over the Dacron felt pledgets.
back into the abdominal capacity.” During this period of 7 to 14 days, the abdominal cavity rapidly expands and the eviscerated organs reduce in size, finally enabling the margins of the abdominal wall defect to be approximated. In this procedure, persistent tension is produced on the sutures that attach the silastic silo to the fascia of the linea alba, with a possibility
Fig 2. Cross-section of the abdomen. With the skin flaps lifted under moderate traction, the margins of the linea alba are sutured to the undersurface of the skin flaps (arrows) to prevent development of hernia.
be tied relatively loosely to avoid strangulating the skin flaps sandwiched between the pledgets (Fig 3). Two to 3 months later, definitive reconstruction of the abdominal wall is undertaken. The margins of the linea alba are approximated using the same technique described for primary closure. Mastic Silo Technique In patients with a large defect or great disparity between the eviscerated abdominal contents and the size of the abdominal cavity, a silastic silo is created to temporarily accommodate the abdominal viscera.‘-’ Following this procedure, the silastic silo is daily plicated to reduce its capacity, providing substantial pressure to reduce the eviscerated abdominal organs
Fig 4. In silastic silo technique, the silastic sheets are sutured to the margins of the linea albe using the sutures on Dacron felt pledgets in horizontal mattress fashion.
66
KIMURA AND SOPER
that the sutures might tear through the tissue and detach the silo from the abdominal wall. Use of pledgets on the sutures can prevent this complication. A Dacron-reinforced silastic sheet of an appropriate thickness is tailored to match the size of the abdominal wall defect. We use two identical sheets, one for the right-hand side and the other for the left-hand side of the linea alba. The silastic sheet is approximated to the abdominal wall fascial rim using double-armed 3-O Tevdek sutures in an interrupted horizontal mattress fashion, with pledgets on the abdominal wall fascial edge in an everting fashion (Fig 4). The sides and top of the silastic sheets are approximated using continuous stitches of 3-O Tevdek to completely wrap the eviscerated abdominal organs. Seven to 14 days later, when the daily plications of the silo have allowed the herniated viscera to return to the abdominal cavity, the abdominal wall defect is closed by approximating the margins of the linea alba. After resecting the silo, the technique identical to primary closure is used. DISCUSSION
In patients with gastroschisis treated by primary closure of the abdominal wall defect during the early 1970s we experienced serious complications of bowel fistula, which were caused when bowel was lacerated by suture material that bridged between dehisced fascial margins.4 Elevated intraabdominal pressure would thrust the bowel segment against the suture material and contribute to the injury. This experience motivated us to try to improve the suturing techniques used to close the abdominal wall defect. We
knew that in cardiac surgery pledgets were used to safely attach synthetic materials to myocardial tissue without tearing through this constantly moving target. This experience suggested that we might use pledgets to repair abdominal wall defects. In primary closure, it is not necessary to use pledgets in all sutures. In most instances, sutures with pledgets can be placed every three or four stitches as retention sutures, so that the remaining convential interrupted stitches can be secured free of tension.8 In the skin flap technique, water-proof approximation of skin edges is required to prevent infection and evisceration. However, dense and tight approximation of the skin flap margins may cause strangulation and necrotic dehiscence of the skin edges. With relatively loose tying of the sutures placed on pledgets, viability of the skin sandwiched between pledgets is preserved and yet water-proof approximation of the wound is achieved. Patients with gastroschisis have been treated by this technique without complication. In the postoperative management of patients who undergo silastic silo closure, continuous traction with substantial tension is produced by daily reefing of the silastic silo to reduce the protruded organs into the abdominal cavity.” Increased tension remains persistently on the fascia approximated to the silastic sheet, which frequently causes the fascia to fragment and tear resulting in detachment of the silo and herniationl evisceration. Pledgets cushion the interface between suture and fascia and can abort necrosis and dehiscence. This technique allows the silo to function as a substitute abdominal wall for up to 3 weeks if necessary.
REFERENCES 1. Ein SH, Rubin SZ: Gastroschisis: Primary closure or silon pouch. J Pediatr Surg 15549-552, 1980 2. Canty TG, Collins DL: Primary fascial closure in infants with gastroschisis and omphalocele: A superior approach. J Pediatr Surg 18:707-712,1983 3. Thompson J, Fonkalsrud EW: Reappraisal of skin flap closure for neonatal gastroschisis. Arch Surg 111:684-687, 1976 4. Muraji T, Tsugawa E, Nishijima H, et al: Gastroschisis: A 17-year experience. J Pediatr Surg 24:343-345,1989 5. Shermeta DW, Hailer JA: A new preformed transparent silo for the management of gastroschsis. J Pediatr Surg 10:973-975, 1975 6. Rubin SZ, Ein SH: Experience with 55 silon pouches. J Pediatr Surg 11803-807, 1976
7. Aaronson IA, Eckstein HB: The role of the silastic prosthesis in the management of gastroschisis. Arch Surg 112:297-302,1977 8. Luck SR, Sherman JO, Raffensperger JG, et al: Gastroschisis in 106 consecutive newborn infants. Surgery 98:677-683,1985 9. Yaster M, Buck JR, Dudgeon DL, et al: Hemodynamic effects of primary closure of omphalocele/gastroschisis in human newborns. Anesthesiology 69:84-88,1988 10. Wesley JR, Drongowski R, Coran AG: Intragastric pressure measurement: A guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis. J Pediatr Surg 16:264270,198l 11. Shim WKT: Surgical treatment of gastroschisis-Description of a modification of the staged treatment for large defects. Arch Surg 102:524-529, 1971
