Surgical Management of Omphalocele: A Plastic Surgeon’s Perspective

Brian I. Labow, MD, FACS, FAAP

Department of Plastic SurgeryChildren’s Hospital Boston

Harvard Medical School

• Heterogenous population and associated anomalies common

• Many approaches, techniques and tools

• No single approach will suit all patients

• Outcome data based limited by numbers and confounding variables

IntroductionIntroduction

• General considerations• Tools/techniques • Adjuvant procedures• Summary

OutlineOutline

• Usually not an emergency• Most cases can be

managed with “conventional approaches”

• Circumstances may mandate change in course…

General Comments

• Medically unstable• Damage control (e.g. ruptured

membrane, silo disruptions)• Incomplete reduction • Extreme visceral-peritoneal

disproportion

Clinical Situation?

Tools and TechniquesTools and Techniques

• NPWT/VAC™ hopefully not necessary!

• Decrease edema and bacterial colonization accelerate granulation

• Used with absorbable mesh, biological fascial substitute

• Bridge to definitive reconstruction (Kilbride et al. J Ped Surg (2006) 41, 212–215)

Negative-Pressure Wound Therapy Negative-Pressure Wound Therapy

• Mechanical process to increase surface area of adjacent tissues

• Examples: Growth, Silo, External Skin closure devices

• Adjunct to flap transfer• Progressive process takes time

Tissue-ExpansionTissue-Expansion

• Tissue expanders require a clean field with minimal inflammation

• Epidermis thickens, dermis and fat atrophy, muscle thins, angiogenesis

• Multiple expanders, small, frequent fillings

Tissue-ExpandersTissue-Expanders

• Subcutaneous, submuscular and intraperitoneal placement all reported

• Small case series, longest follow-up 3 yrs

Tissue-ExpandersTissue-Expanders

(Tanenbaum et al. Plas Rec Surg (2007)120,1564–7)

• Useful in a subset of patients• Additional GA, time and good local

tissue conditions required• Judgment in rate of expansion• Extrusion and infection most

frequent complications

Tissue-ExpandersTissue-Expanders

• Relaxing incision(s) separating rectus sheath from ext obliq aponeurosis

• Autologous tissue, 1-stage• Skin deficit?• Large experience in adults

Component SeparationComponent Separation

• 1 series of 10 consecutive omphalocele patients (mean age 6.5 months) Van Eijck et al. J Ped Surg (2008)

• Mean defect size 8 cm• Required temporary prosthetic in 1 case• Complications in 3 patients (skin necrosis,

hematoma, infection)• Mean follow-up 2 years, no hernias

Component SeparationComponent Separation

• Usually a lifeboat• Allows egress of fluid,

visualization of bowel• Used with NPWT • Lasts 3-4

months….hernia• Cost Vicryl™ 15x 15”

$1800*

Absorbable MeshAbsorbable Mesh

* BCH list price 2013

• Allows tissue ingrowth, stronger

• Higher rate of enterocutaneous fistulae

• Onlay support• Cost e.g. Marlex™

10x14” $500

Non-absorbable, MeshedNon-absorbable, Meshed

• Temporary use silo construction (e.g. Silastic™)

• No ingrowth, minimal adhesions

• Permanent use (e.g. Goretex™) higher hernia rate?

• Cost* $600 for 10x15”Goretex™

Non-absorbable, Non-meshedNon-absorbable, Non-meshed

* BCH list price 2013

• Variety of freeze-dried, acellular dermal or intestinal products (e.g. Alloderm™, Surgisis™)

• Inlay graft or onlay above fascia

• Neovascularized, tissues replaced by native cellular ingrowth

Biological MaterialsBiological Materials

• Small series/case reports in pediatric literature (Alaish et al. J Ped Surg (2006) 41, E37–E39)

• Variable reports in adult abdominal wall reconstruction literature

• Cost has come down, 5x10” sheet of Alloderm™ ~$1800*

Biological MaterialsBiological Materials

* BCH list price 2013

• Local tissues usually sufficient

• Mobilization wide undermining

• Can be facilitated with relaxing incisions

FlapsFlaps

Zama et al. Br Assoc Plas Surg (2004) 57, 749–753

FlapsFlaps

Br Assoc Plas Surg (2004) 57, 749–753

• Skin closure: secondary but important part of reconstruction

• Umbilicoplasty if possible

• Secondary procedures: hernias, bulges, hypertophic/depressed scar

Adjunctive ProceduresAdjunctive Procedures

Adjunctive ProceduresAdjunctive Procedures