Surgical Management
Surgical management of the infant with gastroschisis remains controversial. While primary closure of the abdominal defect is the preferred surgical approach, each pediatric surgeon must subjectively assess the degree of abdominal wall tension anticipated before deciding the nature of the repair.[8,22] If primary closure cannot be obtained, the alternative management strategy is a staged silo repair.[31]
Because of the increased risk of sepsis and hypovolemic shock, primary closure is considered in all cases where reduction does not cause hemodynamic or respiratory compromise.[7,33] Airway and intra-abdominal pressures should be kept less than 25 and 20 mm Hg, respectively, to prevent adverse hemodynamic consequences to other organs and tissues.[7] Strategies to achieve primary repair include stretching of the abdominal wall, evacuating the contents of the stomach and small bowel, irrigating meconium from the intestines, and enlarging the defect by leaving a fascial hernia.[20,35] If primary closure is attempted without sufficient space in the abdominal cavity, potential complications secondary to abdominal compartment syndrome may occur.[36,37] These complications are listed in Table 1 .
If the surgeon is unable to achieve primary closure or if a primary closure leads to hemodynamic and/or ventilatory compromise, an alternative method of closure must be used. Currently, most surgeons use a silastic silo for gradual reduction of herniated abdominal contents (Fig 2). Secondary closure occurs at a later time when the intestinal contents fit within the abdominal cavity.[7,20] Closure of the silo is usually performed in stages over 7 to 10 days, with reduction of the silo occurring one to two times daily.
Silo reduction.
A variety of methods including umbilical tape ties, sutures, clamps, or staples are used for silo reduction.[20,38] While slow reduction of the silo reduces the risk of abdominal compartment syndrome, the nurse must remember that the infant remains at risk for complications associated with abdominal compartment syndrome. The infant should be carefully assessed during and immediately after the reduction for complications.
A major concern for nurses and family members is the issue of pain associated with the reduction process. To date there is only one published study addressing this topic.[39] Kimble et al prospectively collected data on 35 newborns with gastroschisis born between 1999 and 2001. They concluded analgesia for reduction is "safe if strict selection criteria are adhered to."[39] Infants with noticeable atresia, bowel perforation or ischemia, or clinical instability were excluded from the study.
The investigators of a pilot study involving 14 infants with gastroschisis who underwent midgut reduction without anesthesia, concluded that the practice "appeared safe, carrying no additional morbidity or mortality."[40] Davies et al conducted a meta-analysis of the available literature from 1966 to 2002 on the issue of reduction with or without general anesthesia.[41] Although these investigators were unable to find any studies that meet their inclusion criteria, they concluded "there is no evidence from randomized clinical trials to support or refute the practice of ward reduction...."[41] The authors of both of these studies are from England. Silo reduction in the NICU in the United States is seldom performed under anesthesia, so the relevance of these studies to American practice is questionable. The issue of concern is whether the silo reduction is painful and warrants pain management. Based on clinical experience, the authors recommend that each infant undergoing a reduction procedure must be assessed for pain before, during, and after the reduction. Appropriate pharmacologic and nonpharmacologic pain therapies should be used for those infants who exhibit signs of pain or distress with the reduction.
NAINR. 2003;3(2) © 2003 W.B. Saunders
Cite this: Management of the Infant With Gastroschisis: A Comprehensive Review of the Literature - Medscape - Jun 01, 2003.
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