IS EARLY FASCIAL CLOSURE NECESSARY FOR OMPHALOCELE AND GASTROSCHISIS

Before the introduction of the ''silo'' for gastroschisis, the main go al of surgery was to cover the defect with skin. Since the silo has be en used, the goals have been (1) to cover the defect with SILASTIC(R) sheets and return the extraabdominal contents tb the abdominal cavity by progressive plication of the silo and (2) to eventually close the d efect by fascia-to-fascia approximation, before 1 month of age. In man y series, early definitive abdominal wall closure resulted in mortalit y rates of 10% to 30%, usually because of bower necrosis and resulting sepsis. At the author's institution, 20 newborns with large omphaloce les or gastroschisis have been treated, and fascial closure was obtain ed by the second week in 10 infants. in ten babies it was impossible t o obtain early fascial closure without tension, and these children wer e managed differently. A nonaggressive two-stage approach was used, in which the goals were (1) early return of contents to the abdominal ca vity and (2) only skin and granulation coverage of the defect (without aiming tor early fascial closure or partial fascial closure) with a s mall central SILASTIC(R) patch: Stage 1 is reduction of abdominal cont ents to the abdomen, through plication of the site, over a 9 to 14 day period. Stage 2 is removal of the site and closure of the ventral abd ominal wall defect using a SILASTIC(R) patch to close most of the defe ct, after approximating fascia in the superior and inferior portions. If the skin cannot be closed, the patch usually separates in 14 to 21 days, the pellicle remaining becomes completely epithelialized in 1 to 2 months, and further surgery has not been necessary. If the skin can be approximated, the patch is removed in a few months, when fascial c losure can be performed easily. Five cases of omphalocele and five of gastroschisis were treated by this method; all the patients are doing well, most without definitive fascial closure. Copyright (C) 1995 by W .B. Saunders Company