[A rare case of epigastric heteropagus twinning]

Epigastric heteropagus is a very rare form of conjoined twins. It results from an ischemic atrophy of the body structure of the monozygotic conjoined twins at an early gestational age. Diagnosis is made by prenatal echography which must look for congenital heart disease associated in 28% of epigastric heteropagus. Cesarean section is indicated to prevent for mechanical dystocia. The autosite component of epigastric heteropagus can successfully be treated with early minor surgery. Autosite twin survival is good. Discussion with the family is important to avoid needless terminations. We report a rare prenatal diagnosis of epigastric parasitic twinning in which the parasite had pelvis with lower limbs. At birth, the autosite had omphalocele containing only bowel loops from the parasite.

Lordosis of lumbar vertebrae in omphalocele: an important factor in regulating abdominal cavity capacity

PURPOSE

Although it is well known that the tiny abdominal cavity associated with larger omphalocele enlarges rapidly after surgery, the responsible mechanism remains obscure. The authors have studied the curve of lumbar vertebrae and established a hypothesis in which lordosis of lumbar vertebrae plays a major role in changing the capacity of the abdominal cavity.

METHODS

Fifty-three patients with intact omphalocele and 10 normal newborns as the control were studied. The size of omphalocele was determined from the mean value of the length and breadth of the sac. The curve of lumbar vertebrae (lordotic angle) was measured using Cobb's technique on the lateral radiograph serially taken in the supine position.

RESULTS

The mean lordotic angle of 53 patients was 22.2 degrees (range, 0 to 65), which was significantly greater than 11.0 degrees of the control (P <.012). The individual lordotic angle before surgery was significantly correlated with the size of omphalocele (r = 0.668, P <.0001). In serial studies carried out in 15 patients with larger omphalocele, the mean lordotic angle was decreased significantly from 30.5 degrees to 20.0 degrees (P <.009) on the first postoperative day and returned to the control level within a few weeks.

CONCLUSIONS

These results suggest that severe lumbar lordosis may well become an alternative factor to produce visceroabdominal disproportion observed before surgery, and its correction after surgery may well induce the abdominal cavity to rapidly enlarge. It may be speculated that the dehiscence of abdominal rectus muscles associated with omphalocele causes the tension of ventral muscles to decline, and, then, imbalance in tension between ventral (abdominal) and dorsal (back) muscles causes the lumbar lordosis to increase. Accordingly, at the staged procedure, the prosthetic sheet should be attached under moderate tension, and its plication should be carried out at regular intervals to maintain the tension of abdominal rectus muscles.

Hansenula anomala infection in a neonate

We present an unusual neonatal fungal infection, Hansenula anomala in a very low birthweight infant who underwent abdominal surgery for an omphalocele. Despite treatment with adequate doses of amphotericin B, the yeast continued to grow from the blood culture, and was only eradicated with the use of oral ketoconazole.

[Histoacryl vs Dermabond cyanoacrylate glue for closing small operative wounds]

Acrylate glues used in a childrens' day care unit to close small surgical wounds were compared. In 157 children, aged 12 weeks to 3.7 years, either Histoacryl or Dermabond was used (respectively, H: Ethicon Inc., Johnson & Johnson, NJ or D: Dermabond, Braun Surgical Gmbh, Melsungen, Germany). Operations were for inguinal hernia (110 cases), hydrocele (25), undescended testis (16), umbilical hernia (13) and funiculocele (3). 1 week after surgery the wounds were evaluated in terms of integrity of closure, redness or infection, need for antibiotics, wound granuloma, and parental satisfaction with instructions and actual method of wound caring. 3 months after surgery the wound/scar was reexamined. The margins of the wounds were separated partially or completely in 8 of 85 in group H (9.4%) while in the D group, 2 wounds (2.4%) had partially opened (p < 0.05). There were no differences between the glues with regard to wound infection or cosmetic results. Parental satisfaction was higher with D (96%) than H (82%) but the difference was not statistically significant. It is convenient to use glue to close operative wounds in children after ambulatory surgery. The use of D significantly reduced wound ruptures compared to H. Long-term cosmetic results were similar.

[Omphalocele and gastroschisis. Outcome--complications--follow-up--quality of life]

From 1970 to 1998, 35 children with omphalocele (OC) and 31 with gastroschisis (GS) were treated at the Department of Paediatric Surgery at Lübeck Medical University. Forty of 43 survivors were examined in 1990, the data of 30 patients were renewed in 1999 and 12 new cases added. Total follow-up was 1-28 years. Primary closure was possible in 25 OCs and 20 GSs. Eighteen children with OC and 8 with GS suffered from additional abnormalities, which were treated simultaneously. Twenty percent of the babies with OC died mostly because of severe congenital anomalies and 12.9% of GS because of infectious complications in combination with other diseases. There were no more deaths in the last decade. Accordingly, there was a reduction in consecutive operations. Improvements were due to better operative and perioperative treatment as well as abortions following improved ultrasound examinations. The results of the literature and our own experience show the benefit of primary closure. A two-stage approach with dura/amnion or a silo procedure prevents high intra-abdominal pressure, therefore, indirect measurements of intra-abdominal pressure can be used exceptionally. Umbilical preservation offers better cosmetic results. Long-term follow-up reveals normal growth and development of the children except for those with severe congenital anomalies. All the others are participating without problems in normal activities and education without reduction in their quality of life. Today an isolated OC or GS is not an indication for abortion. If prenatal OC or GS is diagnosed, paediatric surgeons should be involved in the consultations.

[Contribution of ambulatory digestive surgery]

In France, ambulatory surgery is controlled by specific regulations which outline the organization of the facilities. It is practiced less in France than in other countries, but specific governmental incentive policies have been instituted. The characteristic feature of digestive surgery is the high occurrence of post-operative nausea and vomiting due to the peritoneal incision. New surgical procedures and anesthetic regimens allow ambulatory care in children and adults. But the choice of ambulatory care is based on the patient's characteristics more than on surgical procedure and follows well-known selection criteria. The procedures concerned in general surgery are groin hernia repair, proctologic surgery, and subcutaneous tissue surgery. Laparoscopic cholecystectomy and neck surgery in increasing numbers of patients on an ambulatory basis is the first step before expanding ambulatory surgical procedures toward major surgery. Physicians must have a thorough knowledge of ambulatory surgery as an organizational concept.

[Diagnosis and treatment of embryonal hernia]

In 1994-1999 years in clinic 19 children with omphalocele were treated, 8 of them died. Authors proposed tactic of treatment of their own, giving preference to conservative method, what permitted to reduce mortality of children with embryonal hernia.

Neonatal outcome of gastroschisis and exomphalos: a 10-year review

OBJECTIVE

To study neonatal outcomes associated with gastroschisis and exomphalos in a regional neonatal unit.

METHODS

A retrospective (1988-97) data analysis to study the effect of the type of defect/surgery, mode/place of delivery and associated anomalies on time to start and reach full feeds, duration of total parental nutrition (TPN) support and total hospital stay. Exact bivariate test procedures were used for data analysis.

RESULTS

Twenty-one cases of gastroschisis (17 inborn) and five cases (four inborn) of exomphalos were identified. Of these, 23.8% cases of gastroschisis and 60% of cases of exomphalos had associated gut anomalies. The survival rates for gastroschisis and exomphalos were 91 and 100%, respectively. The median time to start and reach full enteral feeds in outborn neonates was longer than in inborn neonates (9 vs 25 days, respectively, P = 0.01; and 16 vs 49 days, respectively, P = 0.01), as was the duration of TPN support (14 vs 42 days, respectively; P = 0.02). Neonates with gastroschisis had significant delays in starting and reaching full feeds compared with neonates with exomphalos (median 13 vs 4.5 days, respectively, P = 0.03; and 24 vs 8, respectively, P = 0.02) and they required prolonged support with TPN (median 23 vs 6 days, respectively; P= 0.01). Antenatal detection was significantly more frequent in inborn compared with outborn neonates (100 vs 67%, respectively; P = 0.03). The severity of associated gut anomalies and the delivery to surgery interval did not differ significantly to explain the increased morbidity in outborn neonates. Outcome was not significantly different after analysis by type of surgery and mode of delivery.

CONCLUSIONS

Increased morbidity in outborn neonates may be related to factors such as temperature, care, hydration status, care of the defect and vascular compromise of prolapsed gut during prolonged transportation.

Cloacal exstrophy: a unified management plan

BACKGROUND/PURPOSE

The belief that patients with cloacal exstrophy have a short and therefore useless colon is all too common. Frequently, the colon is used for urinary or vaginal reconstruction, and the possibility of a pull-through is lost. In the authors' experience, the use of a unified management plan allowed most patients to undergo pull-through and avoid a permanent stoma.

METHODS

Twenty-five patients were treated for cloacal exstrophy in the authors' institution from 1985 through 1999. In all patients, bladder closure, omphalocele repair, and creation of a colostomy were performed at birth. All available colon, no matter how small, was incorporated into the fecal stream. After at least 1 year, patients were assessed for the ability to form solid stool through their stoma. Normal colonic length, capacity to form solid stool, or success with a bowel management regimen through the stoma were considered indications for pull-through. Genitourinary reconstruction was contingent on the colorectal plan.

RESULTS

Colonic length ranged from normal in 12 patients, 40 to 70 cm in 3 patients, 10 to 30 cm in 4 patients, and less than 10 cm in 2 patients. All 25 patients underwent pull-through. Three are totally continent, 4 are continent with occasional soiling, 11 remain clean with a bowel management regimen, and 4 are too young to assess. One patient was clean, but now refuses bowel management. Two early patients, both with less than 10 cm of colon, now have ileostomies.

CONCLUSIONS

During neonatal repair, a colostomy should be formed incorporating all pieces of colon, no matter how small. With time, most patients will be able to form solid stool, and a pull-through should be undertaken if that ability exists. Decisions regarding genitourinary reconstruction should be made only after the gastrointestinal plan is established to achieve the optimal use of available bowel.

Laparoscopic umbilical herniorrhaphy

BACKGROUND

Laparoscopic technique is an alternative approach to ventral hernia repair. This study evaluated the feasibility of performing umbilical hernia repair using a single 5-mm trocar technique.

PATIENTS AND METHODS

During February 1999 to November 1999, we performed laparoscopic umbilical hernia repair in 16 consecutive patients. All operations were performed under general anesthesia. One 5-mm port was used to visualize the defect. A second 5-mm port was inserted only if there was incarcerated omentum requiring reduction. The Endo Close was inserted through a 2-mm incision made directly over the hernia to perform transabdominal closure of the defect using nonabsorbable suture.

RESULTS

The mean size of the umbilical hernia defects was 1.2 cm +/- 0.4 (range 1.0-2.0 cm). All operations were completed laparoscopically with no intraoperative or postoperative complications. The mean operative time was 35 +/- 15 minutes (range 21-75 min). All cases were performed in an outpatient setting. There have been no recurrences at a mean follow-up of 5.9 months.

CONCLUSIONS

Laparoscopic umbilical herniorrhaphy is safe and technically feasible. Its potential advantages, such as a lower rate of recurrence, will need to be validated with longer follow-up.

Abdominal wall defects in infants with very low birth weight

Management strategies for infants with very low birth weight (VLBW) who have abdominal wall defects essentially are the same as for those in larger infants. The authors favor primary closure in infants with gastroschisis, and have achieved this goal in 91% of infants since 1985. Treatment of infants with omphalocele is based on the size of the defect and the presence of respiratory insufficiency or severe associated anomalies. Nonoperative treatment is used initially for infants with large defects or associated anomalies, with planned closure of the resultant ventral hernia when the infant weighs 20 pounds or is 1 year old. This technique helps avoid the complications associated with mechanical ventilation and with tight primary closure such as intestinal dysfunction and wound problems.

Repair of the huge umbilical hernia in black children

Surgical repair of large umbilical hernias may present a challenging surgical problem. The currently described surgical techniques often yield disappointing results. The authors describe a new technique that allows for the repair of the fascial defect and the creation, with the use of a square cutaneous flap, of a neoumbilicus with sufficient depth and a good cosmetic appearance.

Omphalocele in a foal

An omphalocele was detected at birth in a male Arabian foal. The mass contained small intestine and after releasing a constricting band at the body wall, the contents slipped easily back into the abdomen. On the outside was the hairless pink membrane. The interior, now empty of small intestine, contained the umbilical arteries and vein, and a large urachus that extended from the bladder to the opening at the extremity of the mass. Six days after corrective surgery the foal was sent home and remained healthy.

Delayed cure of an omphalocele requiring abdominosternoplasty, right hepatectomy and partial splenectomy

A large ventral hernia resulting from the primary treatment of an omphalocele according to the Gross technique was repaired at age 16. The girl presented with extra-abdominal development of the liver and the spleen along with hypotrophy of the abdominal and thoracic cavities. The operation included enlargement sternoplasty, liver and spleen-size reduction and prosthetic abdominal closure. The cosmetic and functional results are good and stable on 7-year follow-up. Surgical issues and blood transfusion policy are discussed. A multi-disciplinary pediatric surgical approach is advocated.

Ruptured exomphalos and gastroschisis: a retrospective analysis of morbidity and mortality in Nigerian children

The survival of infants with major abdominal-wall defects (AWD) has improved over the years in developed countries. In Zaria, northern Nigeria, survival from intact exomphalos (EX), has improved with the adoption of non-operative management. Ruptured EX (REX) and gastroschisis (GS), however, remain problematic. This is a report of the mortality in REX and GS in a retrospective review of 16 infants with REX and 14 with GS managed over 10 years at the Ahmadu Bello University Teaching Hospital, Zaria. The median age at presentation was 3 days and 24 h for REX and GS, respectively; 29 of the 30 patients were delivered at home. Two patients with REX and 4 with GS had associated anomalies involving mostly the gastrointestinal tract. Bowel or omental strangulation occurred in 13 patients, resulting in gangrene in 8. Fascial closure was achieved in 20 patients, skin closure only in 4, and in 4 improvised silo coverage was used, the latter associated with high infection rate. Neonatal intensive care units (NICU) and total parenteral nutrition (TPN) were not available. The overall mortality was 18.6% (gastroschisis 10, ruptured exomphalos 8, 11 from sepsis and 7 due to respiratory embarrassment). The management of these AWDs thus continues to be problematic in our environment, and mortality remains high. Provision of more modern supportive facilities (NICU and TPN) may improve the survival in our and similar environments.

The management of exomphalos

BACKGROUND/PURPOSE

The management of exomphalos in the authors' department over a 26-year period is reported together with a technique for delayed closure of the ventral hernia resulting from conservative treatment of exomphalos major.

METHODS

Patients were classified into exomphalos minor and major. Exomphalos minor was treated by early surgical closure. Exomphalos major was treated preferentially conservatively with delayed repair of the ventral hernia.

RESULTS

There were 104 patients (68 boys and 36 girls; exomphalos minor, 45; exomphalos major, 59). Forty-two patients with exomphalos minor underwent operation. Three patients died before surgery, and 9 others postoperatively of overwhelming sepsis. Fifteen babies with exomphalos major needed early operation (skin closure only in 3 and prolene mesh repair in 12), there were 2 preoperative and 4 postoperative deaths. Forty-two patients were treated conservatively, among these, 8 died of sepsis. Thirty-four children had closure of the ventral hernia (prolene mesh, 7 and native tissue, 27); there was no morbidity. Two children died after laparotomy for adhesive intestinal obstruction.

CONCLUSION

Mortality rate was related to sepsis, complications of delayed presentation, and severe congenital anomalies. There were no ill effects attributable to mercury or iodine absorption. Delayed ventral hernia repair by double breasting of the fibrous tissue sheet underlying the skin was found to be a reliable technique with low morbidity.

Repair of a giant omphalocele by a modified technique

Large omphaloceles that contain centrally herniated liver pose challenges to surgical closure, the most significant being the space limitation of the abdominal cavity. In addition, the "pedicled" nature of the liver on the inferior vena cava creates a predisposition to acute hepatic vascular outflow obstruction as the liver is reduced into the abdominal cavity. In such cases, the alternatives include conservative treatment or staged silo reduction. The worst complication of silastic silo (SS) placement is tension and infection of the fascia with disruption of the suture line. Once infection or premature disruption occurs, closure of the defect is difficult or impossible. This case report details a different management technique for a newborn with a giant omphalocele and presents an interesting variation of the usual SS technique that may be helpful in the management of some cases, especially in an emergency. The thick silk sutures applied in the present case absorbed the tension and the silastic sheet prevented the risks of infection and adhesions.

Silo reduction of giant omphalocele and gastroschisis utilizing continucous controlled pressure

A method is described utilizing continuous controlled pressure to achieve smooth, rapid, and safe silo reduction of an anterior abdominal-wall defect. A metal tube with larger wheels at each end is suspended by runners and counterweights to slowly roll the silo and squeeze the contents into the abdominal cavity.

A simple technique for trocar site closure after laparoscopic surgery

Hernias have been reported to occur at trocar sites and small anterior wall defect has been casually identified during laparoscopic surgery. The aim of this article is to describe a simple, fast, and cheap technique for the safe closure of trocar sites in laparoscopic surgery. Closure is accomplished with a #0# absorbable suture, which is applied in a pursestring manner using 15 gauge spinal cord needle. This procedure is also suitable for the laparoscopic repair of uncomplicated small hernias or fascial defects of the anterior abdominal wall; a mesh prosthesis in case the defect is > cm(2). This technique allows a secure closure of umbilical or fascial defects of the anterior abdominal wall. It is a useful method for large trocar sites closure and is recommended for small uncomplicated hernias or fascial defects of the anterior abdominal wall. In case of > cm(2) defects the technique could be an optimal laparoscopic alternative for patch tension free repair.