1. ABDOMINAL WALL DEFECTS
GASTROSCHISIS
OMPHALOCELE

2. Exomphalos and gastroschisis are two different congenital anomalies
Overall incidence is approximately 1: 3000 live births
Usually diagnosed prenatally on ultrasound
Exomphalos and gastroschisis can usually be differentiated prenatally
Do not inevitably require delivery by caesarian section
Differ markedly in their clinical appearance

3. Exomphalos (omphalocele)
CONGENITAL Anterior abdominal wall defect at the base of the umbilical cord with herniation of the abdominal contents

4. Pathophysiology
Failure of the midgut to return to abdomen by the 10th week of gestation

5. Clinical Findings Always covered by sac
central defect of the abdominal wall beneath the umbilical ring.
Defect may vary from 2-10 cm
Always covered by sac
The sac may be intact or ruptured
Sac is composed of amnion, Wharton’s jelly and peritoneum
The umbilical cord inserts directly into the sac in an apical or occasionally lateral position.
Sac contains intestinal loops, liver, spleen and bladder , testes/ovary
>50% have associated defects
Prognosis depends on theses associated anomalies
Mortality is approximately 40%

6. GASTROSCHISIS
Congenital defect of the anterior abdominal wall just lateral to the umbilicus

7. Pathophysiology
Rapid dissolution of the right umbilical vein after the standard period of organogenesis leaves an area of relative weakness in the mesenchyme through which bowel or abdominal viscera can herniate and eventually rupture.
Rupture of a small omphalocoele

8. Clinical Findings
Defect to the right of an intact umbilical cord allowing extrusion of abdominal content
Umbilical cord arises from normal place in abdominal wall
Opening  5 cm
No covering sac (never has a sac )
Evisceration usually only contains intestinal loops
Bowels often thickened, matted and edematous
Infants have better prognosis than those with an omphalocele (Mortality is approximately 10% )
10-15% have associated anomalies (intestinal atresia)
40% are premature/SGA

9. Prognosis (mortality)
Omphalocoele
Gastroschisis
Incidence
more
less
Covering Sac
Present
Absent
Size of Defect
Small or large
Small
Cord Location
Onto the sac
On abdominal wall
Bowel
Normal
Edematous, matted
Other Organs
Liver often out
Rare
Prematurity
10-20%
40%
Associated Anomalies
>50%
10-15%
Treatment
Often primary
Often staged
Prognosis (mortality)
10%

10. MANAGEMENT ABC Heat Management Sterile wrap or sterile bowel bag
Radiant warmer
Fluid Management
IV bolus 20 ml/kg RL/NS
D10¼NS 2 maintenance rate
Nutrition
NPO and TPN
Gastric Distention
OG/NG tube
Infection Control
Ampicillin and Gentamicin
Associated Defects
Closure of the defect (see next slides)

11. Omphalocele Conservative treatment Surgical treatment
Reduction by squeezing the sac or placement of a silo for sequential tightening and staged closure
Children with giant omphaloceles or concomitant problems that make them poor anesthetic risks may be treated with topical application of Betadine ointment or silver sulfadiazine to the intact sac. This allows secondary eschar formation and eventual epidermal ingrowth. Residual abdominal wall hernias are then repaired at 1 year of age.
Surgical treatment
Primary closure
Staged closure

12. Gastroschisis
Often be treated by direct full-layer closure of abdominal wall
May be associated with postoperative gut dysfunction Usually require postoperative nutritional and ventilatory support

13. UMBILICAL HERNIA
all pediatric umbilical hernias are congenital and form as a hernia through a persistent umbilical ring.
subcutaneous tissue and skin covering the protruding bowel
Incidence : one in every six live birth
Premature and low birth weight infants have a higher incidence than full-term infants
spontaneous resolution rates of 83% to 95% by 6 years of age, so it seems very safe to simply observe the hernia to allow closure to occur.
If complications occur, the defect is large or defect not close spontaneously surgical closure is indicated

14. EPIGASTRIC HERNIA
Hernias of the abdominal wall through the midline linea alba, termed epigastric hernias,
Presents as small masses, between the umbilicus and xiphoid process.
usually contains extra peritoneal fat.
Can be multiple.
Epigastric hernias do not resolve and should be repaired.

15. Staged Closure

16. Skin Flaps