1. Surgical Management of Omphalocele: A Plastic Surgeon’s Perspective
Brian I. Labow, MD, FACS, FAAP
Department of Plastic Surgery
Children’s Hospital Boston
Harvard Medical School

3. Introduction 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 3

4. Outline General considerations Tools/techniques Adjuvant procedures
Summary

5. General Comments Usually not an emergency
Most cases can be managed with “conventional approaches”
Circumstances may mandate change in course…

6. Clinical Situation? Medically unstable
Damage control (e.g. ruptured membrane, silo disruptions)
Incomplete reduction
Extreme visceral-peritoneal disproportion

7. Tools and Techniques

8. Negative-Pressure Wound Therapy
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)

9. Tissue-Expansion
Mechanical process to increase surface area of adjacent tissues
Examples: Growth, Silo, External Skin closure devices
Adjunct to flap transfer
Progressive process takes time

10. Tissue-Expanders
Tissue expanders require a clean field with minimal inflammation
Epidermis thickens, dermis and fat atrophy, muscle thins, angiogenesis
Multiple expanders, small, frequent fillings

11. Tissue-Expanders
Subcutaneous, submuscular and intraperitoneal placement all reported
Small case series, longest follow-up 3 yrs
(Tanenbaum et al. Plas Rec Surg (2007)120,1564–7)

12. Tissue-Expanders 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

13. Component Separation
Relaxing incision(s) separating rectus sheath from ext obliq aponeurosis
Autologous tissue, 1-stage
Skin deficit?
Large experience in adults

14. Component 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

15. Absorbable Mesh Usually a lifeboat
Allows egress of fluid, visualization of bowel
Used with NPWT
Lasts 3-4 months….hernia
Cost Vicryl™ 15x 15” $1800*
* BCH list price 2013

16. Non-absorbable, Meshed
Allows tissue ingrowth, stronger
Higher rate of enterocutaneous fistulae
Onlay support
Cost e.g. Marlex™ 10x14” $500

17. Non-absorbable, Non-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™
* BCH list price 2013

18. Biological Materials
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

19. Biological 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*
* BCH list price 2013

20. Flaps Local tissues usually sufficient Mobilization wide undermining
Can be facilitated with relaxing incisions
Zama et al. Br Assoc Plas Surg (2004) 57, 749–753

21. Flaps
Br Assoc Plas Surg (2004) 57, 749–753

22. Adjunctive Procedures
Skin closure: secondary but important part of reconstruction
Umbilicoplasty if possible
Secondary procedures: hernias, bulges, hypertophic/depressed scar

23. Adjunctive Procedures