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ABDOMINAL WALL DEFECTS
Dr. Catherine B. Canete
OMPHALOCOELE
• Anterior abdominal wall defect at the base of the umbilical cord with herniation of the umbilical contents
Incidence
• Small omphalocoele 1:5000
• Large omphalocoele 1:10000
• Male to female ratio 1:1
• Pacific Islanders have low risk for omphalocoele
Pathophysiology
• Failure of the midgut to return to abdomen by the 10th week of gestation
Clinical Findings
• Covered clinical defect of the umbilical ring
• Defect may vary from 2-10 cm
• Sac is composed of amnion, Wharton’s jelly and peritoneum
• 50% have accompanying liver, spleen, testes/ovary
• >50% have associated defects
• Location:– Epigastric
– Central
– Hypogastric
• Cord attachment is on the sac
GASTROSCHISIS
• Defect of the anterior abdominal wall just lateral to the umbilicus
Incidence
• 1:20,000-30,000
• Sex ratio 1:1
• 10-15% have associated anomalies
• 40% are premature/SGA
Pathophysiology
• Abnormal involution of right umbilical vein
• Rupture of a small omphalocoele
• Failure of migration and fusion of the lateral folds of the embryonic disc on the 3rd-4th week of gestation
Lateral folds• Form
– Lateral abdominal wall– Future umbilical ring
Clinical Findings
• Defect to the right of an intact umbilical cord allowing extrusion of abdominal content
• Opening 5 cm• No covering sac
• Bowels often thickened, matted and edematous
• 10-15% with intestinal atresia
MANAGEMENT
• ABC
• Heat Management– Sterile wrap or sterile bowel bag– Radiant warmer
• Fluid Management– IV bolus 20 ml/kg LR/NS– D10¼NS 2-3 maintenance rate
• Nutrition– NPO and TPN
• Gastric Distention– OG/NG tube
• Infection Control– Ampicillin and Gentamicin
• Associated Defects
• Conservative treatment– Reduction by squeezing the sac– Painting sac with escharotic agent
• 0.25% Silver nitrate• 0.25% Merbromin (Mercurochrome)
• Surgical Management– Skin Flaps– Primary Closure– Staged Closure
• Staged repair using silo pouch
Skin Flaps
Primary Closure
Staged Closure
UMBILICAL HERNIA
• Defect in linea alba, subcutaneous tissue and skin covering the protruding bowel
• Frequent in premature infants
PRUNE BELLY SYNDROME
• Thin, flaccid abdominal wall
• Dilation of bladder, ureter and renal collecting system
• 1:30,000-50,000
• 95% are male
BLADDER EXTROPHY
• Defective enfolding of caudal folds
• 3.3 in 100,000 births• Associated with
prolapsed vagina or rectum, epispadias, bifid clitoris or penis
PENTALOGY OF CANTRELL
• Omphalocoele
• Anterior diaphragmatic hernia
• Sternal cleft
• Ectopia Cordis
• Intracardiac defect
BECKWITH-WIEDEMANN SYNDROME
• Macrosomia• Macroglossia• Organomegaly• Abdominal wall
defects• Embryonal tumors
Omphalocoele GastroschisisIncidence 1:6,000-10,000 1:20,000-30,000
Delivery Vaginal or CS CS
Covering Sac Present Absent
Size of Defect Small or large Small
Cord Location Onto the sac On abdominal wall
Bowel Normal Edematous, matted
Omphalocoele GastroschisisOther Organs Liver often out Rare
Prematurity 10-20% 50-60%
IUGR Less common Common
NEC If sac is ruptured 18%
Associated Anomalies
>50% 10-15%
Treatment Often primary Often staged
Prognosis 20%-70% 70-90%