EA034635B1 - Method of two-stage surgical treatment of newborns with large-size omphalocele - Google Patents

Abstract

The invention relates to medicine, in particular to pediatric surgery, and can be used for surgical treatment of congenital malformation of the anterior abdominal wall - large omphalocele. Omphalocele is a ventral defect in the umbilical ring and is one of the most common congenital malformations of the anterior abdominal wall in newborns. A method is claimed of two-stage surgical treatment of newborns with large omphalocele, in which a defect is closed with skin flaps during the first operation and loops are sutured to muscular-aponeurotic edges, to be further used to gradually extend all the layers of the anterior abdominal wall and skin within the postoperative period; in 7-8 days after the first operation, when the volume of the abdominal cavity becomes sufficient for layer-by-layer plastic surgery of the anterior abdominal wall, the second operation is performed, during which the postoperative cicatrix is excised with bordering incision and traction loops are removed, skin flaps are dissected from both sides to the outer edge of the rectus abdominis muscles, starting from the lower corner of the wound, individual muscular-aponeurotic nodal sutures are applied until the defect is completely closed, the skin is sutured with nodular sutures without tension.

Description

The invention relates to medicine, in particular to pediatric surgery, and can be used in the surgical treatment of congenital malformation of the anterior abdominal wall - large omphalocele.

Omphalocele is a ventral defect in the umbilical ring and is one of the most common congenital malformations of the anterior abdominal wall in newborns. Omphalocele occurs with a frequency of 1-2.5: 5000 newborns and occurs due to a violation of the return of the intestine to the abdominal cavity after the natural period of the embryonic hernia, when it goes beyond the abdominal cavity to the umbilical cord for 6-10 weeks of embryonic development [3]. The term omphalocele of large sizes means the presence of a defect in the anterior abdominal wall of more than 4 cm in diameter, in which more than 50% of the liver is in the hernial sac [4, 5, 13, 16].

Surgical treatment of children with large omphalocele remains an urgent problem in pediatric surgery. With this defect in newborns, there is a pronounced viscero-abdominal imbalance, which leads to a significant increase in intra-abdominal pressure during the initial closure of the defect and the development of intra-abdominal compression syndrome. In addition, due to the central location of the liver, the latter has a long leg of hepatic veins (caval gates), which creates the prerequisites for inflection and obstruction of the venous outflow from the liver when the latter is immersed in the abdominal cavity [7].

The optimal method of surgical treatment of large omphalocele remains controversial since the first description of this malformation of the anterior abdominal wall in 1634. Despite the fact that many methods have been proposed for closing the defect, today there is no operation that would be considered the gold standard worldwide [23]. Existing surgical methods for treating large omphalocele are divided into primary, staged and delayed closure of the defect.

The most famous and widely used method of primary aponeurotic plastic surgery of the anterior abdominal wall is longitudinal layering of the anterior abdominal wall with interrupted sutures [24].

However, in most cases, due to severe viscero-abdominal imbalance, the primary closure of the defect is not possible. The most problematic area is the epigastrium, where the hypoplastic rectus rectus muscles are closely adjacent to the edge of the costal arch, and there is a significant deficit of the muscular aponeurotic layer [9]. Many authors used intraoperative manual stretching of the anterior abdominal wall in the anteroposterior direction to increase the volume of the abdominal cavity [11, 22]. The disadvantage of this method is its low efficiency, very high morbidity, with muscle rupture and the formation of multiple hemorrhages.

Some surgeons prefer to use synthetic patches to repair a muscle defect, covering them with skin patches on top. The experience of using non-absorbable materials such as Marlex, Polypropylene and Gore-Tex showed a high percentage of infectious and inflammatory complications, the formation of intestinal fistulas, which required the removal of these patches [11, 15]. Innovative technologies such as the use of biodegradable materials (submucosal layer of the small intestine, dura mater or human acellular dermis) are expensive and require further clinical research [9, 10].

In addition, the deficiency of skin flaps and their significant tension during plastic surgery gives a high risk of cosmetic defects in the long term, such as asymmetry of the abdominal wall and the formation of a disfiguring postoperative scar that reduces the patient's quality of life.

In many cases, this dictates the need for staged immersion of hernial contents to prevent possible complications of increasing intra-abdominal pressure, which include respiratory distress, decreased venous return with oliguria and decreased cardiac output, intestinal ischemia and acidosis associated with bending of the hepatic veins during liver immersion [4, 21 ]. Stage closure of the defect is based on the slow, gradual immersion of the hernial contents in the abdominal cavity.

In 1967, Schuster first described the use of a silicone bag, silo, for staged placement of contents into the abdominal cavity in newborns with omphalocele [20]. With this technique, at the first stage of surgical treatment, the omphalocele shell and the silicone bag are excised - silo is hemmed along the perimeter to the aponeurosis of the rectus abdominis muscles after dissection of the skin flap. The day after the operation, a gradual reduction of the hernial contents into the abdominal cavity with a lower ligation of the sac began. After complete immersion of the hernial contents, which occurred on average after several weeks, the child was re-taken to the operating room for plastic surgery of the anterior abdominal wall.

However, the use of the silo technique is associated with an increase in intra-abdominal pressure, respiratory failure, and hemodynamic disorders, since the abdominal organs themselves (hernial contents) are used as a source of increasing intra-abdominal pressure and increasing the volume of the abdominal cavity [14]. Often, a wound infection occurs, which significantly worsens the prognosis of treatment and casts doubt on the closure of the defect with its own tissues [7].

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In a large percentage of cases, staged immersion ends with the use of synthetic materials to close the remaining central defect of the anterior abdominal wall [1], which can lead to serious complications, such as infection, allergic reactions, and severe adhesions in the abdominal cavity. In addition, this method does not solve the problem of deficiency of skin grafts, which necessitates subsequent skin grafting, which can be very difficult in newborns who have a lack of suitable donor sites [2].

Given the fact that rupture of the membranes of omphalocele is quite rare, 10-15%, some surgeons for the treatment of large omphalocele have used stage-by-stage ligation of the membranes themselves to gradually immerse the hernial contents and increase the abdominal cavity for 7-14 days. The sequential ligation of the hernial sac, using it as a natural silo, was first successfully applied by Hong A.R. and Sigalet D.L. [8]. However, this method has not found widespread use. In many cases, immersion in their own shells is impossible, since the omphalocele shells are tightly soldered to the liver and the crescent ligament, and the caval gates are quite long, and when corrugating their own shells, their bend can occur.

The delayed defect closure is also widely used. Historically, for the surgical treatment of children with large omphalocele, skin flaps were used to cover the contents of the abdominal cavity - surgery according to Gross [6]. Thus, a large ventral hernia was formed, the treatment of which was carried out at a later age (Fig. 1).

Another alternative treatment was the epithelialization of omphalocele membranes. This treatment is based on the ability of amnion to support the proliferation of the epithelium and its migration from the skin edges of the wound. For these purposes, mercourochrome, iodine preparations, silver sulfadiazine, an eosin solution were used, however, according to some authors, these substances can cause pronounced general toxic effects with a mortality rate of up to 25% [12]. In addition, in the process of epithelialization, infectious complications with the development of sepsis, rupture of hernial membranes, bleeding, and dynamic intestinal obstruction are often noted. Usually this treatment takes many months before epithelization of the membranes of omphalocele is achieved and a ventral hernia is formed. After this, the child undergoes a multi-stage surgical treatment, usually requiring the use of synthetic materials, or the use of tissue expanders to increase the volume of the abdominal cavity [18, 19]. In many cases, the correction is delayed for several years, requires great patience from the parents and leads to a pronounced adhesive process in the abdominal cavity and the formation of coarse disfiguring scars of the anterior abdominal wall, which significantly reduces the quality of life of patients.

The prototype of the proposed method is a method in which the vented abdominal organs were placed in a synthetic bag with a semi-permeable lining, which was sutured around the circumference to the edges of the defect and suspended using a system with active external traction, the gradual progressive expansion of the abdominal wall and the increase in the abdominal cavity made it possible to close the defect between 2 and 6 in the afternoon after surgery [17].

The disadvantages of the prototype are the high likelihood of developing infectious complications; loss of elasticity and density of the edge of the muscle-aponeurotic defect, for which the bag was hemmed, and traction was performed, which complicates the aponeurotic closure of the defect and leads to relapse of the ventral hernia.

In addition, the traction along the circumference of the hemmed bag, without multi-vector application of traction force, does not contribute to the closure of the defect edge to edge and retains a residual circular defect in the epigastric region.

The objective of the invention is the creation of a less traumatic and short-term method of surgical treatment of children with large omphalocele.

The inventive method will avoid serious complications: the development of infection, the formation of adhesions and a residual circular defect in the epigastric region, with this method of treatment, the defect closes edge to edge. In addition, this method of treatment is more physiological, will reduce the patient's stay in the hospital and expand the arsenal of similar drugs for the treatment of omphalocele.

This problem is solved by a two-stage surgical treatment, which consists in the fact that during the first operation, which is performed on the 1-2 day of the child’s life, omphalocele membranes are excised along the border of the skin transition with ligation of the umbilical vessels and urachus, and the edges of the muscular-aponeurotic are palpated layer of the anterior abdominal wall, in the corresponding projection on the skin on each side, 3 transverse incisions are made up to 1 cm long, providing access to symmetrical points in the in / 3, s / 3 and n / 3 defects, additional (seventh oh) the incision is made along the midline at the lowest point of the muscular defect of the anterior abdominal wall, at the indicated points, loops of Gor-tex material up to 1 cm long are sutured to the muscle-aponeurotic edges of the defect with fixation through all layers of the anterior abdominal wall, the skin wounds of the contrapertura are sutured to the loops, after this, an operation is performed to form a ventral hernia, using skin grafts to close the abdominal cavity, immediately after the operation, in the incubator, an external traction system of the muscular-aponeurotic layer of the anterior abdomen is established sutural wall for hemmed loops (No. 7) with vertical

- 2 034635 direction of the force vectors, the total load for active traction is determined from the calculation of 30-35% of the child’s body weight (4-5% for each loop). On the 3-4th day after the operation, symmetrical traction traction crosses in the direction to close the defect for the gradual immersion of the liver in the abdominal cavity.

The second operation is performed 7-8 days after the first operation, when the volume of the abdominal cavity becomes sufficient for layer-by-layer plastic surgery of the anterior abdominal wall, a postoperative scar is excised with a bordering incision (usually there is an excess of skin) and traction loops are removed, skin flaps are dissected from both sides to the outer edge of the rectus abdominis muscles, starting from the lower corner of the wound, muscle-aponeurotic separate nodal sutures are applied until the defect is completely closed, the skin is sutured with nodular sutures without tension, which ensures AET healing by first intention with a good cosmetic result.

The advantages of the proposed method.

The method can significantly reduce the invasiveness of surgical treatment, since it provides uniform gradual extension of the muscle-aponeurotic layer of the anterior abdominal wall and skin without increasing intra-abdominal pressure and intra-abdominal compression syndrome. The method allows to complete the surgical correction of the defect by the 7-8th day of the child’s life, and also provides a good cosmetic result of surgical treatment, due to the closure of the defect edge to edge, which does not affect the patient’s quality of life. The inventive method aims to expand the arsenal of similar treatments for omphalocele.

Clinical example 1.

Child Ts., A boy, 275 days of gestation, was born on January 24, 2015 with a body weight of 2850. Diagnosis of congenital malformations: omphalocele was established prenatally when performing ultrasound.

When examining a newborn, a defect of the anterior abdominal wall in the umbilical cord area measuring 5.0 x 5.0 cm was determined, through which the liver and the loops of the small and large intestine went out of the abdominal cavity into the hernial sac (umbilical cord membrane) (Fig. 2 ) The size of the hernial protrusion was 5x7x6 cm.

In the maternity room, along with primary resuscitation measures (mechanical ventilation, placement of a nasogastric tube and peripheral venous catheter), the hernial sac is covered with moist sterile wipes. The resuscitation team transferred the child for treatment to the intensive care unit of the Republican Scientific Practical Center for Pediatric Surgery. Screening diagnostics did not reveal severe concomitant malformations. During the first 12 hours, the child left meconium.

After preoperative preparation by the end of the first day of life, the child is operated on. Omphalocele shells excised. Almost the entire liver was located outside the abdominal cavity. Due to the pronounced viscero-abdominal imbalance and the impossibility of the primary closure of the defect, 6 loops of Gore-tex material were hemmed through additional incisions to fit the muscular-aponeurotic edges to establish the traction system and the defect was closed with moderate flap skin flaps according to Grossc. Immediately after receipt from the operating room, an extension began with a weight of 120 g / loop (4% of body weight) strictly in the vertical direction through the block system (Fig. 3).

The postoperative period was uneventful. The child was on mechanical ventilation, sedated, parenteral nutrition, antibiotic therapy was performed. Already on the 2nd day after the operation, a decrease in the size of the ventral hernia was noted, the liver settled 50% into the abdominal cavity, skin folds formed on the sides of the postoperative wound, which indicated a significant decrease in skin tension. Moreover, according to clinical, laboratory and instrumental methods of research, there were no signs of intra-abdominal compression syndrome. On the 4th day after the operation, loopback rods were crossed for oncoming traction of the muscular aponeurotic edges (to close the defect), by this moment the hernial contents were almost completely inserted into the abdominal cavity (Fig. 4).

The second stage of surgical treatment was performed on the 12th day after the first operation. After excision of the postoperative scar and removal of loops, the muscle-aponeurotic edges of the rectus abdominis muscles were mobilized and layer-by-layer plastic surgery of the anterior abdominal wall with separate interrupted sutures was performed. There were no complications during the operation; hemodynamic disturbances were not noted.

The postoperative period was uneventful. Enteral nutrition began on the 8th day after surgery. The wound healed by first intention, providing a good cosmetic result of surgical treatment (Fig. 5).

Clinical example 2.

Child M., a boy, 269 days of gestation, was born on 06/01/2015 with a body weight of 3200 g. Diagnosis of congenital malformations: omphalocele established prenatally, when performing ultrasound.

Transferred for treatment to the intensive care unit of the Republican Scientific Practical Center for Pediatric Surgery 7 hours after birth. On examination, large omphalocele, 6x6x5 cm, containing the right and left lobes of the liver, loops of the small and large intestine (Fig. 6) was determined.

Of the concomitant malformations, CHD was diagnosed: DMS, secondary ASD, moderate pulmonary

- 3 034635 hypertension (40% of systemic), CH1.

The first stage of surgical treatment was completed by the end of the first day of life. After excision of the omphalocele membranes, 7 loops (Gore-tex) were hemmed to the skin-aponeurotic edges, a ventral hernia was formed along Gross. The traction was carried out with a load of 110 g / loop (4% of the body weight of the child).

By the end of 7 days after the first operation, the volume of the abdominal cavity was sufficient to completely close the defect. The second stage of surgical treatment was performed on the 8th day after the first operation. After excision of the postoperative scar, layer-by-layer plastic surgery of the anterior abdominal wall was performed. Symptoms of intra-abdominal compression during surgery were not observed.

The postoperative period was uneventful. Enteral nutrition began on the 7th day after the operation. The wound healed by first intention, the sutures were removed on the 12th day after the second operation (Fig. 7).

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Claims (1)

CLAIM A method of two-stage surgical treatment of newborns with large omphalocele, characterized in that during the first operation, the defect is closed with skin flaps, and loops are sutured to the muscle-aponeurotic edges, for which, in the postoperative period, all layers of the anterior abdominal wall and skin are gradually extended through 7-8 days after the first operation, when the volume of the abdominal cavity becomes sufficient for layer-by-layer plastic surgery of the anterior abdominal wall, a second operation is performed in which the bordering region A postoperative scar is excised with an incision and traction loops are removed, skin flaps are dissected from both sides to the outer edge of the rectus abdominis muscles, starting from the lower corner of the wound, individual neuropsychiatric separate nodal sutures are applied until the defect is completely closed, the skin is sutured with nodular sutures without tension.