Approach and component separation for suture closure and underlay mesh...
With Dr. Todd Ponsky · hosted by Dr. Todd Ponsky · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
spk_0 uses escharotic painting (escharization) followed by epithelialization for giant omphaloceles
Jack's first choice for omphalocele without pulmonary hypoplasia or cardiac problems is early skin coverage
For patients with pulmonary hypoplasia, bad hearts, prematurity, or defects too large for skin coverage, Jack uses escharotic technique
Jack's team uses silver sulfadiazine (Flamazine in Canada) for escharotic treatment, a technique taught by Sigy Ein
Silver-impregnated sponges offer same advantage as Silvadene but are less messy and don't require painting
spk_0 tried silver-impregnated Aquacel which stuck to the sac, became incorporated, and could not be removed - described as a disaster
The Duoderm compression technique requires daily adjustments and significant work
The Duoderm technique cannot be used in patients with pulmonary hypoplasia or bad hearts where intra-abdominal pressure cannot be safely increased
Component separation in small babies is not easy, especially if the omphalocele has been on a silo for a long period and tissues are scarred together
Jack's concern about component separation: uncertain what the abdominal wall will be like when the patient is 20 years old and whether they will be able to function normally
Jack uses absorbable patches (previously Surgisis with many recurrences, now Strattice with better results) to leave abdominal wall musculature intact
Advantage of patch approach: as child grows, the patch becomes a smaller percentage of the abdominal wall area
Many omphaloceles have defects extending to the costal margin, making complete closure difficult even with component separation
Jack often closes the lower defect primarily but requires a patch along the costal margin
Component separation requires dissection to the mid-axillary line to adequately mobilize tissue
spk_0 now uses six-ply Surgisis which has 22 tension lines, allowing tension on the patch while bringing fascia together
Delayed closure approach: apply fatty gauzes until epithelialization, wait until 6-7 months, then perform delayed primary closure
Suad manages most giant omphaloceles with painting followed by delayed primary closure when older, usually achieving closure without patch
Holly Williams successfully used Duoderm technique on two giant omphaloceles with liver out, maintaining patients on nasal cannula with morphine during manipulation, avoiding intubation until repair
Holly Williams applied Duoderm and redid it only every 3 days, making very gradual progress
Holly Williams previously used multi-stage operations with patches over a couple of years rather than painting
In neonates, tissue compliance allows significant reduction with Duoderm pulling; the amnion is left (usually stuck to liver centrally), Duoderm applied over it, then skin closed
Holly Williams uses Alloderm as bridging material, which over time turns into thick fascia resembling rectus diastasis
spk_0 had one massive omphalocele case with muscle only at lateral edge requiring combination of lateral component separation, Gore-Tex attachment, and serial stretching over 3 sessions (like Witzman patch) to achieve muscle-to-muscle closure
Biologic dressings are not meant to be bridged - they turn into liquid as temporary material, not muscle, unless permanent
spk_0 observed one pediatric case where biologic patch appeared to turn into muscle or scar
Benefit of Alloderm approach: muscle edges don't continue to separate over time, unlike painting-and-waiting where muscle stays lateral and defect may enlarge
Most challenging cases are smaller defects with entire liver out - these don't reduce with painting-and-waiting because the liver is 'locked out' with a mushroom shape
For locked-out liver cases, the fascial defect must be enlarged to allow reduction
Dr. Abello's Duoderm technique involves creating T-shaped Duoderm pieces that form an external silo, which is progressively compressed like gastroschisis reduction over approximately 1-2 weeks
Case presented: 28-week gestation, 1130g premature female with giant omphalocele including liver, identified by prenatal ultrasound
Component separation as described by Ramirez involves incision parallel to semilunar line with dissection of lateral fascia toward external oblique to mid-axillary line, gaining 2-4 centimeters
In the presented case, rectus muscles were joined centrally and umbilical cord mobilized caudally to create future umbilicus
Dr. Abello reports this as probably the smallest patient with lowest weight and giant omphalocele treated with his method and component separation for definitive anatomic closure without eventration
Dr. Abello has long-term follow-up with the Duoderm technique showing all patients healed well without problems, but no long-term follow-up yet with component separation
Cardiac surgeons report biologic patches in VSD closure turn into cardiac muscle
Dr. Abello's algorithm: first perform relaxation test under sedation to assess how much stretching is needed and determine silo size requirements
Dr. Abello's decision tree: if primary closure tolerated, proceed; if not, perform component separation; if intra-abdominal pressure still too high after component separation, add mesh
If at any point pressure becomes too high or pulmonary hypertension occurs, Dr. Abello aborts the procedure and reverts to traditional painting-and-waiting