High Abdominal Perfusion Pressure Using Umbilical Cord Flap in the Management of Gastroschisis

Abstract

Background: Gastroschisis management remains a controversy. Most surgeons prefer reduction and fascial closure. Others advise staged reduction to avoid a sudden rise in intra-abdominal pressure (IAP). This study aims to evaluate the feasibility of using the umbilical cord as a flap (without skin on the top) for tension-free repair of gastroschisis.Methods: In a prospective study of neonates with gastroschisis repaired between January 2018 to October 2020 in Tanta University Hospital, we used the umbilical cord as a flap after the evacuation of all its blood vessels and suturing the edges of the cord with the skin edges of the defect. They were guided by monitoring abdominal perfusion pressure (APP), peak inspiratory pressure (PIP), central venous pressure (CVP), and urine output during 24 and 48 h postoperatively. The umbilical cord flap is used for tension-free closure of gastroschisis if PIP > 24 mmHg, IAP > 20 cmH2O (15 mmHg), APP <50 mmHg, and CVP > 15cmH2O.Results: In 20 cases that had gastroschisis with a median age of 24 h, we applied the umbilical cord flap in all cases and then purse string (Prolene Zero) with daily tightening till complete closure in seven cases, secondary suturing after 10 days in four cases, and leaving skin creeping until complete closure in nine cases. During the trials of closure, the range of APP was 49–52 mmHg. The range of IAP (IVP) was 15–20 cmH2O (11–15 mmHg), the range of PIP was 22–25 cmH2O, the range of CVP was 13–15 cmH2O, and the range of urine output was 1–1.5 ml/kg/h.Conclusion: The umbilical cord flap is an easy, feasible, and cheap method for tension-free closure of gastroschisis with limiting the PIP ≤ 24 mmHg, IAP ≤ 20 cmH2O (15 mmHg), APP > 50 mmHg, and CVP ≤ 15cmH2O.

Umbilical hernia repair post umbilical cord graft closure of gastroschisis: A cohort study

“…Even though this method seems foul-proof, one of the outcomes to look out for is the development of an umbilical hernia after complete healing, which was described in a few studies [5] , [6] , [10] , [11] particularly after cutting the rectus fascia [6] , as well as shown in our cases; though in our patients the rectus fascia was not breeched. We followed up a cohort of four patients who had umbilical cord graft without cutting of the of rectus fascia.…”

“…Other methods mentioned before require suturing of the fascia and skin which limits the intra-abdominal space and may result in a significant rise in the intra-adnominal pressure, risking the development of acute compartment syndrome [6] . Acute compartment syndrome is a constant rise in the intra-abdominal pressure (IAP) above 10 mmHg that leads to ischemia of the abdominal organs quickly, escalating to necrosis if emergency surgery is not done [10] . Studies show that closure of the defect using the umbilical cord does not result in a rise in the abdominal pressure even when the space is limited, which allowed the babies to be fed at an earlier time; improving the overall health and prognosis [6] .…”

“…5 ), the central venous pressure was measured and values >15 cmH 2 O indicated the use of the umbilical cord graft ( Fig. 2 ) [10] .

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“…Even though science is advocating for gastroschisis repair using umbilical cord graft for its impressive end results, we should note that the developing umbilical hernia is not to be taken lightly as its surgical repair is done with caution due to bowel adhesions to anterior abdominal wall. We also advocate umbilical cord grafts for patients presenting relatively late 4–5 h post birth when oedema sets in the bowel making facial and skin closure more challenging and according to objective measurement criteria [10] .…”

Role of Surgery in the Outcome Difference of Gastroschisis between High-income and Lowmiddle- income Countries: A Review

“…The flap is autogenic, so there is less chance of infection, and no extra cost. [18][19][20] Resection of various lengths of the gut has been reported to facilitate successful primary closure with lower intra-abdominal pressure. Okoro PE et al achieved >67% survival rate in African resourceconstrained centers with primary closure after extended right hemicolectomy.…”