EARLY PRIMARY REPAIR OF GASTROSCHISIS WITHOUT GENERAL ANAESTHESIA

Abstract

The surgical management of the abdominal wall defect has generated much discussion among paediatric surgeons. Attitudes
range from primary closure whenever possible to serial closure with prosthetic material because of the hazards of tight primary
closure. During the study period between Jan 2012 to June 2015, five patients of gastroschisis presented in institute (n=5). Out of
five, four were inborn undergone primary repair within one hour of birth. Repair of one out born neonate was done 24hr. after
birth because of late presentation. Infants undergoing primary closure were more quickly established on full enteral feeding and
discharged home significantly earlier than those either treated by primary closure under anaesthesia or by staged repair.

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Jemds.com Original Article
Journal of Evolution of Medical and Dental Sciences/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 4/ Issue 98/ Dec. 07, 2015 Page 16292
EARLY PRIMARY REPAIR OF GASTROSCHISIS WITHOUT GENERAL ANAESTHESIA
Dhiraj Parihar1, Nitin Goel2, Preeti Raikwar3, Arvinder Pal Singh Batra4, Jeewandeep Kaur5, Sourabh Nandi6
1Assistant Professor, Department of Pediatric Surgery, BPS GMC for Women, Sonepat.
2Associate Professor, Department of Pediatric Surgery, BPS GMC for Women, Sonepat.
3Associate Professor, Department of Pediatric, BPS GMC for Women, Sonepat.
4Professor & Head, Department of Anatomy, BPS GMC for Women, Sonepat.
5Assistant Professor, Department of Physiology (CRL), BPS GMC for Women, Sonepat.
6Senior Resident, Department of General Surgery, BPS GMC for Women, Sonepat.
ABSTRACT
The surgical management of the abdominal wall defect has generated much discussion among paediatric surgeons. Attitudes
range from primary closure whenever possible to serial closure with prosthetic material because of the hazards of tight primary
closure. During the study period between Jan 2012 to June 2015, five patients of gastroschisis presented in institute (n=5). Out of
five, four were inborn undergone primary repair within one hour of birth. Repair of one out born neonate was done 24hr. after
birth because of late presentation. Infants undergoing primary closure were more quickly established on full enteral feeding and
discharged home significantly earlier than those either treated by primary closure under anaesthesia or by staged repair.
KEYWORDS
Gastroschisis, Primary Repair, Anaesthesia, Inborn Neonate.
HOW TO CITE THIS ARTICLE: Dhiraj Parihar, Nitin Goel, Preeti Raikwar, Arvinder Pal Singh Batra, Jeewandeep Kaur,
Sourabh Nandi. “Early Primary Repair of Gastroschisis without General Anaesthesia.” Journal of Evolution of Medical and Dental
Sciences 2015; Vol. 4, Issue 98, December 07; Page: 16292-16294, DOI: 10.14260/jemds/2015/2403
INTRODUCTION
Babies who have gastroschisis typically are born at 34 to 38
weeks’ gestational age and undergo placement of a silo or
primary abdominal closure within the first few hours after
birth.1 Major controversies affecting the obstetrician,
neonatologist and paediatric surgeon surround the
management of gastroschisis. The surgical management of
the abdominal wall defect has generated much discussion
among paediatric surgeons. Attitudes range from those who
advocate primary closure.2 whenever possible because of the
higher mortality and morbidity rates of staged repair to those
who recommend serial closure with prosthetic material
because of the hazards of tight primary closure.3 In this study,
primary closure was attempted whenever it was considered
to be safely possible. Adopting this policy based on subjective
clinical judgment, infants undergoing primary closure were
more quickly established on full enteral feeding and
discharged home significantly earlier than those treated by
staged repair.
MATERIAL AND METHOD
Its retrospective analysis of data of cases of gastroschisis
treated in BPS GMC for Women Khanpur Kalan Sonepat
between Jan 2012 to June 2015.
SURGICAL TECHNIQUE
Soon after birth nasogastric and per rectal feeding tube were
inserted and nasogastric aspiration and decompression of
large gut was done. Intravenous antibiotic (metronidazole,
amikacin and ceftriaxone) and maintenance fluids (n/3) was
started. Once stable, infant was given paracetamol (15mg/kg)
rectally.
The fully conscious neonate was then placed supine,
Financial or Other, Competing Interest: None.
Submission 15-11-2015, Peer Review 16-11-2015,
Acceptance 27-11-2015, Published 04-12-2015.
Corresponding Author:
Dr. Arvinder Pal Singh Batra,
Professor & Head, Anatomy.
E-mail: apsbatra@yahoo.com
DOI:10.14260/jemds/2015/2 403
abdomen draped with sterile towel and bowel gently washed
with warm saline and carefully inspected for presence of
atresia or perforation. Reduction of the gut was then
accomplished slowly over 5 to 10 minutes by manual
returning the bowel, loop by loop, until the entire bowel was
within the abdomen. Meanwhile assistant had to decompress
gut by nasogastric and per rectal aspiration to assist
procedure. Abdomen wall defect then closed in one layer by
suturing with silk 1-0.
OBSERVATIONS
During the study period, five patients of gastroschisis
presented in institute (n=5). Out of five, four were inborn
undergone primary repair within one hour of birth. One out
born neonate was presented more than 24hr. after birth. All
patients were female with gestational age between 36 to 38
weeks and birth weight between 1.8kg and 2.15kg.
Fig.1: Neonate of Gastroschisis with Normal Sibling
One neonate was product of twin pregnancy with normal
sibling (Fig. 1). After IV access stabilization, patient was
hydrated with n/3 saline; 10FR infant feeding tube placed
nasogastric and per-rectally. Gastric and per-rectal aspiration
done to decompress the gut and primary repair done in labor
room (Fig. 2).

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Fig.2: Postoperative Picture of Gastroschisis
Postoperatively, patients were kept nil orally and IV
antibiotic were given. Postoperative ileus was resolved
within three days in three neonates and oral feeding initiated
in fourth postoperative day, discharged on seventh
postoperative day. In follow-up, patients were reviewed in
Paediatric Surgery OPD at the age of 3 months and 6 months
(Fig. 3).
Fig.3: Patient Followup at the Age of 1 Month
No other abnormality was found in followup ultrasound. One
of inborn neonates with birth weight of 1.8kg primary repair
was succeeded, but 48hr. after surgery patient developed
septicemia and could not be survived. One out born neonate
was presented after 48 hours of birth, had edematous bowel
and thick peel formation could not be survived 72hr. after
surgery.
DISCUSSION
First successful repair of gastroschisis reported in 1943
(Watkins).4 Schuster’s landmark.5 paper of 1967 reported the
progressive reduction of eleven omphaloceles using a "keel"
or "reef" of Teflon-0 mesh. His technique was modified by
Allen and Wrenn.6 in 1969, who fashioned the prosthetic
material into a "silo" or "chimney" and accomplished
reduction by milking the prosthetic tube downward every 1
to 3 days.
The principles of management are to reduce the viscera
safely followed by closure of the abdominal wall defect and
proper nutrition support, in addition to detection and proper
management of any associated anomalies or complications.7
Prenatal diagnosis and transfer of patient to a specialized
center is in favor of more frequent successful primary
closure, less postoperative ventilation and reduced hospital
stay because of earlier surgery and early management of
patient.8
Reduction of the abdominal content should be done
within hours after birth, as delay in repair may cause water
and heat loss from the exposed bowel, compromised gut
circulation and infarction.1 Reduction of gut can be done as
primary reduction or as stage reduction. Operative primary
reduction with closure of the abdominal defect continued to
be the standard initial surgical strategy. In 1970,
pharmacologic paralysis and prolonged mechanical
ventilation after aggressive attempts at primary closure were
recommended.9 some authors suggest that all patients with
gastroschisis may be primarily closed with paralysis and
ventilator support.2
Primary repair can be done with or without general
anaesthesia. Bianchi and Dickson.10 in 1998 published series
of cot side reduction of 14 cases, out of them 12 were
survived without anesthesia, used umbilical cord sutured to
the rectus sheath to cover the defect and concluded minimal
interventional management of gastroschisis is safe and
applicable in our retrospective case control study and we
could succeed in suturing the defect. Davies (2005).2 in his
retrospective comparative study between ward reduction
and repair under GA of 31 infants suggested that in ward
reduction group avoided ventilation in 62% of cases and
avoided GA in 81% of cases. Psychological impact on the
parents of the diagnosis of Gastroschisis can be lessened if we
can counsel the parents that in most cases general
anaesthesia and mechanical ventilation can be avoided, also
decrease in length of stay in NICU, faster time to full feeds and
shorter hospital stay. However, there was a non-significant
trend toward septicemia in those patients reduced on the
ward without anesthesia.
Staged reduction is frequently used as a rescue strategy
when reduction is deemed unsafe or physically impossible
because of visceral abdominal disproportion.7 If primary
closure is not possible because of insufficient size of
abdominal domain, an artificial pouch or silo is constructed to
contain the eviscerated abdominal content. Premade
SILASTIC (Dow Corning, Midland, MI) silo with spring loaded
rings (SLS) as well as various technique for silo construction
are used.3 Staged closure carries the risk of loss of facial
strength at the margins of the defect, the infection risk from
the lack of a watertight seal and the risk of evisceration due
to disrupt suture line.11
Preformed silos (including SLS) have been used
routinely without general anaesthesia and irrespective of the
viscero-abdominal disproportionate. Randomized controlled
trial (27 pts. in each arm) demonstrates no difference
between Spring-Loaded Silo (SLS) and primary closure with
respect to time on TPN, Length Of Stay (LOS), Incidence of
Sepsis and Necrotizing Enterocolitis (NEC); there was a trend
toward decreased days on ventilator but it was not
significant.12 One of the disadvantages of SLS is the
progressively increased abdominal wall defect, which may be
explained by the development of lateral distractive forces
being applied to the abdominal wall.13
CONCLUSION
Despite the several advantages of SLS, it has potential pitfalls
including ischemic complications, dislodgment, bowel
twisting and difficulties with final closure. Preformed silo is
not easily available in our locality and resources are limited.
Maintenance of complete asepsis for long period is not always
feasible due to limited resources. Adopting this policy based
on subjective clinical judgment. Infants undergoing primary
closure without anaesthesia were more quickly established
on full enteral feeding and discharged home significantly

Jemds.com Original Article
Journal of Evolution of Medical and Dental Sciences/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 4/ Issue 98/ Dec. 07, 2015 Page 16294
earlier than those either treated by primary closure under
anaesthesia or by staged repair.
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