Gastroschisis / Omphalocele Repair
What the Examiner Expects
Surgical correction of congenital abdominal wall defects. The examiner expects you to differentiate gastroschisis (right-sided paraumbilical defect without a covering membrane, bowel is exposed and edematous) from omphalocele (midline defect through the umbilicus with an intact peritoneal sac, associated with chromosomal abnormalities and other congenital anomalies). For gastroschisis, the goal is reduction of bowel into the abdomen with primary fascial closure if possible. If the visceroabdominal disproportion is too great (high ventilatory pressures, high bladder pressure), a spring-loaded silo is placed with serial reductions over days. For omphalocele, small defects can be closed primarily; giant omphaloceles may require staged closure or nonoperative management.
Key Examiner Focus Points
- Gastroschisis: right paraumbilical defect, NO membrane, bowel exposed to amniotic fluid (matted, inflamed)
- Omphalocele: midline defect with peritoneal sac (membrane), associated with Beckwith-Wiedemann, trisomies
- Gastroschisis: primary closure if the bowel fits; silo (staged reduction) if not
- Giant omphalocele (> 5 cm): may require nonoperative management (paint and wait with escharotic agents)
- Monitor for abdominal compartment syndrome after reduction (bladder pressure, ventilatory pressures)
Common Curveballs
After reducing the gastroschisis, peak airway pressures rise to 35 cmH2O and bladder pressure is 22 mmHg
Abdominal compartment syndrome developing from forced reduction. The abdomen cannot accommodate all the viscera at once. Back out — place a silo (preformed spring-loaded silo) and perform staged serial reductions over 5–7 days, gradually reducing bowel into the abdomen as the abdominal cavity stretches.
The omphalocele sac has ruptured during delivery
Cover the exposed viscera with warm saline-soaked sterile dressings and a plastic bowel bag to prevent heat and fluid loss. This becomes an emergency requiring either primary closure or silo placement, similar to the management of gastroschisis. Protect the bowel from desiccation and hypothermia.
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