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Anterior abd wall defects presentation.pptx
- 1. ATBUTH DEPARTMENT OF SURGERY PEDIATRICSURGERY UNIT ANTERIOR ABDOMINAL WALL DEFECTS BY DR ABDULLAHI IBRAHIM 23/7/2024
- 2. Outline • INTRODUCTION • EMBRYOLOGY •TYPES • AETIOLOGY • DIAGNOSIS • INVESTIGATION • COMPLICATION • TREATMENT • PROGNOSIS • REFRENCES
- 3. introduction • gastroschisis andomphalocele are the 2 most common congenital abdominal wall defects • Often diagnosed prenatally by ultrasound scan • Associated with other anomalies in different rates
- 4. Embryology of anteriorabdominal • 3rd week- formation of trilaminar disc- ectoderm, mesoderm and endoderm • Mesoderm lie in 3 longitudinal strips alongside the notochord and neural tube- paraxial, intermediate and lateral plates • The paraxial is segmented into the sclerotome and myotome which form the muscles of the body wall • The embryo begin to fold at the caudal, cephalic and lateral folds to become convex towards the amnion and concave towards the yolk sac
- 5. Embryology Contd…. • Thelateral plate divides to form • somatopleuric or parietal layer intraembryonic mesoderm that is in contact with ectoderm • Splanchnopleuric or visceral layer of intraembryonic mesoderm that is in contact with the endoderm • The paraxial mesoderm migrate into the somatopleuric layer to form the flexor and extensor muscles of the body wall • The gut tube has communication at the umbilicus to the yolk sac • 6th week- physiological herniation of the midgut • 10th week- the already herniated gut returns to the peritoneal cavity
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- 9. Types • Omphalocoele (Exomphalos) •Gastroschisis • Cephalic defect- Pentalogy of Cantrell • Anterior diaphragmatic hernia • Sternal Cleft • Ectopia Cordis • Cardiac anomalies • Caudal defects • Bladder / Cloacal Exstrophy • Hernias • umbilical
- 10. omphalocele • A centraldefect of the umblical ring through which bowel and other abd viscera herniate • Incidence – 1 in 6000 live births – 2nd most common abd wall defect • Embryology – Omphalocele is thought to be secondary to failure of physioligically herniated small bowel to return to the abdominal cavity by the 12th week of gestation
- 12. Aetiology/pathophysiology (Exomphalos/Omphalocoele) • Omphalocoele arisedue to failure of migration and fusion of the embryonic folds and this explain the association with other midline defects • Failure of all/part of midgut to return to the caelom during fetal life. • Risk factors – Old maternal age
- 13. Clinical presentation • Massarising from a defect in the ant abd wall covered by membrane • Abdominal contents covered with amniotic membrane, wharton’s jelly and peritoneum • Contents: small and large intestine, +-liver, spleen, stomach, gonads • About 40 – 60% are associated with other congenital abnormalities
- 14. Omphalocoele – AssociatedAnomalies • Upper midline syndrome- pentalogy of Cantrell • Trisomies 13, 18 and 21 • Prune belly syndrome • Cardiac anomalies e.g. TOF, ASD, VSD • Beckweith-weideman syndrome (omphalocoele-macroglossia- hyperinsulinism ) • Neural tube defects
- 15. classification • Based onsize • Up 5cm described as minor • >5cm described as major • Based on contents of sac • Bowel loops only • Bowel loops and liver • Membrane coverage • Intact • Ruptured • Associated anomalies • Syndromic • Non syndromic
- 16. diagnosis • PRENATAL – α-Fetoprotein- high in both maternal serum and amniotic fluid – Ultrasound scan • Postnatal • Random blood sugar • FBC + DIFF • Electrolyte/urea and creatinine • Radiological • Abd uss • ECHO • CXR • Chromosomal analysis
- 17. treatment • Fluid resuscitation •Prevention of heat loss • Correct hypoglycemia • Careful cleaning of sac to prevent injury • Give iv antibiotics
- 18. • Intact sac-closed dressing – Whole abd cleaned and a layer of sufratulle is applied to cover the whole lesion, soft gauze is applied and crepe bandage is applied around the whole circumference of the abd – Dressing is done every 24-48hrs – Patient can be discharged after to continue dressing – When omphalocele heals, there is a ventral hernia which can be repaired at a later stage • Ruptured sac – Silo application
- 19. • Closure ofomphalocele minor – Primary closure – Delayed primary closure • Infected sac and edematous abdominal wall – Cleaned and covered with sufratulle and gauze and then wrapped with a soft crepe bandage, done twice daily – closure maybe done
- 20. Treatment…. • Closure ofomphalocele major – Primary closure • Rule out intra-abdominal compartment syndrome – Staged abdominal wall closure • Only skin maybe closed • Heal, leaving a ventral hernia – Secondary abdominal wall closure • Repair of the ventral hernia • Fascial wall closure, use of prosthetic materials(surgisis, permacol, gore-tex) • Post op antibiotics and wound dressing
- 22. Gastroschisis • Incidence • 1in 4,000 births • M>F • A defect on the abd wall lateral (usually Rt side) to the intact umbilical cord with herniation of the abd contents • Embryology • Caused by failure of umbilical coelom to develop • The elongating intestine then ruptures out of the body wall directly into the amniotic cavity • The defect is almost always on the right side
- 24. Aetiology/pathophysiology of gastroschisis • Failureof the mesoderm to form in the anterior abdominal wall • Failure of the lateral folds to fuse in the midline leaves a defect to the right side of the umbilicus • The exact mechanism is unknown • Vascular theory: • vascular accident with intra uterine occlusion of right omphalomesenteric artery • Obliteration of the right umbilical vein • Maternal • Smoking • Use of vasoconstrictive agents such as ephedrine, cocaine
- 25. Risk factors • Youngmaternal age • Use of addictive drugs such as methamphetamine, marijuana • Maternal use of tobacco, aspirin, and ibuprofen • Low socioeconomic status
- 26. Clinical presentation • Ithas no covering • Is not associated with chromosomal abnormalities • The most common associated anomaly is intestinal atresia • Vascular compromise • Better prognosis than omphalocele
- 27. Diagnosis • PRENATAL -α-Feto protein-high in both maternal serum and amniotic fluid - USS- 2nd trimester • Shows small abd wall defect to the right of the umbilicus • herniated bowel floating in amniotic fluid (gastroschisis) • Elevated amniotic fluid acetylcholinesterase more in gastroschisis • Postnatal • Fbc + diff • eucr
- 28. management • Non operativemgt – Apply warm saline soaked sterile gauze on eviscerated bowel – Mgt of neonatal temperature by placing in radiant warmer – Fluid resuscitation – Give iv antibiotics – GI decompression-NG tube – Preformed silo application and gradual reduction of the bowel into the abdominal cavity over 24-72hrs • Iv solution bags, blood bags, condoms – Final closure of the defect consist of closing the defect • adhesive strips(steri-strips)
- 31. • Primary closure Thesmall defect is extended, and exploration of the abdomen is done to exclude gut anomalies such as atresia or malrotation • The bowel is cleaned with warm saline and reduced into the abdominal cavity and wound is closed • Post op antibiotics • Wound dressing
- 32. OMPHALOCELE VS GASTROSCHISIS LocationUmbilical ring Right of umbilicus sac present absent cord On sac Inserted normally intestine normal edematous liver herniated unusual malrotation present present Abdominal cavity small normal Ass anomalies common rare Bowel strangulation rare Greater risk Bowel atresia rare common
- 33. Complications: • Sepsis • Rupture •Bowel descication • Bowel obstruction/ileus • Fluid/Electrolyte imbalance • Hypoglycaemia
- 34. Prognosis • Depends on: •Severity/ Time of presentation • Associated Anomalies (Syndromic) • Available care
- 35. references • Holcomb andashcraft’s pediatric surgery • Coran pediatric surgery • Operative pediatric surgery • Langman’s medical embryology • Pediatric surgery, a comprehensive textbook for Africa 2nd edition
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