The goal of abdominal wall reconstruction in pediatric patients should be primary closure of the abdominal wall in as few procedures as possible. If primary closure is unachievable, adjuncts such as tissue expanders, component separation, and mesh implantation can be considered. Of the 57 patients reviewed, only seven patients (12.3%) were referred to and intervened on by Plastic Surgery. Despite the significantly larger defects seen in the Plastic Surgery cohort, 0% of patients required mesh compared to eight patients (16%) who had mesh implanted by Pediatric Surgery, all of whom had giant omphaloceles. As noted above, four patients who had mesh implanted by Pediatric Surgery developed infections and required explantation. In both peripartum ruptured and giant omphaloceles, the most common complication and cause of mortality is sepsis ; accordingly, infection prevention and management are paramount, which can be mitigated by primary fascial closure and avoidance of foreign body usage.
Complications of omphalocele repairs can be secondary to surgical technique or the inherent nature of the disease. Creation of a subcutaneous space via tissue expander placement or component separation can lead to seroma, hematoma, or abscess formation . In addition, use of bioabsorbable materials in abdominal wall repairs has been shown to induce inflammation and foreign body reactions. Zero patients in the Plastic Surgery cohort had recurrence of the defect at their most recent follow-up; however, long-term followup of these patients will be needed to monitor for evidence of hernia  and/or enterocutaneous fistula formation , which can be precipitated by mesh use. These trends should be compared to patients who had mesh implanted to assess long-term outcomes and efficacy of repair techniques. Future research should follow patients who have matured out of pediatric clinics to evaluate the incidence of hernias in adults with Plastic Surgery-repaired omphaloceles.
A number of case reports have demonstrated the successful management of large omphalocele soft tissue defects using tissue expanders [10, 11]. These expanders can be placed in a variety of tissue planes, including the intramuscular plane between the internal oblique and the transversus abdominis or the subcutaneous plane [12, 13]. Three patients (42.8%) treated in combination with Plastic Surgery underwent tissue expander placement prior to omphalocele repair. In certain instances, the overlying tissues will not accommodate tissue expander placement with large loss of domain, necessitating component separation. In these cases, we advocate for preoperative discussion between Pediatric Surgery and Plastic Surgery teams for component separation and complex closure. Of note, these expanders were placed in collaboration with Plastic Surgery at the request of Pediatric Surgery with plan for closure by the latter team; this inciting event should rather set the stage for collaborative surgical efforts when managing abdominal wall reconstruction for omphalocele, especially given the early realization of tissue limitations and need for future complex closure. Additionally, Plastic Surgery consultation should also be considered in cases of revisional surgery given the potential for scar revision and soft tissue rearrangement.
There is a strong relationship between omphalocele size with morbidity and mortality. Many children with omphaloceles have concurrent comorbidities, chromosomal abnormalities, and syndromes/sequences. Often, these patients have various respiratory conditions secondary to limited chest wall growth and resultant pulmonary hypoplasia [3, 14]. Primary respiratory insufficiency, such as pulmonary hypertension and pulmonary hypoplasia, requiring positive pressure ventilation at birth is an independent risk factor for mortality in patients with omphaloceles [15, 16]. Surgical intervention aimed at reducing the extracorporeal viscera can cause secondary respiratory insufficiency due to increased abdominal pressures and the elevated diaphragm, further worsening underlying pulmonary disease [17, 18]. Surgical closure has been shown to reduce forced vital capacity (FVC), maximum expiratory flow at 25% of vital capacity (MEF25), and pulmonary compliance . Changes in FVC and MEF25 are suggested to be temporary , yet lung compliance does not change, and thus, these patients may require postoperative ventilatory support. Of the patients who underwent repair by Plastic Surgery, two (28.6%) remained intubated postoperatively given elevated PIP at surgery stop time compared to start time. In addition, these two patients had underlying cardiopulmonary disease, furthering the decision for postoperative ventilation. Interestingly, there was no significant difference between the number of Plastic Surgery and Pediatric Surgery patients requiring postoperative mechanical ventilation (p = 0.863). Factors such as underlying pulmonary disease and comorbidities, omphalocele size, and changes in intraoperative ventilatory parameters should all be assessed when deciding to extubate postoperatively.
While an inherent selection bias exists for patients who present to Plastic Surgery clinic for abdominal wall reconstruction, the number of patients with comorbidities was not significantly different across cohorts. However, the data indicates that the Pediatric Surgery patients had more severe and multiple comorbidities compared to the Plastic Surgery cohort, which is further highlighted by the higher mortality rate (10%) in the Pediatric Surgery cohort. Given this increased morbidity, we advocate for Plastic Surgery and Pediatric Surgery collaboration for component separation and assistance with fascial closure to mitigate mesh use and decrease infection risk, especially in giant omphaloceles.
We present a collaborative approach between Pediatric Surgery and Plastic Surgery to abdominal wall reconstruction for giant omphaloceles. Our results demonstrate favorable outcomes with primary fascial closure without the need for mesh and highlight the benefits of adjunctive techniques, such as component separation, for abdominal wall reconstruction. Lastly, postoperative ventilation should be considered based on intraoperative parameters, pre-existing comorbidities, and communication with the anesthesia team to ensure patient safety during abdominal wall reconstruction and closure.