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KELAINAN DINDING ABDOMEN PADA

ANAK

KEPANITERAAN KLINIK ILMU BEDAH PERIODE 27 FEBRUARI 2017 06 MEI 2017


Disusun oleh : Nathaniel A. Pakpahan (11-174)
FAKULTAS KEDOKTERAN
Pembimbing UNIVERSITAS KRISTEN
: dr. Stanley K. Olivier, Sp.B INDONESIA JAKARTA
EMBRIOLOGI
Herniasi Umbilikus Fisiologi (Minggu ke 6)
Sebagai hasil dari perkembangan
cepat dan ekspansi hati, maka
kavum abdomen secara sementara
akan menjadi terlalu kecil untuk
menampung semua usus.

Semua usus akan memasuki kavum


ekstraembrionik di dalam korda
umbilikus selama perkembangan
minggu ke-6.

Sebagai hasilnya, terjadi hernia,


untaian usus akan berotasi 900
berlawanan arah jarum jam sekitar
arteri mesenterika superior.
Minggu ke-10
Kembali Ke Kavum Abdomen

Selama minggu ke-10


perkembangan, herniasi umbilikus
akan kembali ke kavum abdomen.

Akan mengalami rotasi 1800


berlawanan arah jarum jam di sekitar
arteri mesenterika superior.

Faktor yang bertanggung jawab pada


proses ini belum diketahui.
Diperkirakan sebagai regresi dari
mesonefros (ginjal), pengurangan
pertumbuhan hati dan ekspansi
kavum abdomen.
ANATOMI
Gastroschisis Omphalocele
o Disruption of the right o Due to failure of the midgut
omphalomesenteric artery as
midgut returns to abdomen by to return to abdomen by the
the 10th week causing ischemia 10th week of gestation
of the abdominal wall and during midgut rotation.
weakness then herniation. o Congenital abdominal wall
o Failure of migration and fusion of defect with protrusion of
the lateral folds
abdominal viscera contained
o Congenital abdominal wall
defect towards the right side of
within a parietal peritoneum
the umbilicus and protruded and amniotic membranous
bowel is not covered by a sac with Whartons jelly.
membrane.
Epidemiologi
Gastroschisis Omphalocele
Incidence - 4 per Incidence - 3 per 5,000
10,000 >70% association with
10-15% association congenital anomalies
such Bowel atresia,
with congenital
Imperforated anus,
anomalies such as
Beckwith-Wiedemann
VSD, cleft palate and Syndrome & Pentalogy
intestinal atresia of Cantrell
40% are premature
Risk Factors
Gastroschisis Omphalocele

Increased maternal
Young maternal age
age
Low gravida
Twins
Prematurity
High gravida
IUGR
GASTROSCHISIS OMPHALOCELE
Clinical Features

GASTROSCHISIS OMPHALOCELE
Defect to the right of an intact umbilical cord central defect of the abdominal wall

allowing extrusion of abdominal content


beneath the umbilical ring.
Defect may be 2-12 cm (Small-<5cm)
Opening 5 cm
(Large>8cm)
No covering sac (never has a sac )
Always covered by sac
Evisceration usually only contains intestinal Sac is made of amnion, Whartons jelly
loops and peritoneum

Bowels often thickened, matted and Small contains intestinal loops only. Large
may involve liver, spleen and bladder,
edematous
testes/ovary
10-15% have associated anomalies
>50% have associated anomalies
40% are premature
Diagnosis
Alpha-feto-protein-synthesized in fetal
liver and excreted by fetal kidneys.
Elevated maternal AFP - neural tube
defects, abdominal wall defects, duodenal
or esophageal atresia
40% false positive rate
Fetal ultrasound after 14 weeks gestation
Prenatal Ultrasound
Gastroschisis

Small bowel loops


seen in the amniotic
cavity
No covering
membrane over the
loops of bowel
Can include large
bowel
Prenatal Ultrasound
Omphalocele

Umbilical cord
insertion is typically
midline on the mass
Located centrally
Contents are
intestinal loops and
maybe liver, spleen
and gonads.
Management
Perinatal Management
Maternal Screening
Fetal Ultrasound
Alpha-feto-protein elevated
Prenatal counselling
Pre-operative Management
ABC
Heat Management
Sterile wrap or sterile bowel bag
Radiant warmer
Fluid Management
IV bolus 20 ml/kg
Abdominal Distention
NG tube
Infection Control
Broad-spectrum antibiotics - Ampicillin and Gentamycin
Closure of the Defect
Omphalocele
Conservative
1. Large omphalocele (10-12cm) o Primary Closure
apply topical application -
Betadine ointment or silver Small defects
sulfadiazine to the intact sac.
2. Secondary eschar formation (<4cm)
and granulation.
3. Healing lasts for 12 months
excision of the sac
then repaired as ventral hernia. and closure of the
fascia and skin over
the abdominal
contents
Post operative
care
o NICU
o Ventilation
o Feeding:
Minimal volume
o 48 hrs Antibiotics
Gastroschisis
Primary closure
o If bowel easily reduced
Staged closure
o Silo fashioning:
Silo sewn to rectus fascia/full thickness
Post operative care
o NICU
o Feeding delayed for
weeks
o Oral stimulation/sucking
reflex
o Broad spectrum
antibiotics