2021

Abdominal Wall Defects

Omphalocele vs Gastroschisis
Pembimbing :
dr. Melvin Pascamotan Togatorop, SpB
MOHD SHAHMIN BIN MAT GHANI
 Omphalocele Gastroschisis
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 Omphalocele Gastroschisis
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Epidemiologi
Gastroskisis Omphalocele
 Insiden – 1:3000-8000  Insiden – 1 : 4000-7000
 L: P is 1:1  L:P is 1.5:1
 Ibu usia muda (<20 tahun)  Ibu usia lanjut
 Merokok  Lahir cukup bulan
 Bayi premature  >70% dikaitkan dengan kelainan
 BBLR kongenital seperti Bowel atresia,
• 10-15% dikaitkan dengan kelainan Imperforated anus,
kongenital seperti CHD (VSD), CLEFT  Trisomies 13, 18, 21,
PALATE dan malrotasi

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Etiologi
Gastroskisis
o Kelainan vaskularisasi
o Arteri omphalomesenterica
dextra
o Vena umbilicalis dextra
o Distrupsi dari artery
omphalomesenterika kanan pada
kejadian midgut masuk ke abdomen
di usia minggu ke-10 gestasional
yang menyebabkan iskemik dinding
abdomen dan akhirnya menimbulkan
rupture dinding abdomen.
Omphalocele vs Gastroschisis
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Omphalocele
o Dikarenakan kegagalan midgut
untuk masuk kedalam rongga
abdomen pada minggu ke-10 gestasi
o Kelainan dinding abdomen
kongenital dengan protusi selaput
visera abdomen kedalam peritoneum
parietal dan kantong membrane
amnion yang terisi Wharton’s jelly
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Faktor Resiko
Gastroskisis Omphalocele

• Young maternal age • Increased maternal age

• Low gravida • Twins
• Prematurity • High gravida
• Low birth-weight secondary to • Consecutive children
IUGR
• Smoker
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Lokasi dan Size

Gastroskisis Omphalocele

• Right lateral to umbilicus • Epigastric

• Mid-abdominal
• 2-5cm • Hypogastric
• Vertical • 4-10cm
• Small and large intestine • > 10cm
• Rarely liver • Giant omphalocele
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 Gejala Klinis - Omphalocele
• Defek sentral pada dinding abdomen dibawah cincin
umbilicus.
• Defek berukuran 4-12 cm (Small-<5cm)
(Large>8cm)
• Selalu dibungkus dengan kantong /Sac
• Sac terbentuk dari amnion, Wharton’s jelly dan
peritoneum
• The umbilical cord inserts directly into the sac in an
apical or lateral position.
• Pada ukuran yang kecil mungkin mengandungi
intestinal loop only, tapi pada ukuran besar tidak
menolak kemungkinan juga diisi oleh liver,
spleen dan bladder, testes/ovary
• >50% mempunyai anomali lain

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 Gejala Klinis - Gastroschisis
• Defek selalunya di sebelah kanan tali
pusat yang intak
• Tali pusat biasanya muncul dari dinding
abdominal yang normal
• Saiz bukaan <=5 cm
• Tidak ada kantong / Sac
• Penonjolan biasanya hanya mengandungi
intestinal loop
• Usus biasanya menebal, kusut dan
bengkak
• 10-15% disertai dengan anomaly lain
• 40% are premature/ BBLR

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 Diagnosis
• Alpha-Feto-Protein- di sintesis di dalam fetal liver dan di ekresi oleh fetal
kidney dan melewati placenta pada minggu ke-12
• Peningkatan maternal AFP - Neural Tube Defects, Abdominal Wall
Defects, Duodenal Or Esophageal Atresia
• 40% false positive rate
• Fetal ultrasound  setelah 14 minggu gestasi untuk tes konfirmasi

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 Prenatal Ultrasound -
Gatroschisis
• Normal umbilical cord insertion site
• Small bowel loops seen in the
amniotic cavity
• No covering membrane over the
loops of bowel
• Can include stomach and large
bowel
• Majority occur to the right of the
umbilical cord

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 Prenatal Ultrasound -
Omphalocele

• Umbilical cord insertion is

typically midline on the mass
• Located centrally
• Contents are intestinal loops and
maybe liver, spleen and gonads.

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 Management pra-bedah
• ABC
Tatalaksana • Heat Management
– Sterile wrap or sterile bowel bag
– Radiant warmer
Perinatal Management • Management cairan
– IV bolus 20 ml/kg LR/NS
– D10¼NS 2-3 maintenance rate
• Skrining maternal
• Nutrisi
 Peningkatan Alpha-feto-protein = – TPN (central venous line )
90% Omphalocele 10% Gastroschisis • Distensi Abdomen
 Fetal Ultrasound  temuan pasti – NGT
• Edukasi dan konseling prenatal – Kateter Urin
• Infeksi
• Broad-spectrum antibiotics -
Ampicillin and Gentamycin
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• Tutup defek
 Heat loss

• Large surface area exposed

• Radiant warmer
• Cover defect with non-adherent dressing
 Warm saline gauze
• Quickly loses warmth and may promote cooling of not
constantly changed
 Bowel bag
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Timing of Surgery
Gastroskisis Omphalocele

• Emergent / urgent • Not Emergent/ urgent

• Evaluasi preoperative terutama
pada
• Volume status
• Keseimbangan Elektrolic/
Asam-Basa
Omphalocele vs Gastroschisis
• Evaluasi preoperative terutama
dalam identifikasi
• Kelainan kngenital
• CVS dan Renal
• Kelainan Kromosomal
• Giant omphalocele 19
• Urgent
 Omphalocele
• Terapi Konservatif
1. . Omphalocele yang besar (10-
12cm) dikasi terapi topical 
Betadine ointment atau silver
sulfadiazine pada kantong
yang intak.
2. Secondary eschar formation and
granulation.
3. Penyembuhan selama 12 bulan
dan nanti di reparasi sebagai
hernia ventralis
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•o Primary Closure
 Small defects (<4cm)
 excision of the sac and closure of the
fascia and skin over the abdominal
contents
•o Mesh patch
 Medium defects (6-8cm)
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 Staged Closure

• Creation of a Silo
• Abdominal organs reduced
slowly over days

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o NICU
o Ventilation
o
Post operative care o
Feeding:– Minimal volume
48 hrs Antibiotics
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o Hernia dealt with at 1 yr old
 Gastroschisis

• Primary closure
o If bowel easily reduced
• Staged closure
o Silo fashioning:
 Sac excised
 Silo sewn to rectus fascia/full
thickness

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o NICU
o Feeding delayed for weeks
Post operative care o Oral stimulation/sucking reflex
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o Broad spectrum antibiotics 24
 Outcome jangka panjang
Omphalocele
• Kecil  Sembuh
• Besar 
– Gastro-oesophageal reflux - 43%
– Majority improve over time
– 20% pulmonary insufficiency
– Respiratory Infections
– Asthma
– Feeding difficulties;
• 60% with giant omphalocele
• May need gastrostomy for feeding
– Failure to thrive
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Gastroschisis
• Generally excellent if no atresia
• NEC:
– 18.5% of neonates more with formula
– Bowel loss - short gut syndrome
• Cryptorchidism:
15-30%
– Due either being outside/prematurity
– Replacement and orchidopexy by 1 yr
• 60% have psychosocial stress if umbilicus
sacrificed
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 Ringkasan

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THANK YOU!
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