What is the most common procedure for gastroschisis (gastrochesis) in neonates?

Gastroschisis: Most Common Surgical Procedure

The most common procedure for gastroschisis is primary fascial closure, which can be performed either with sutures or using the newer sutureless technique, with the sutureless approach increasingly becoming the preferred method at the bedside without general anesthesia. 1, 2

Current Surgical Approaches

Primary Closure (Most Common Overall)

• Primary fascial closure is performed in approximately 70% of gastroschisis cases, making it the most frequently used approach 3
• This involves direct reduction of the eviscerated bowel and closure of the abdominal wall defect, typically within the first 24 hours of life 3, 4
• The technique requires vigorous manual stretching of the abdominal cavity and manual emptying of the entire GI tract to facilitate reduction 4
• Primary closure achieves faster return of GI function (average 3 days) and shorter hospital stays compared to staged approaches 4

Sutureless Closure (Emerging as Preferred Method)

• The sutureless technique has become increasingly prevalent and represents a significant advancement, allowing closure at the bedside without general anesthesia 2
• This innovative approach avoids the risks associated with general anesthesia in neonates and offers improved outcomes over traditional sutured closure 1
• The sutureless method is particularly advantageous for resource utilization and patient safety 1, 2

Staged Silo Reduction (Alternative Approach)

• Staged closure using a preformed silo is performed in approximately 30% of cases when primary closure cannot be safely achieved 3
• The silo allows gradual visceral reduction over 5-6 days, with strict adherence to aseptic technique to prevent septic complications 5
• Enlargement of the abdominal wall defect is essential to allow optimum reduction of edematous bowel and achieve closure within one week 5
• If the bowel cannot be returned to the abdominal cavity within 5-6 days, re-exploration is mandatory to determine the cause 5

Clinical Outcomes and Considerations

Survival and Complications

• Contemporary survival rates for gastroschisis exceed 90% with appropriate management 1
• Primary closure demonstrates superior survival (89%) compared to staged reduction (43%) in historical series 4
• Recent series report 100% survival with primary closure when performed by experienced teams 4
• Complicated gastroschisis (associated with intestinal atresia, volvulus, stenosis, or perforation) occurs in 25% of cases and significantly increases morbidity and mortality 1, 5

Factors Affecting Surgical Approach Selection

• The degree of intestinal compromise is the most critical factor determining outcomes, with severe compromise associated with increased medical (RR 1.46) and surgical complications (RR 1.83) 3
• Timing of closure (before or after 24 hours) does not significantly affect hospital stay or outcomes 3
• The choice between primary and staged closure should be based on the ability to safely reduce the bowel without causing respiratory compromise or vena caval compression 4

Postoperative Management Essentials

• Initial management requires total paralysis and mechanical ventilation as the tense abdominal wall softens over 1-2 days, followed by ventilator weaning 4
• Gastrostomy tube insertion, early peripheral venous nutrition, and later central venous catheter placement facilitate postoperative care 5
• Vigorous fluid support is essential due to third-spacing and increased insensible losses 4
• Neonates require 4-6 weeks of intensive care in specialized neonatal units regardless of closure method 1

Common Pitfalls to Avoid

• Failure to enlarge the abdominal wall defect adequately can lead to midgut infarction when attempting primary closure 5
• Delayed re-exploration beyond 5-6 days in silo patients risks missing unrecognized intestinal lesions 5
• Inadequate manual stretching of the abdominal cavity before primary closure increases risk of respiratory and vascular compromise 4