[size=20px]A 28-week gestation premature newborn has a giant omphalocele. The sac was torn during delivery and a ten cm loop of small intestine has herniated through the tear. Although otherwise stable, he requires mechanical ventilation.

 

The best initial management of this complicated omphalocele is

 

A excision of sac and primary fascial repair.

 

B comfort care only.

 

C excision of sac and split thickness skin graft.

 

D suture repair of the sac and topical antibiotic.

 

E excision of sac and bowel resection.​[/size]

D

D

D

D

D

D

D

D

D

Correct answer

D suture repair of the sac and topical antibiotic.

 

Giant omphalocele is a formidable surgical challenge. Immediate reduction of the omphalocele contents and closure of the abdominal wall is associated with a high mortality and morbidity. It is increasingly common to initially manage giant omphalocele nonoperatively with either topical treatment of the membrane, or other wound care techniques, and allow the baby to grow in order to perform a delayed repair. A wide variety of topical agents, including silver sulfadiazine and providone iodine, have been successfully used to manage the membrane and allow for skin growth and contracture to cover the omphalocele contents. An important goal of all these methods of delayed repair is to preserve coverage of the herniated abdominal contents.

 

Avoidance of a ruptured omphalocele is important as it is more difficult to manage and associated with a higher mortality and morbidity. It is possible to repair some disruptions of the omphalocele membrane and convert a complicated ruptured omphalocele into a more easily managed intact giant omphalocele. In the case described of a small, premature baby with a giant omphalocele requiring ventilator support at birth, an immediate omphalocele repair would be especially hazardous so attempting to repair the omphalocele membrane to allow for topical treatment and delayed repair is the best option of those presented. Split thickness skin grafts have been used in the treatment of complicated omphaloceles in conjunction with other techniques and would not be recommended as an initial treatment. Resection of viable bowel would not be indicated in a patient with omphalocele.

 

Premature infants with giant omphalocele have a high mortality. For example, a baby with a giant omphalocele and a birth weight of less than 1500 gm has a one year mortality of 75%. For the patient presented, survival would not be unprecedented so it is reasonable to offer treatment with a goal of eventual closure of the abdominal wall.