No operative management
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correct answer
D non operative management
Giant omphalocele is a major clinical challenge for pediatric surgeons. Whereas small- to medium sized defects can be repaired in the newborn (either primarily or using a staged approach); patients with larger omphaloceles have lost considerable abdominal domain so that reduction may be associated with excessive abdominal compartment pressures. It is clear that such anomalies can be managed nonoperatively allowing epithelialization of the intact omphalocele sac followed by repair of the residual ventral hernia at six to twelve months of age. Epithelialization usually takes several months. Once the child is stable, primarily from a pulmonary standpoint, the omphalocele sac can be gently wrapped with an elastic bandage to promote gradual reduction of the omphalocele. Much of the nonoperative treatment is accomplished as an outpatient.
A variety of surgical techniques have been described for these very large anomalies to augment the traditional serial fascial mesh tightening described by Schuster. Options include use of porcine small intestine submucosa, placement of tissue expanders and vacuum assisted closure (VAC) suction dressings. Component separation has been described but is usually done later in infancy.
The most appropriate treatment option is dependent on the size and location of the defect as well as the infant’s overall medical condition. In the clinical scenario cited above with a large defect in a ventilated infant, nonoperative treatment is associated with a significantly lower risk of mortality compared to operative management.
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DComment
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