Kilbride Kandice E, Cooney Donald R, Custer Monford D
Division of Pediatric Surgery, Department of Surgery, Texas A and M Health Science Center, Temple, TX 76508, USA.
J Pediatr Surg. 2006 Jan;41(1):212-5. doi: 10.1016/j.jpedsurg.2005.10.003.
Closure of giant omphalocele can present a surgical challenge. Neither silo, skin flap, nor primary closure has been successful in treating all patients. We present a novel application of the vacuum-assisted closure (VAC) device, which allows for improved results in these difficult cases.
The VAC device (KCI, San Antonio, Tex) consisted of a sponge applied directly to the bowel and liver, covered with impermeable transparent dressing, and attached to a low negative pressure system. The sponge was changed every 3 to 5 days under local sedation.
All 3 patients had giant omphaloceles. The first infant, a 34 week gestational age (WGA) male, was initially treated with silo reduction, which disrupted after 21 days. The large mass of bowel and liver made primary closure impossible. The VAC was applied for 45 days. The viscera was easily reduced and subsequently covered with acellular dermal matrix (AlloDerm). The VAC was reapplied, and the small remaining defect was skin-grafted. The second male infant was a 34 WGA male infant who became septic after failure of prosthetic mesh closure. The VAC was applied for 22 days after removal of the mesh. The infection resolved, and the defect size was reduced, allowing for skin flap closure. Mesh infection and development of an enterocutaneous fistula in the last patient, a 37 WGA female child, were treated by mesh removal and application of the VAC for 36 days. The VAC allowed for control of the fistula output and development of a healthy granulation bed.
Vacuum-assisted closure was associated with (1) rapid shrinkage and reduction of the viscera (22-45 days); (2) cleansing of the wound; (3) excellent granulation; (4) maintenance of a sterile environment; and (5) ease of use, with changes possible at the bedside.
The VAC device should be considered a safe and effective alternative in treating complicated cases of giant omphalocele until a more definitive closure method can be used.
巨大脐膨出的闭合是一项手术挑战。袋状缝合法、皮瓣法或一期闭合术均未能成功治疗所有患者。我们介绍一种真空辅助闭合（VAC）装置的新应用，该装置在这些困难病例中可取得更好的效果。
VAC装置（KCI，得克萨斯州圣安东尼奥）由一块直接敷于肠管和肝脏上的海绵、不透水透明敷料覆盖，并连接至低负压系统组成。在局部麻醉下，每3至5天更换一次海绵。
所有3例患者均为巨大脐膨出。首例婴儿为孕34周（WGA）男性，最初采用袋状缝合法缩小脐膨出，但21天后出现破裂。大量肠管和肝脏使得一期闭合无法进行。应用VAC 45天。内脏易于回纳，随后覆盖脱细胞真皮基质（AlloDerm）。再次应用VAC，剩余小缺损行植皮术。第二例男性婴儿为孕34周WGA，人工补片闭合失败后发生败血症。移除补片后应用VAC 22天。感染得到控制，缺损尺寸减小，可行皮瓣闭合。最后一例患者为孕37周WGA女性儿童，出现补片感染和肠皮肤瘘，通过移除补片并应用VAC 36天进行治疗。VAC可控制瘘口排出物并促进健康肉芽床形成。
真空辅助闭合与以下情况相关：（1）内脏快速收缩和回纳（22 - 45天）；（2）伤口清洁；（3）肉芽生长良好；（4）维持无菌环境；（5）使用方便，可在床边更换。
在采用更确切的闭合方法之前，VAC装置应被视为治疗复杂巨大脐膨出病例的一种安全有效的替代方法。
