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A newborn with a mummified right paraumbilical intestinal remnant, closed abdominal wall, and loss of most of the midgut raises important questions concerning embryonic abdominal wall closure and the intrauterine events leading to gastroschisis and “congenital” short gut syndrome.

Between January 1985 and December 1994, 164 liver transplantations were performed on 141 children. There were 100 reduced-size and 64 whole-liver grafts. Primary closure of the abdominal wound was not possible in 21 patients because of liver size, bowel edema, and distension. Temporary SILASTIC ® patch closure of the abdominal wound was used. For 16 of the 21 patients, removal of the SILASTIC ® patch and abdominal wall closure were completed by the seventh postoperative day; for the others, these were accomplished by the end of 2 weeks. The method is recommended when primary wound closure is not possible.

Hypothesis Newborns with congenital diaphragmatic hernia (CDH) have a high risk of mortality, ranging from 50% to 70%. Tensioned closure of the narrowed abdominal cavity is detrimental. Patients and Methods Twelve high-risk newborns underwent operation for CDH. To achieve tension-free closure of the abdominal wall, a Silastic patch was used. The Silastic patch was sutured intermittently to the edges of the abdominal wall fascia with absorbable sutures and left open to the air. The skin was not closed above the Silastic patch, which was lubricated with 1% gentamicin sulfate ointment. Results Eleven patients (91.6%) survived. No local or systemic septic complication occurred. The abdominal wall was gradually closed, and total closure was achieved within 4 to 6 weeks (mean, 4.9 weeks). Conclusion Because of the high survival rate and the complication-free rapid healing of the abdominal wall, the technique can be used in any case of CHD in which tension-free closure of the abdominal wall cannot be achieved by other methods.

É apresentada uma técnica de controle da evisceração, empregada nos casos com indicação formal de laparostomia. Através da combinação de dupla prótese temporária (tela de polipropileno e película de poliamida), realizamos o "fechamento progressivo", o qual permite a síntese primária tardia da parede abdominal, sem o risco de fístula entérica. Os resultados da primeira série de 23 pacientes (1990-1994) são comparados a outro grupo (outras técnicas de laparostomia) do mesmo hospital. A mortalidade global foi de 39,1% em nossa série, contra 55,9% quando utilizadas outras técnicas (p = 0,003), não havendo diferença entre seus índices prognósticos (Apache II). Em todos os casos em que o fechamento progressivo foi concluído (22 pacientes), a síntese primária tardia da parede abdominal foi possível, mesmo que com longos períodos de laparostomia. O emprego da técnica não aumentou o tempo de internação. A reoperação programada e o controle dos focos sépticos foram mais efetivos, com uma média de revisões de cavidade igual a 6,8 contra 1,8 no outro grupo. Nenhuma fístula e nenhuma eventração decorreram do emprego da técnica. O recente emprego da técnica na Síndrome Compartimental do Abdome tem demonstrado grande benefício para estes pacientes críticos. Os novos conceitos sobre a laparostomia trouxeram importantes mudanças quanto aos seus critérios de indicação e novas exigências quanto ao seu refinamento técnico.

Summary— Posterior iliac osteotomy is a recognised method employed to facilitate and support anterior abdominal wall closure in patients with bladder exstrophy, but it adds considerably to the already lengthy procedure of bladder exstrophy surgery. Anterior pelvic osteotomy of the superior ramus of the pubic bone was developed to overcome this problem and to achieve a stable anterior pelvic ring with tension-free soft tissue closure. It can easily be performed after completing the bladder closure, without the need to turn the patient.

One hundred sixty-one consecutive patients who underwent bowel procedures were randomly assigned a nonabsorbable multifilament suture material, a nonabsorbable monofilament suture material or a long-term absorbable suture material for abdominal closure. All patients had midline incisions; closure was by an interrupted single layer technique. Patients were evaluated 1 month, 6 months and 1 year after operation. No statistically significant difference was seen in the incidence of wound infection in these groups. By 1 year, six patients had incisional hernias, none in the long-term absorbable suture group. The absence of suture sinus formation and the failure to demonstrate an increased incidence of wound dehiscence or incisional hernia imply that long-term absorbable suture material may be the most appropriate choice after bowel operations.

Eleven children underwent second stage repair of giant omphaloceles containing the liver. Simultaneous SVC and IVC pressure before, during and after closure of the abdominal wall was recorded. In all patients with circulatory complications the SVC pressure decreased following surgery. The postoperative pressure ratios in IVC and SVC (Formula: see text) was found to be four times greater in the group with complications. It is suggested that this ratio might serve as an important index in the prediction of abdominal wall closure feasibility in giant omphaloceles.

Use of the stapled abdominal wall closure over a 5 year period is reviewed. It was found to cause the least morbidity and to be the most rapid closure yet described.

In Reply .—Many surgeons state that postoperative ventral hernia is a rarity. Ellis et al 1 believe that this is because patients are not examined carefully and are not followed up sufficiently. They add that the ideal method of midline incision closure has not been discovered yet and emphasize the necessity of prospective controlled studies to answer this question. Our article, which Dr Gray "read with some alarm," reports such a randomized trial, comparing two widely used techniques of abdominal wall closure. Obviously, its results cannot be useful for surgeons who use both techniques and material with no complications. As far as we are concerned, scientific conclusions seem better than "impression" or "certainty." I would like to thank Dr Gray for giving us the opportunity to recall this option.