Selective repair of neonatal gastroschisis based on degree of visceroabdominal disproportion.

Based on 14 years' experience with the surgical repair of gastroschisis abdominal wall defects in 32 infants at the UCLA Hospital, certain aspects of care evolved which have served to reduce the overall long-term mortality to 6.2%. The severity of gastroschisis defects appears to be related to the length of time the eviscerated intestine has been exposed to amniotic fluid, and the degree of vascular obstruction to the viscera. In contrast to reports by previous authors recommending a specific operative technique for all infants with this malformation, we believe that choice of the optimal surgical repair depends on the degree of disproportion between the size of the eviscerated intestine and the size of the abdominal cavity. Three of the 32 patients with minimal disproportion underwent primary skin and muscle closure followed by early recovery. Twenty-seven who had primary skin flap closure later underwent secondary ventral hernia repair within six to 12 months. Two of the 32 infants had severe viscerobadominal disproportion and required temporary prosthesis coverage in addition to extensive skin flaps during the primary repair. The low morbidity and mortality following gastroschisis repair are apparently related to these factors: avoiding undue compression of the viscera; early coverage of the contaminated viscera with skin or muscle to minimize infection; careful supportive perioperative management to maintain body heat and provide adequate fluid repletion; and the infusion of intravenous hyperalimentation solutions during the lengthy period of post-operative ileus. Prosthetic materials should be reserved for more complex abdominal wall reconstruction in infants who have severe visceroabdominal disproportion.