General Surgery Oral Board Review: Abdominal Wall Defects (Gastroschisis & Omphalocele)

Initial Patient Assessment and Management

• 🩺 Immediate assessment of airway, breathing, and circulation is crucial for stability.
• 🔍 A thorough physical exam should focus on defect size, bowel viability, and signs of atresia.
• 💧 IV fluid resuscitation with a 20 ml/kg bolus of normal saline is administered, followed by maintenance fluids.
• 💊 Broad-spectrum IV antibiotics are initiated, along with basic lab studies.

Differentiating Gastroschisis and Omphalocele

• 💡 Gastroschisis typically presents with eviscerated bowel not covered by a membrane.
• ⚠️ Omphalocele is characterized by a covering membrane or sac and is often associated with other congenital anomalies.
• 📍 The umbilical cord implantation site differs: on the abdominal wall in gastroschisis, and into the membrane in omphalocele.

Management of Gastroschisis

• 🏥 A spring-loaded silo is often placed for large defects to gradually reduce the bowel.
• 📈 Serial reduction of the bowel into the abdomen is performed daily, with monitoring for ischemia.
• 🏥 TPN administration is necessary due to prolonged periods without oral intake.
• 🪡 Abdominal closure involves freeing the fascia and assessing suitability for primary closure or using mesh if necessary.

Postoperative Care and Complications

• 💊 Multimodal pain control, continued OG tube decompression, and TPN are essential postoperatively.
• ⏳ Prolonged ileus is common, often lasting 2-3 weeks.
• ❓ A missed intestinal atresia should be suspected if bowel function does not return after approximately 3 weeks.
• 🔬 Contrast enema may reveal signs like a microcolon, prompting further investigation with an upper GI series and small bowel follow-through.
• 🏥 If atresia is confirmed, re-exploration is planned for 6-8 weeks post-closure.

Key Takeaways for Board Review

• 🎯 Understanding the differences between gastroschisis and omphalocele is critical.
• 🔑 Mastery of the step-by-step management of abdominal wall defects, from initial assessment to surgical closure and complication handling, is expected.
• 📚 The scenario highlights the importance of diagnostic imaging and recognizing signs of missed atresia.