Although several methods and materials for staged reduction have been developed over the years, most surgeons utilize preformed silos with a spring-loaded ring [10, 29, 33, 34, 43, 46, 52]. The Silastic preformed spring-loaded silo comes in a variety of diameters and can be placed at the bedside upon arrival of the patient without the need for general anesthesia. Before placement of the silo, it is important to closely inspect the bowel. Absolute contraindications for bedside placement include any perforation or necrosis [29]. Obstructing bands and adhesions from the fascia to the bowel are gently disrupted with manual blunt dissection, electrocautery, or sharp dissection. The bowel is then gently pushed up into a preformed Silastic silo and the base of the spring-loaded ring slipped beneath the fascial defect (Fig. 15.2). In some instances, the fascial defect may be small and require widening either laterally or vertically in the midline in the operating room before placement of the silo. In these situations, the preformed silo cannot be utilized and a custom silo must be fashioned and sutured to the fascia. It is important that no twisting of the mesentery occurs during placement into the silo. The silo is then suspended above the bed to provide upward traction on the silo and the abdominal wall. The bowel will begin to reduce with gravity alone during the first 24 h after silo placement. The viscera is progressively reduced either daily or twice daily with sequential ligation of the silo using umbilical tape, an umbilical cord clamp, or silicone tubing with a slipknot [1, 33, 34, 43, 53]. The transparency of the Silastic silo allows continuous inspection of the bowel for any changes in perfusion. In the event of bowel ischemia, the fascia may be enlarged and a larger silo applied or a custom silo can be created and sewn to the fascia [1, 29]. Complete bowel reduction usually occurs by 4–7 days after silo application [29, 33, 43]. Once the bowel is completely reduced, the fascial defect is closed primarily in the operating room [33, 43]. If the defect cannot be closed primarily, a synthetic or biological patch can be used [1, 33, 34, 54].

An alternative to primary fascial closure is primary reduction with a “plastic” sutureless “flap” closure of the abdominal wall defect using the umbilical cord. After reduction of the bowel, the umbilical cord is laid over the small residual defect and held in place with an adhesive dressing (Fig. 15.3) [55]. The technique was first described by Bianchi in Dickson [56] in 1998 and later modified by Kimble [57] and Sandler [55]. At our institution, we have adopted the use of a negative pressure wound vacuum to aid in closure [58]. The umbilical cord is tailored to fit into the abdominal wall defect and covered with a non-adherent dressing (Adaptec, Johnson and Johnson, Langhorne, PA). The black foam (KCI, San Antonio, TX) is then cut to an appropriate size and applied directly over the wound bed and secured in place using clear adhesive film. The Trac pad (KCI, San Antonio, TX) is then applied over the black foam and placed to 50 mmHg continuous suction. The wound vacuum is removed on postoperative day 5 and the umbilical cord is allowed to desiccate.

The use of sutureless closure has gained popularity since the early 2000s. Compared to fascial closure of the defect, sutureless closure is associated with equivalent outcomes [59]. A recent meta-analysis of twelve studies demonstrated that there were no significant differences in mortality, length of stay, and days on TPN between patients who had sutureless closure versus fascial closure [59]. Furthermore, the sutureless group had significantly less surgical site infections compared to the fascial closure group even among patients who initially had a silo placed for reduction [59]. The rate of umbilical hernia after sutureless closure ranges from 22–91% and is significantly higher than after fascial closure [59–62]. However, the majority of these hernias will spontaneously close and will ultimately not require an operative repair [55, 61, 62]. This is in contrast with hernias after fascial closure which require operative repair significantly more often [59]. The cosmetic result after sutureless closure is often excellent with little to no scar formation [55, 63].

One of the appeals of the sutureless closure is that reduction and closure of the defect can be done at the bedside and general anesthesia avoided. Ward reduction of gastroschisis without the use of general anesthesia was first introduced by Bianchi and Dickson in 1998 [56]. The technique was further modified with the addition of analgesia and/or sedation [57, 64, 65]. Although some initial reports had unsatisfactory outcomes, the subsequent introduction of selection criteria demonstrated that more than 80% of neonates were suitable for ward reduction [1, 57, 61, 64, 66, 67]. Exclusion criteria for ward reduction include unstable patient with poor general condition, poor bowel condition including intestinal perforation or necrosis, bowel/mesentery attached to the defect, narrow defect, gross viscero-abdominal disproportion, and conversion in the presence of deteriorating metabolic acidosis, patient distress/tenderness, and increased respiratory support [57, 64, 65, 67].

Some have advocated silo placement at beside without general anesthesia followed by sutureless closure as a preferred method for uncomplicated gastroschisis because of the advantage of avoiding general anesthesia and similar outcomes to primary fascial closure [29]. The cord is protected from desiccation by wrapping it in antibacterial-impregnated paraffin gauze and cling film. The bowel is then serially reduced until the entire bowel is reduced below the level of fascia for at least 12 h. The silo is removed and the cord is elevated and pulled to the contralateral side to attempt to close the defect. If closure is possible, steri-strips and a dressing are applied to approximate the skin edges. The umbilicus is allowed to desiccate and cicatrize [29].

Complex gastroschisis includes those patients with bowel complication including intestinal atresia , perforation, and necrosis (Fig. 15.4) [68]. Compared to patients with simple gastroschisis without associated bowel abnormalities, complex gastroschisis patients have worse outcomes including delayed enteral feeding, prolonged TPN use, longer ventilator days, longer hospital length of stay, and possibly increased mortality [68, 69]. When there is associated bowel abnormality such as intestinal atresia, the bowel can be reduced and the abdomen closed. After 4–6 weeks of nasogastric decompression and supplementation with TPN, the patient is re-evaluated for the presence of intestinal atresia with contrast studies. If an atresia is present, the patient can undergo an elective resection and primary repair [63]. Alternatively, some surgeons will remove the area of atresia and perform a primary anastomosis in the presence of minimal inflammation at the time of defect closure [70–72]. If the atresia is located distally or associated with a perforation, an ostomy can be created followed by ostomy closure at a later date [73]. Delayed intestinal surgery in patients with gastroschisis complicated by intestinal atresia allows bowel inflammation to decrease and facilitates an anastomosis, possibly decreasing anastomotic leaks and other complications [73, 74]. However, a recent study from the Canadian Pediatric Surgery Network demonstrated that early establishment of intestinal continuity in patients with gastroschisis complicated by intestinal atresia is safe, allows for earlier initiation of enteral feeding, and does not increase complications [70].