Repair of cloacal exstrophy, omphalocele, and gastroschisis using porcine small-intestinal submucosa or cadaveric skin homograft.

The traditional surgical methods typically used to repair the abdominal wall defect present in cloacal exstrophy, omphalocele, and gastroschisis during the neonatal period include definitive primary muscle, fascia, and skin closure, primary skin closure only with late ventral hernia repair, and a staged closure using a silo. The method chosen usually depends on the extent of visceral edema, the size of the defect, and physiologic derangements related to an increase in intraabdominal pressure during placement of abdominal contents into the coelom.1 Although definitive muscle, fascia, and skin closure is preferred, increased intraabdominal pressures during attempts to reduce the herniated contents may prevent the use of this option. The technique of widely mobilizing skin flaps with late fascial repair is associated with low rates of morbidity and mortality. However, there are some important disadvantages to this technique. Large dead spaces within the wound are common, thereby increasing the risk of infection. Additionally, loss of abdominal domain may produce a giant ventral hernia, which may be difficult to repair.2 Abdominal silos prevent loss of body fluid and heat and allow progressive reduction of abdominal contents.3 However, silo removal is usually required 5 to 7 days after placement. If primary fascia closure still cannot be achieved upon silo removal, a variety of alternative treatments including biologic dressings can be used to cover the abdominal wall defect to achieve a definitive or temporary closure. The use of porcine skin and amniotic membranes for the treatment of complicated gastroschisis and omphalocele was first described in 1975 by Seashore et al.4 Although these biologic dressings are useful adjuncts that promote wound healing and are often used for burn victims, they have a number of disadvantages, including a daily replacement requirement, increased risk for wound infections including sepsis, enteric fistula formation, abdominal wall cellulitis, and loss of abdominal domain and creation of giant ventral hernias.4 Various topical drugs and chemicals, such as mercurochrome and benzalkonium chloride, stimulate the formation of a thick eschar and have been used for large omphaloceles. Morbidity and mortality rates of these topical drugs are comparable to those associated with conventional primary or staged closure techniques. However, these drugs can be absorbed systemically and may result in intoxication, metabolic acidosis, or electrolyte abnormalities.5–8 We present two alternative methods in the repair of complicated abdominal wall defects using porcine small-intestinal submucosa or a cadaveric skin homograft. We describe the preparation and application of these grafts for a giant omphalocele associated with cloacal exstrophy and for complicated omphalocele and gastroschisis.