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Prenatal imaging of patient #1. Prenatal imaging showed a large abdominal wall defect without evidence of a sac. Notice the small thoracic cavity, indicative of pulmonary hypoplasia.
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The first case is a newborn male with a prenatal ultrasound and fetal MRI confirming an extensive anterior abdominal wall defect containing the small bowel, colon, all of the liver, and stomach without a definitive covering and pulmonary hypoplasia (Figure 1).
PMC6350565_02
Gastroschisis contents at initial trip to the operating room. Upon birth, the patient was taken to the operating room for management of his massive gastroschisis. The liver has a rounded globular shape.
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The patient was taken directly to the operating room for silo placement, which was anchored to his abdominal wall fascia and placed on external traction (Figure 2).
Placement of the silastic silo. Two silastic sheets were required to cover the entirety of the abdominal defect. Prolene suture was used to attach the two sheets together. Felt pledgets and Prolene sutures were used to attach the silastic silo to the abdominal fascia (a). (b) The completed silo.
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To create a silo large enough to encompass the entire defect, two large sheets of silastic mesh were sewn to the abdominal fascia with 3-0 polypropylene sutures and felt pledgets (Figures 3(a) and 3(b)).
External traction system after dressing application was complete. Once the silo was placed under tension, betadine, petrolatum gauze, and dry gauze were used to keep the area sterile and prevent fluid loss.
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Antibiotic ointment was applied to the sides of the silo and fascial edges, and the entire silo was wrapped in dry gauze (Figure 4).
PMC6350565_03
Placement of polypropylene sutures in the mesh to encourage visceral reduction. Polypropylene sutures were placed in the mesh silo to encourage reduction of the viscera into the abdominal cavity.
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To manage the massive defect, rows of sutures were placed on the upper part of the silo to encourage descent of the bowel (Figure 5).
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Placement of acellular dermal allograft mesh for covering and use of braided polyester sutures for tension-inducing abdominal wall growth. After placement of the allograft, 4-0 braided polyester sutures were placed on either side of the abdominal fascia using Roeder's knots, thus allowing for intermittent tightening without replacement of the sutures (a). A wound vac sponge was placed on top of the mesh and sutures (b).
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Ethibond  (Ethicon, Johnson & Johnson, Belgium) sutures (2-0 in size) were placed in a horizontal mattress fashion with pledgets, connecting the two sides of the abdominal fascia; these sutures were secured with Roeder's knots to allow for intermittent tightening of the fascia without needing to replace the sutures (Figures 6(a) and 6(b)).
(a-c) Sequential closure of the abdominal fascia. Tightening of the retention sutures was done on a weekly basis until the fascia could be completely closed (a, b). The allogaft mesh was removed upon final closure of the abdomen (c).
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Wound dressing change with tightening of the fascial sutures was performed 1-2 times weekly until the fascia was able to be closed (Figures 7(a) and 7(c)).
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(a, b) Patient #2 at delivery. This figure shows the large abdominal defect with bowel, liver, and stomach herniation of patient #2 at birth before transfer to the operating room (a). The defect was to the left of midline with no identifiable sac. The very apex of the heart can be seen at the cranial edge of the defect (b).
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APGAR scores at birth were 4, 5, and 8; she was intubated for respiratory insufficiency prior to transfer to the operating room (Figure 8).
External traction with silo covering for patient #2. To cover the bowel and allow for growth of the abdominal cavity, a silastic sheath was sewn to the abdominal fascia. The silo will be suspended around the isolette for external traction on the abdominal fascia. A dressing that included bacitracin, petrolatum gauze, and dry gauze bandages was applied.
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A similar silastic silo was sutured to the fascia. 2-0 polypropylene sutures were used to close the top of the silo and then to suspend the silo for traction (Figure 9).
Negative pressure dressing placement in patient #2. Placement of a mesh silo with a negative pressure dressing in patient #2.
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A negative pressure dressing was placed on top of the Strattice  mesh and placed to -125 mmHg of continuous suction (Figure 10).