Silo Closure

Silo closure surgery

Silo closure surgery is an operation done to a baby with gastroschisis which is an inward born condition in which the baby is born with the intestines (or other organs) out of the abdomen through a gap in the abdominal wall. Surgical closure of the abdominal wall is a final procedure, which is done after achieving some level of stability and installing a silo bag.

What Is Silo Closure?

• The last surgical procedure of gradual silo repair is silo closure.

As soon as the bowel is fully returned to the abdomen, surgeons are sewn:

• The abdominal wall defect
• Skin and fascia (muscle layer)
• No postoperative pressure on organs.
• This is meant to correct abnormal abdominal anatomy and complications.

Silo closure procedure

Silo closure is the last surgery process in the treatment of gastroschisis, which is the result of an intestine sticking out of the abdominal wall of the newborn. Once the bowel is slowly narrowed down to the abdomen with the use of a silo bag, the surgeons do silo closure in order to close the abdominal wall defect.

Silo Closure Indications

Silo closure is carried out in case:

• There is complete bowel reduction in the abdomen.
• No necrosis or bowel ischemia.
• The infant is hemodynamic stable.
• The postoperative abdominal pressure can be supported by ventilation.

Pre-operative Preparation

• NICU monitoring
• Infection/sepsis control.
• Temperature, Fluids, electrolyte stabilization.
• Daily staged reduction completed with the help of the silo.
• Abdominal capacity to avoid compartment syndrome.
• General anaesthesia planning.

Anaesthesia

• General anaesthesia is imposed on the baby.
• There is a need of intubation and mechanical ventilation.
• The regular check of heart rate, oxygen saturation, blood pressure.

Silo Closure Process Step-by-Step

Step 1: Silo Removal

• The silo bag (which was sutured or had been attached to the abdominal wall) is depressed.
• The bowel is examined on the presence of injuries, ischemia or perforations.

Step 2: Abdominal Cavity inspected.

• Surgeons determine the ability of the abdominal cavity to hold the shortened bowel without straining it.
• Adhesions and kinks are repaired.

Step 3: Confirmation of Reduction.

• In case of need, final manual bowel loop reduction is provided.
• Precaution is observed to ensure that the bowel is not compressed or blood flow is not disturbed.

Step 4: Fascial Closure

• Non absorbable or slowly absorbable sutures are used to bring the fascia (muscle layer) together.
• A tension-free closing is done to prevent the abdominal compartment syndrome.

Step 5: Skin Closure

• Interrupted or continuous sutures are used in closing the skin.
• Sometimes, the partial or delayed skin closure can be applied when the swelling continues.

Step 6: Dressing and Stabilization of the post-operative period.

• Sterile dressing is applied.
• The adjustment of ventilation is done to counteract high pressure in the abdomen.
• Surveillance at NICU proceeds.

Postoperative Management Post-closure

• In the case of a high level of abdominal pressure, babies are placed on a ventilator until the pressure decreases.
• The use of IV fluids, antibiotics, and pain management is offered.
• The feeding is not introduced until the bowel moves again (typically a few days).
• Gradual replacement of TPN by milk feeds. 
• Repeated occurrence of abdominal distension, vomiting, or feed intolerance. 

Silo closure for abdominal wall defect

Silo closure is a surgical procedure, which is done after the staged abdominal organ rejection of the abdomen in infants with abdominal wall defects, most commonly gastroschisis. It is the last procedure upon the removal of silo bag by slowly returning the intestines to the abdomen. When the reduction is finalized and the baby is stable, the defect of the abdominal wall is closed to restore normal anatomy by closing the silo.

Silo Closure indications

Silo closure is conducted in case:

• There is complete reduction of intestines in the stomach.
• Bowel is viable, perfused well.
• Abdominal pressure is acceptable (no threat of compartment syndrome)
• In the NICU, baby feels hemodynamically stable.
• None of ongoing infection and necrosis.

It is primarily used in:

• Gastroschisis (most common)
• Huge hydrocele in which gradual reduction is needed.
• Complex defects of the abdominal wall that require staged reduction.

Silo closure recovery

Post-silo closure is a significant step in the management of gastroschisis newborns or any other defects of the abdominal wall. It is concentrated on the normalization of bowel functioning, safe transition to feeding, avoidance of complications, and wound healing in the NICU.

Early Post-operative Recovery (Initial 24-72h) 

Respiration Control 

• Babies may need ventilation following the closure because of the elevated abdominal pressure.
• Ventilator parameters are changed according to the required breathing.
• When abdominal pressure stabilizes, then extubation (removal of the breathing tube) is performed.

Pain Management

• The treatment is continuous IV analgesia or sedation.
• Regular scoring of pain is carried out.

Fluid and Electrolyte Management

Strict monitoring of:

• Urine output
• Electrolytes
• Blood pressure
• Blood gases
• TPN and IV fluids will be used until feeds can get going.

Monitoring abdominal pressure 

• Abdominal compartment syndrome 

Symptoms of abdominal compartment syndrome are monitored:

• Reduced urine output
• Tachycardia
• Difficulty breathing. 
• Abdominal tightness

Gastrointestinal Recovery

Return of Bowel Function

• It can take some days to one week to get bowel functioning normally.

Signs of recovery:

• Bowel sounds return
• Gas/stool passage
• Abdominal swelling reduces

Feeding Progression

• NPO (nothing by mouth) in first few days.
• PN (Total Parenteral Nutrition) Continue.

Start slow feeds as soon as the bowel perforates:

• Trophic feeds: 0.5–1 ml/kg/hr
• Daily increase depending on tolerance.
• Weaning to full feeds requires:
• 12-14 weeks in uncomplicated gastroschisis.
• Longer in complex cases

Signs of Feed Intolerance:

• Vomiting
• Abdominal distension
• Residuals in feeding tube
• Blood in stools
• Needs the suspension or dissolution of feeds.

Wound and Surgical Site Care

• Dressings kept clean and dry

Inspection for:

• Redness
• Pus
• Skin separation
• Tenderness
• Usually, absorbable sutures dissolve.
• Prior to discharge, parents are taught wound care.

The NICU Monitoring in Recovery

• Weight Change Day to Day and Hydration.
• Bowel permeability and abdominal circumference.
• Respiratory checks
• Infection monitoring
• TPN-related care in line infection prevention.
• Nourishment and development aid.

Complications of silo closure

The closure of silos is considered to be quite safe, when it is performed after due staged reduction, however, due to the fact that the abdominal capacity and bowel of neonates are too weak; various complications may be observed. These can either be immediate, early, post-operative or long-term.

Immediate Complications During or After Closure

• Abdominal Compartment Syndrome (ACS)
• Difficulty breathing
• Hemodynamic Instability
• Bowel Ischemia or Injury
• Bleeding

Early Post-operative Complications (First Days–Weeks)

• Prolonged Ileus
• Feeding Intolerance
• Wound Infection
• Sepsis
• Enteric Necrosis
• Wound Dehiscence

Long-Term Complications

• Ventral Hernia
• Adhesive Bowel Obstruction
• Development and nutritional concerns
• Gastroesophageal Reflux 
• Chronic Feeding Difficulty

Factors Affecting Silo closure cost India

The price of an abdominal wall defect (such as gastroschisis) silo closure in India may differ significantly as it may depend on numerous factors. The following are the key aspects that may affect the cost:

Hospital Type & Reputation

• It can be a tertiary-care or a super-specialty hospital that is pediatric.
• Public or private hospital: the private hospitals cost more.
• Hospital infrastructure (NICU facilities), surgeries).

Location of Hospital

• The big metro cities are generally more expensive than the less populated cities. 
• Regionally, cost of operating theatre, ICU and bed varies.

Length of stay in NICU

• The babies subjected to silo closure require more time in NICUs.
• Ventilator days, TPN (parenteral nutrition) days and monitoring expenses accumulate.
• It is found out that delayed closure (i.e., silo) results in much longer NICU, increased TPN, and ventilator days >, therefore, costly. 

Complexity of the Case

• Complicated gastroschisis (bowel atresia, necrosis, edema) compared with simple gastroschisis requires more care, longer operation time, and more postoperative intervention.
• Babies who are premature or very low weight could be at higher risk and may take longer to recover.

Silo Type Used

• The use of standard silos with a built-in spring weight as opposed to simpler or locally produced silos.
• Silos material (sterile silo, special equipment) cost can change.

Time spent Silo Reduction Phase

• The length of days that the baby is kept in staged reduction before closure impacts on cost. The more days, the greater the hospital resources.
• Greater reduction time reduction period results in greater risk of infection.

Operating Theatre (OT) Charges

• Complexity, surgical time and cost (pediatric surgeon + anaesthetist).
• Application of special surgical equipment in neonatal practice.

Charges for Anaesthesia and Ventilation

• The anaesthesia required for the neonate is very specific and the anaesthetists need to be experienced. 
• Post-op ventilation (where necessary) is very expensive.

Consumables & Medications

• Sutures, operative materials (where necessary).
• Antibiotics, pain relievers, IV fluids.
• TPN is expensive 

Diagnostic & Monitoring Expenses

• Preoperative tests such as x-ray, ultrasound and blood tests
• Vital signs monitoring devices in NICU.
• Post-surgery tests (to verify bowel perfusion, wound, etc.)

Complications & Extra Operative procedures

• In case of complications such as infection, abdominal compartment syndrome, wound dehiscence, cost is increased.
• Re-surgery or more surgery (e.g. hernia repair afterward).

Length & Type of Hospital Stay

• Days in NICU vs general ward.
• Room category: general room, private room or VIP room.

Follow-up Care

• Follow up visits, wound management, physiotherapy (where necessary) costs.
• Growth follow-up, nutrition follow-up.

Best hospital for silo closure India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

A high-level closure of silos is very crucial when managing such abdominal wall defects as gastroschisis in a staged approach. Once the bowel is slowly retracted with the use of a silo, the abdominal wall integrity is regained through the process of closure, which also acts in stabilizing the newborn to achieve a long-term recovery. Most of the infants through proper NICU support attention to surgical technique, and observing complication closely have good outcomes. The success of silo closure is largely based on bowel health, timely intervention, quality of NICU and the non-occurrence of postoperative complications. Early diagnosis, specialized neonatal surgery and specialized critical care are very useful in enhancing recovery and eventual growth in the affected infants.

Affordable silo closure India GetWellGo

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FAQ

1. At what time is silo closure done?

• Closure is accomplished when the bowel is totally shortened into the abdomen, and the baby is stable enough to undergo surgery- which normally takes between 2-7 days after birth depending on the bowel distension and the abdominal size.

2. Are silo closure and primary closure identical to each other?

• No.

Primary closure occurs right after birth when the swelling is negligible.

Silo closure late bowel reduction with the help of a silo bag

3. What is the purpose of having a silo prior to closure?

• A silo allows the loops of swollen fragile bowel to be removed progressively in the abdomen with reduced pressure and without excessive pressure on breathing.

4. What is the prognosis of infants following silo closure?

• In most instances, the long-term outcomes of most babies are excellent, normally grow and do not suffer serious complications, particularly simple gastroschisis.

5. Can silo closure be repeated?

• No. It is a single operation that is done after full staged reduction. More surgeries can however be done in future in case of complications such as hernia.

6. Can silo closure be effective?

• The success rates are great particularly when it is conducted in a special neonatal surgical center. The results are determined by bowel well-being and lack of complications.