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Large hernias may require the use of a mesh to bridge the defect or to rein­force the suture if the edges can be approximated. Obviously, the mesh must be centred on the defect. Some authors suggest suturing the mesh to the previous diaphragmatic suture and gluing the edges of the mesh to the diaphragm [35]. An alternative technique is to suture the four corners of the mesh to the diaphragm and glue the rest, but it is important to be exible and adapt your operative tech­nique based on the location and features of the diaphragmatic hernia. The use of

Infants with omphalocele may suffer from complications associated with the dis­ease itself or with the method of repair. The most frequent complication is sepsis [68]. Primary repair can lead to hernia, particularly if under tension. Separation of the abdominal wall layers can lead to seroma or haematoma development in the subcutaneous space, and damage to perforating vessels can lead to skin necrosis. The use of a silo or a bridging mesh can damage fascial edges and lead to infection. With regard to topical therapies, the chronic use of iodine can lead to hypothyroid­ism, and in general, escharotic agents can lead to ruptured omphalocele [62].

Immediately after birth, the herniated viscera must be protected from the exter­nal environment, so humidity and temperature can be kept constant. The most com­mon option for achieving this is to use a Lahey bag (or ‘bowel bag’). This is a sterile bag into which the lower half of the newborn is placed; the bag is then loosely tied around the chest. The bowel must be positioned in a way that protects the mesen­tery, and the vessels therein contained from twisting or kinking against the abdomi­nal wall to preserve the intestinal blood ow. Intravenous access should be obtained in order to stabilise the newborn with uids when necessary and in anticipation of starting total parenteral nutrition soon after birth. Fluid resuscitation must be judi­cious, to prevent pulmonary oedema and the subsequent need for mechanical venti­lation, and should be guided by vital parameters, capillary rell time, urine output and acid-base status [73]. Primary surgical closure of the defect is the strategy of choice if achievable without causing abdominal compartment syndrome. Normally, it is obtained suturing the fascia after reduction of the viscera in the abdomen. More recently a ‘sutureless’ method has gained popularity. This approach consists of coil­ing or hanging the umbilical cord remnant over the abdominal wall defect and plac­ing a tight adhesive dressing over it, and the dressing is then changed every few days until the fascial defect has closed (Fig.13). This method can be performed at the bedside, and it does not require general anaesthesia. Some infants may initially develop an umbilical hernia, but most of these will close over time [84]. If the herni­ated bowel mass is too large or too oedematous to perform primary reduction and closure, a prosthetic silo can be placed over the viscera. The infant should then be transferred into a NICU, where the silo can be tightened once or twice daily at the bedside, with a small amount of sedation, to progressively reduce its contents into the abdomen. During reductions, constant attention must be given to the haemody­namics of the newborn [56, 73]. Once completely reduced, the infant can then undergo primary surgical closure or ‘sutureless’ repair. Regardless of the method chosen, the herniated bowel should be inspected before reduction to check for the presence of atretic segments before attempting reduction. In children with gastros­chisis complicated by atresia, perforation or necrosis, a bowel resection or creation of stoma may be necessary. At birth, the bowel is usually too oedematous to safely undergo resection and immediate anastomosis to repair intestinal atresia. Therefore, these are treated after 4–6weeks, when anastomoses are thought to be more secure