Gluteal flap for omphalocele repair in a case of epigastric heteropagus: A novel approach for surgical management
A 2-day-old male was referred to us as a case of conjoined twins. The baby was a full-term normal vaginal delivery, first in birth order, born out of non-consanguineous marriage. The mother was 25 years old, not registered for antenatal care and with no antenatal ultrasound scans done.\nOn examination, there was an incomplete parasitic twin attached to the epigastrium of the auto-site with an omphalocele above. The parasitic twin had well-developed lower limbs, a penis with urethra, which was blind beyond its root, a poorly developed scrotum without testes and an anal dimple without an anal opening []. The auto-site had an omphalocele, the contents of which were liver and intestine. No other obvious congenital anomalies were noticed. On auscultation, a pan systolic murmur was audible, and the second heart sound was loud.\nOn investigating, the haematogical profile was normal. Radiographs showed normally developed bones in both lower limbs and pelvis of the parasite. 2D-echocardiography (2D-ECHO) revealed multiple cardiac anomalies (atrial septum defect [ASD], ventricular septum defect [VSD], patent ductus arteriosus [PDA], overriding of aorta, and peripheral pulmonic stenosis). Ultrasonography with Doppler showed the parasitic twin being supplied by a single vascular pedicle arising from the epigastric region. The omphalocele contained right lobe of liver and bowel loops. The patient was taken up for surgery after the complete work-up.\nOperative management consisted of the removal of the parasitic twin and covering the omphalocele with the gluteal skin flap secured from the parasitic twin. The gluteal skin flap was based on the cutaneous branches of the superficial epigastric vessels of the auto-site and superior gluteal perforating artery of the parasite. During removal of the parasitic twin, a large section of skin and fat (flap) was raised by making an incision parallel to the iliac crest [Figures and ]. The fat on the superolateral aspect of the flap was dissected down to the level of the deep fascia covering thr gluteus maximus muscle. This flap was then used to cover the omphalocele of auto-site [].\nPost-operative course was uneventful, except for infection along the edges of the skin flaps, which was managed conservatively. Patient is asymptomatic after 6 months of follow-up.