Neurosurgery notes/Procedures/Myelomeningiocele surgery/Prenatal myelomeningocele surgery

Prenatal myelomeningocele surgery

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Myelomeningiocele surgery
  • Preoperative Medication:
    • Cephazolin (1000 mg IV) and indomethacin (50 mg PR or PO) were administered.
  • Anaesthesia:
    • A combination of general and epidural anaesthesia was used, with an indwelling epidural catheter for continuous postoperative analgesics.
  • Uterus Exposure:
    • The gravid uterus was exposed via a low transverse laparotomy incision and exteriorised. For patients with a BMI over 30 or a previous vertical skin scar, a vertical skin incision was used.
  • Fetus and Placenta Location:
    • The fetus and placenta were located using ultrasound.
  • Hysterotomy Location:
    • The primary surgeon selected the hysterotomy location.
  • Fetal Positioning: The fetus was visualised by ultrasound and manually positioned within the uterus so that the myelomeningocele sac was in the centre of the hysterotomy.
    • If the placenta was anterior, the hysterotomy was fundal or posterior.
    • If the placenta was posterior, uterine entry was anterior.
  • Uterine Incision Preparation:
    • Under sonographic guidance, two monofilament traction sutures were placed through the full thickness uterine wall.
    • Initial uterine entry was sharply accomplished between these traction sutures.
    • A uterine stapling device, loaded with absorbable polyglycolic acid staples (Covidien Auto Suture, Norwalk CT), was passed into the uterine cavity.
    • The stapler was manually palpated and ultrasonography was used to exclude the presence of fetal tissue.
    • The stapler was then used to create a 6-8 cm uterine incision, large enough to expose the fetal myelomeningocele.
  • Fetal Medication:
    • The fetus received an intramuscular injection of fentanyl (20 mcg/kg) and vecuronium (0.2 mg/kg).
  • Fetal Monitoring:
    • Fetal cardiac function was continuously monitored with echocardiography by an individual not directly involved in the surgery.
  • Myelomeningocele Closure:
    • The myelomeningocele was closed in a standardised manner under magnification.
    • The neural placode was sharply dissected from surrounding tissue and allowed to drop into the spinal canal.
    • The dura was identified, reflected over the placode, and closed using a fine running suture.
    • If there was insufficient dura for closure, Duragen (Integra Life Sciences Corporation, Plainsboro, NJ) was substituted.
    • If skin closure was not possible, relaxing incisions were made or Alloderm (Life Cell, Branchburg, NJ) was used.
    • Finally, the skin was mobilised and closed using a fine running monofilament suture.
  • Uterine Closure:
    • The uterus was closed in two layers.
    • The first layer incorporated the absorbable staples and uterine membranes.
    • As the last stitches of this layer were placed, warmed Ringer’s lactate, mixed with 500 mg of Nafcillin or vancomycin, was added to the uterus until the amniotic fluid index was normal.
    • A second imbricating layer of suture was tied.
  • Abdominal Closure:
    • The abdominal fascial layer and dermis were closed in routine fashion.