PREOPERATIVE DIAGNOSES:
1.
Lumbosacral myelomeningocele, greater than 20 cm in diameter.
2.
Evidence of neurologic deficit of both lower extremities, left greater
than right, with absence of anal wink.
POSTOPERATIVE DIAGNOSES:
1.
Lumbosacral myelomeningocele, greater than 20 cm in diameter.
2.
Evidence of neurologic deficit of both lower extremities, left greater
than right, with absence of anal wink.
OPERATIVE PROCEDURE:
1.
Complex repair of a lumbosacral myelomeningocele, greater than 20 cm.
2.
Muscular transposition of paraspinous and gluteal muscles to provide
wound closure.
3.
Use of the operating microscope and microdissection.
RESPONSIBLE SURGEON:
ASSISTANT:
Paul Jackson, M.D., Ph.D.
SECOND ASSISTANT:
ANESTHESIA:
Michael Edwards, M.D.
Robert Dodd, M.D., Ph.D.
General endotracheal anesthesia.
ANESTHESIOLOGIST:
Anita Honkanen, M.D.
PROCEDURE IN DETAIL: Xxxxxxxxxx was brought from the nursery to the operating
room. Because of the large size of the myelomeningocele, he could only be
placed on his side. Careful endotracheal anesthesia was established and
antibiotic prophylaxis was begun with ampicillin and gentamicin prior to
coming to surgery. Appropriate blood was made available. Appropriate venous
lines and arterial lines and monitors were placed. The baby was then
carefully turned prone onto small rolls placed along the chest and the iliac
crest to protect his umbilicus. We then draped out this very large
myelomeningocele sac by draping along the skin just above the anus and along
the buttock region along the lateral margins of the flank and along the chest
area with Steri-Drapes. The meningocele was stabilized and scrubbed for 10
minutes with Betadine, painted with DuraPrep. Sterile towels were placed
along the edges prior to the painting with DuraPrep. Sterile drapes were
placed over the lesion.
Using loupe magnification, we defined the healthy part of skin and marked it
with the marking pen on either side of this large sac, with a small extension
superiorly over the intact spinous processes, and a small incision inferiorly
to the tip of the sacrum and to the intergluteal fold, of which there was only
a minimal fold noted.
We carefully stabilized the lesion and used a small amount of 0.25% local with
1:400,000 of adrenaline; approximately 2.5 cc was used to inject along the
superior and inferior aspect of the sac.
Using a #15 blade and the Colorado needle, we incised first the skin and then
the tissues below the skin identifying the meningocele sac. A circumferential
incision of the large excess amount of skin and the abnormal skin was
accomplished and then we entered into the sac. Xanthochromic cerebrospinal
fluid was obtained. Within the sac was a second sac. This appeared to be
consistent with a myelocystocele or a very complex myelomeningocele. We
carefully protected the edge of the skin with moist sponges throughout the
procedure. We used the operating microscope and microdissection to enter into
the myelomeningocele sac. After entering into the sac, we carefully defined
the margins of the dura superiorly where it entered into the spinal canal and
in the lateral margins of the spina bifida and lateral margins of the sac and
epidural space. The sac extended down to the termination of the subarachnoid
space. The sacrum was widely bifid. The most superior intact lamina was
either L4 or L5. No laminae were removed.
After entering into the myelomeningocele sac, we tracked the distal end of the
spinal cord and neural placode to its attachment along the inverted
myelomeningocele sac and/or myelocystocele. We carefully separated the distal
end of the termination of the placode from the overlying sac, preserving the
intact nerve roots coming from the cord. There were some fine nerve roots
coming from sac, which had no attachment to the neural placode, and these were
sacrificed and sent in with the secondary sac attached to the neural placode.
The dura was preserved around this area, leaving us a good dural sac to close.
The neural placode moved cephalad within the sac. We noted a very thickened
filum terminale, which was identified, coagulated and sectioned to prevent
tethering.
After irrigating copiously with antibiotic solution, we used 6-0 Vicryl to
close the dural sac with a running suture.
In order to close over the defect, it was necessary to make incisions
laterally in the paraspinous and gluteal muscles. They were then elevated and
mobilized medially with the Colorado needle so that they could be brought to
the midline.
After this was carried out, we obtained meticulous hemostasis with the bipolar
cautery. We irrigated again with antibiotic solution and covered the dural
closure with fibrin glue. The muscle and fascia were then reapproximated by
mobilizing the muscle and transposing it to the midline. This was closed with
interrupted 4-0 Vicryl suture.
We again irrigated copiously with saline and bacitracin solution. We excised
any excess skin and were able to then close the subcutaneous tissue over the
myelomeningocele with inverted interrupted 4-0 Vicryl. The skin was closed
with running 5-0 Monocryl in a linear fashion.
Xeroform gauze, Telfa and Tegaderm dressings were applied.
Drape was placed between our dressings and the anus.
A small Steri-
The child was then turned supine. He remained intubated and was transported
back to the Intensive Care Nursery in stable condition.
ESTIMATED BLOOD LOSS:
BLOOD TRANSFUSIONS:
Less than 10 cc.
None.
COMPLICATIONS: Xxxxxxxxx tolerated the procedure well.
intraoperative complications.
COUNTS:
There were no
Needle and sponge count and recount were correct.
SPECIMENS TO PATHOLOGY:
meninges.
INPATIENT ATTENDING:
Myelomeningocele sac, excess skin and portions of
Michael Edwards M.D.
At the end of the procedure the baby was stable and returned to the Intensive
Care Nursery. His examination in the nursery after awaking showed no evidence
of worsening neurologic deficit from his preoperative status.
NOTE: I was the attending and present throughout the procedure with the
assistance of Doctors Jackson and Dodd.