Preparation for Surgery for Cervical Encephaloceles in Children

Indications for Surgery

The primary goals of surgery are as follows (21, 24):

• Remove unwanted tissue: Remove redundant skin and nonviable/nonfunctional tissue while preserving all viable tissue.
• Prevent leak of CSF: Obtain a watertight closure of the dura.
• Close the skin: Close the skin to prevent infection and desiccation of brain tissue.

Preoperative Orders

• Type and cross-match blood: Owing to the close proximity and possible involvement of the dural venous sinuses, the major operative risk is acute hemorrhage. Therefore, adequate venous access and volume replacement must be available during the surgery.

Anesthetic Considerations

• IV access and volume replacement: Owing to the close proximity and possible involvement of the dural venous sinuses, acute hemorrhage is a major operative risk. Therefore, adequate intravenous access and volume replacement must be available including at least 2 large bore IVs and 2 units of packed red blood cells.
• Establish monitoring lines: The encephalocele is repaired under general anesthesia. Depending on the complexity of the encephalocele and anticipated length of the repair, an arterial line and Foley catheter may be required.
• Antibiotics: The patient is given a single dose of IV antibiotics, such as a first-generation cephalosporin, just prior to making an incision.
• Avoid hypothermia: Neonates have difficulty maintaining body temperature. Heat loss should be prevented by keeping the room warm, using warming lights, and placing a warming blanket on the operating table.

Devices to Be Implanted

• Shunt or EVD: Occasionally, a shunt or EVD is required to drain excess CSF from the brain and/or to treat associated hydrocephalus.
• Vascular clips: Large arterial and venous vascular channels are often found coursing through the tissue. Therefore, vascular clips should be available as needed for meticulous hemostasis as the tissue is excised.
• Dural patch graft: A synthetic dural graft may be required for closure of the defect and should be available at the time of encephalocele repair.

Ancillary/Specialized Equipment

• Operating microscope: The increased magnification of the operating microscope can be helpful in identifying neural tissue that has herniated into the encephalocele sac and determining whether to resect or preserve the tissue.