Preparation for Surgery for Myelomeningoceles in Children

Indications for Surgery

• Presence of defect: All myelomeningoceles not associated with fatal anomalies are repaired within 24–48 hours of birth (5-7).
• Hydrocephalus: Shunt placement may be clinically indicated.

Preoperative Orders

• HOB, positioning and activity: It is advisable to place the newborn prone in the isolette and during nursing to prevent injury to the exposed neural tissue.
• Placode care: The neural placode should be covered with a wet dressing to keep it moist. The authors prefer to use a 4 x 4” gauze moistened with sterile normal saline, which should be kept moist at all times. Be careful that the moistened gauze is only over the placode to prevent skin maceration. A dry 4 x 4” gauze can be placed over that or a gauze roll bandage wrapped around the child (28).
• IV antibiotics: Prophylactic antibiotic coverage should be started with broad-spectrum coverage (e.g., ampicillin plus gentamicin).
• Surgical site scrub: Sterile normal saline is used over the neural placode and cyst. The area around the cyst is painted with betadine. The prep should extend to the abdomen on both sides, up to the shoulders, and down to the buttocks. This will allow for skin undermining and possible skin/muscle flaps as needed.

Anesthetic Considerations

• Positioning for intubation: Patients may be supine for intubation. The spinal defect should be placed in a donut or towel rolls to keep pressure off the neural placode.

Ancillary/Specialized Equipment

• Magnified vision: Either loupes or a microscope is recommended for surgery to optimize vision of the placode so that all dermal elements are removed prior to closure.