Open Postnatal Myelomeningocele Surgery
Intervention for spina bifida myelomeningocele.
Spina bifida is a congenital neural tube defect—a type of developmental disorder that arises when the neural tube does not fully close during fetal development. While there are many types and severities of neural tube defects, spina bifida myelomeningocele is one of the most severe, requiring surgical intervention. When technology is not available to operate on the baby fetoscopically, an open surgery can be preformed shortly after birth.
Positioning
The patient is positioned prone, with the head rotated laterally as close to 90 degrees as possible. The body is positioned over two rolled towels—placed parallel—with the placode at the apex of the towel to avoid CSF leakage into unwanted areas. Utilizing two towels allows for easier ventilation while prone.
Accessing the Surgical Site
A midline linear incision from top of placode to distal 2 normal vertebrae is created.
A circumferential incision—surrounding placode at the border of normal skin and arachnoid membrane—is created.
Dissection of Placode
Using microdissectors and microscissors, delicate dissection of the placode from the normal anatomy is completed. Care should be taken to avoid the dorsal and ventral roots which are often immediately adjacent to the placode.
Vessels and smaller non-functional nerves within the placode can be carefully freed to prepare for the next steps.
Tubulization
This step is considered the “reconstruction of the neural tube.” The placode at the bottom of the dural sac (which continues rostrally with the intact cord) has spinal roots emerging ventrally. The two lateral edges of placode are brought midline and sutured. Avoid excessive tight closures. If closure cannot be achieved then skip step.
Dural Closure
The dissected dura should be sutured in a similar fashion to the placode (using a dural patch if not enough tissue is available). Since the closure should be water-tight, a Valsalva maneuver should be performed to test for leaks.
Layered Closure
Thoracolumbar fascia is closed over the defect if possible. Subcutaneous tissue is sutured together and skin margins are debrided.
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