Gastroschisis Repair

Patient Considerations

Introduction

• Gastroschisis involves a full thickness umbilical wall defect, which often results in evisceration of the bowel. The disease occurs in approximately 4 out of every 10,000 live births and can be diagnosed as early as the second trimester with abdominal ultrasound.

Pathogenesis

• There are multiple hypotheses on the pathology of the disease including; disruption of the right vitelline, altered folding of the body, altered involution of the right umbilical vein, and the mesoderm being unable to form the ventral wall.

• Associated Anomalies

  • Some common GI issues related to this disease are perforation, malrotation, atresia, stenosis, volvulus, and necrosis.

  • No increased risk of congenital heart disease

Case Planning

• These patients frequently have SILOs placed in the NICU and undergo a slow reduction over several days prior to presenting to the OR for reduction

• Specific or Unique Room Set-Up Requirements

  • Airway

    • Eviscerated bowel has impaired motility

      • Consider RSI

  • Drugs/Infusions

    • Muscle relaxation may help facilitate abdominal closure

  • Monitors

    • Standard ASA monitors

    • Consider Somatic NIRS

      • Decreased somatic NIRS may be the first sign of impaired renal perfusion secondary to increased intra-abdominal pressures post-reduction

    • Arterial access usually NOT required

  • Blood Availability (if indicated)

    • Blood loss is usually minimal

  • PICU Bed Availability (if indicated)

    • These patients usually present from the NICU

Anesthetic Considerations

• Induction

  • Consider RSI due to impaired gastric motility

• Positioning

  • Supine

• Maintenance

  • Maintenance of Anesthesia

    • Hemodynamic/Physiologic goals

    • As most of these patients are neonates the goal MAP should be the patient’s gestational age

      • Ex. A 1 day old born at 37 weeks should have a MAP of 37 or above

    • Somatic NIRS should be within 20% of baseline post-reduction

    • Post-reduction tidal volumes should be monitored to ensure that reduction has not impaired ventilation

• Surgical Considerations (such as neuromonitoring, muscle relaxation, anticipated blood loss)

  • Muscle relaxation may help facilitate reduction and abdominal closure

  • Blood loss is usually minimal

Emergence/Disposition

• Discuss awake extubation v. return to NICU intubated with the surgeon

Post-Op Pain Management

• IV Narcotics

Case-Specific Complications

• Patients may be an aspiration risk

• Closure of the abdomen may precipitate abdominal compartment syndrome

  • Notify the surgeon if patient is not tolerating closure