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