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Perioperative Logistics
Introduction
As with any other surgical operation, adequate preparation and planning prior to performing the procedure are crucial and paramount to obtaining an excellent result and minimizing complications. In the case of minimally invasive procedures with small incisions and narrow working corridors, said planning and preparation play an even more important role. This chapter will detail a number of principles that are common to all of the different procedures for treating craniosynostosis with endoscopic techniques.
Diagnostic Imaging
Diagnosis of single suture, isolated, nonsyndromic craniosynostosis can be made purely on physical examination and remains a clinical diagnosis. As such, we believe that obtaining imaging is not an absolute necessity to make the diagnosis, although it can corroborate it. It has been our center’s approach not to expose the young infants to unnecessary radiation associated with computed tomograms (CT) and particularly with the protocol required to do three-dimensional (3-D) reconstructions. Each suture synostosis leads to the development of a very specific and characteristic phenotype, which can be easily diagnosed. Plain radiographs of the skull are used sparingly and particularly in situations where associated positional deformational forces (as seen with certain sleeping patterns and/or with torticollis) lead to unusual head shapes. We reserve the use of CT scans to situations: (a) when the diagnosis cannot be easily determined with physical examination; (b) when there is presence or suspicion of multiple suture synostosis; or (c) if the patient has a syndromic phenotypic presentation.
Diagnostic Labs
With an otherwise normal infant, it has been our decades-long policy not to obtain any serum or blood work prior to surgery. If the birth, family, and developmental history indicate no abnormalities, the likelihood of an abnormal blood volume and/or composition with negative or severe consequences is extremely low. The only laboratory value that is obtained prior to commencing the surgical procedure is a hemoglobin and hematocrit (H/H) level either via direct venipuncture, heel stick, or with an I-STAT handheld blood analyzer. A more extensive and detailed blood work is obtained as indicated by family history (i.e., von Willebrand disease or other coagulopathy). In our experience with over 800 patients, only two infants were ultimately found to have rare blood abnormalities. Upon completion of surgery, an immediate postoperative H/H is obtained, and a third one on the next morning. The immediate postoperative H/H has been found to be a very reliable predictor of blood loss and for the need for postoperative blood transfusions. Upon completion of surgery, extreme care is taken to make sure that all bony, scalp, dural, and epidural bleeding is stopped and controlled. As such, the immediate postoperative H/H is a very reliable indicator of the patient’s red blood cell load and typically drops very little, and usually by no more than a gram per deciliter. In the last 24 years of treating these patients, we have not had the need to readmit and transfuse any patient who was discharged with a hematocrit of 15% or greater, nor have the patients had any consequences because of this management approach.
Ophthalmologic Evaluation
Our center’s pediatric ophthalmologist evaluates all of our patients prior to surgery and evaluates for abnormalities that may be present in the retina, vitreous, lens, cornea, muscular abnormalities, or orbital imbalance. A full ophthalmological evaluation takes place 1 or 2 days prior to surgery. Postoperative follow up evaluations are done within 6 months and 1 year. Autorefraction before and after pupillary dilation is done with Plusoptix or Retinomax vision screener to measure refractive errors such as myopia, astigmatism, or hyperopia. Cycloplegic refraction is done with streak retinoscopy to measure and quantify refractive errors and diagnose amblyopia. The eye movement, position, and presence of strabismus are done with each evaluation. Indirect ophthalmoscopy is used to examine the optic nerve, retina, and retinal vasculature. External eye examination and photographs are done to assess proptosis, enophthalmus, orbital rim symmetry, and widening or narrowing of the palpebral fissure. ReTCam or PanoCam digital images of the fundus are obtained, which provide true-color high-resolution images of the optic nerve and retina.
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