Anterior Sacral Meningocele Approaches [Neurosurgery Wiki]

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====== Anterior Sacral Meningocele Approaches ======

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The standard approach for [[Anterior Sacral Meningocele]] is through a posterior sacral laminectomy. This route permits ligation of the base, to disrupt its connection with the thecal sac and also manages tethered cord if present. A dural fibrin patch may be used to close the open defect
((Bayar AM, Yasitli U, Tekiner A, Gokcek C, Edebali N, Erdem Y, Akkaya A. Anterior sacral meningocele. A case report. J Neurosurg Sci. 2007 Jun;51(2):89-92. PMID: 17571042.)).

One has to be careful to preserve nerve roots in the vicinity to prevent postoperative neurological complications.

An open anterior transperitoneal abdominal approach was used in our case as the large ASM was reaching up to the umbilicus and had a large neck. Anticipated difficulty in managing the large ASM, excellent exposure available, and previous experience of this approach guided in preferring this approach. The limitation of this procedure is the management of caudal spinal cord anomalies as deep pelvic dissection is difficult
((Ashley WW Jr, Wright NM. Resection of a giant anterior sacral meningocele via an anterior approach: case report and review of literature. Surg Neurol. 2006 Jul;66(1):89-93; discussion 93. doi: 10.1016/j.surneu.2005.10.020. PMID: 16793455.))
((Tuzun Y, Izci Y, Polat KY. Anterior sacral meningocele: excision by the abdominal approach. Pediatr Neurosurg. 2005 Sep-Oct;41(5):244-7. doi: 10.1159/000087482. PMID: 16195676.)).

Laparoscopic approach for surgical management of ASM is increasingly being used
((Trapp C, Farage L, Clatterbuck RE, Romero FR, Rais-Bahrami S, Long DM, Kavoussi LR. Laparoscopic treatment of anterior sacral meningocele. Surg Neurol. 2007 Oct;68(4):443-8; discussion 448. doi: 10.1016/j.surneu.2006.11.067. PMID: 17905071.))
((Işik N, Balak N, Kircelli A, Göynümer G, Elmaci I. The shrinking of an anterior sacral meningocele in time following transdural ligation of its neck in a case of the Currarino triad. Turk Neurosurg. 2008 Jul;18(3):254-8. PMID: 18814114.))

This is especially useful for narrow-based ASM which may be suture ligated. A posterior sagittal approach may be useful in management of ASM associated with anorectal malformations in Currarino syndrome
((Somuncu S, Aritürk E, Iyigün O, Bernay F, Rizalar R, Günaydin M, Gürses N. A case of anterior sacral meningocele totally excised using the posterior sagittal approach. J Pediatr Surg. 1997 May;32(5):730-2. doi: 10.1016/s0022-3468(97)90018-x. PMID: 9165463.))
((Massimi L, Calisti A, Koutzoglou M, Di Rocco C. Giant anterior sacral meningocele and posterior sagittal approach. Childs Nerv Syst. 2003 Nov;19(10-11):722-8. doi: 10.1007/s00381-003-0814-1. Epub 2003 Oct 24. PMID: 14576957.)).

===== Approaches =====
Different approaches have been described for the treatment of ASM, including the transrectal or transvaginal aspiration, dorsal transsacral approach, ventral transabdominal-transpelvic approach, inferior presacral approach, oblique parasacral approach of Demel and Coqui, lumbar-peritoneal shunt, and endoscopic approach
((Manson F, Comalli-Dillon K, Moriaux A. Anterior sacral meningocele: management in gynecological practice. Ultrasound Obstet Gynecol. 2007 Nov;30(6):893-6. doi: 10.1002/uog.4061. PMID: 17787029.))

===== Dorsal transsacral approach =====

[[Dorsal transsacral approach for anterior Sacral Meningocele approach]]