Neonatal Surgical Issues (Part 2) Sue Ann Smith, MD Neonatologist Anatomic survey (cont) Intestinal obstructions Genitourinary Abdominal masses Inguinal hernia Testicular torsion Neurosurgical
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Transcript Neonatal Surgical Issues (Part 2) Sue Ann Smith, MD Neonatologist Anatomic survey (cont) Intestinal obstructions Genitourinary Abdominal masses Inguinal hernia Testicular torsion Neurosurgical
Neonatal Surgical Issues
(Part 2)
Sue Ann Smith, MD
Neonatologist
Anatomic survey (cont)
Intestinal obstructions
Genitourinary
Abdominal masses
Inguinal hernia
Testicular torsion
Neurosurgical
Intestinal obstructions
Atresias – duodenal, jejunal, colonic
Meconium ileus
Meconium plug
Hirschsprung’s disease
Imperforate anus
Malrotation with volvulus
Adhesions and strictures
Atresias
High obstruction of jejunal atresia
Double bubble of duodenal atresia
Atresias (cont)
Duodenal atresia associated with trisomy
21, or other anomalies
Hx of polyhydramnios
Delee more than 30-50ml from stomach
Jejunal atresia is rarely associated with
other anomalies.
Decompress proximal bowel with repogle
tube to low continuous suction
Meconium Ileus
Obstruction of bowel by thick tenacious
meconium
30% of intestinal obstruction in neonates
Frequent cause of meconium peritonitis
Most are associated with cystic fibrosis
(but only 15% of infants with CF will have
meconium ileus)
Abdominal distention is typically present at
birth
Meconium Ileus (cont)
Diagnosis made with contrast enema
Gastrograffin enema with aggressive
hydration can be used to treat some
Operative evacuation of meconium
May require ostomy
Proximal bowel dilated and distal bowel
may be very small (microcolon) and
require time to dilate with use
Meconium plug
Difference between meconium ileus and
meconium plug is site and severity of obstruction
Preterm infants, infants of diabetic mothers,
IUGR babies, otherwise ill babies
Treatment with glycerin suppositories and warm
saline enemas
May require contrast enema to make diagnosis
Normal stooling pattern should follow evacuation
of plug
Meconium plugs
Hirschsprung’s Disease
Colonic agangliosis
Extent can vary from very short segment
of rectal tissue to entire colon
Should be considered in any baby who
does not pass stool spontaneously by 24
hours of age.
Diagnosis by rectal biopsy to look for
ganglion cells
Hirschsprung’s Disease (cont)
Barium enema can show transition zone
Short segment disease can be treated with
rectal irrigations followed by primary pull
through procedure
Longer segment disease requires ostomy
followed by pull through when older
(months usually).
Imperforate Anus
May pass meconium if a rectovaginal or
rectourinary fistula exists.
Low imperforate anus: the rectum has
descended through the puborectalis sling
and exists as a fistula on the perineum.
May see mec on the perineum, may be seen
in the rugal folds or scrotum of males and
vagina of females.
These fistula may be dilated to temporarily
relieve obstruction
Imperforate Anus (cont)
High imperforate anus: rectum ends above
the puborectalis sling.
No perineal fistula, but may have urinary
fistula
Temporary colostomy is necessary in all
babies with high imperforate anus.
Malrotation with volvulus
Can occur in the fetus – large calcified
shadow in midabdomen on x-ray
Sudden onset of bilious emesis in infant –
requires rule out
Signs of shock and sepsis can be present
Surgical emergency since intestinal
viability is at stake.
UGI to evaluate for position of ligament of
Treitz
Malrotation
Volvulus
Adhesions and strictures
Can occur following any abdominal
surgical manipulation.
Can occur following NEC even if initial
disease process required only medical
treatment.
Necrotizing Enterocolitis
This is a whole lecture unto itself
Incidence varies from center to center and
from year to year within centers
2-5% of all NICU admissions and 5-10% of
VLBW infants
Prematurity is greatest risk factor
Mortality is 9-28% regardless of medical or
surgical intervention
NEC (cont)
To be continued in future lecture……..?
Genitourinary
Posterior urethral valves
Extrophy of the bladder
Cloacal extrophy
Posterior Urethral Valves
Obstruction of urinary flow at level of
bladder outlet
Exclusively in males
May lead to oligohydramnios and
pulmonary hypoplasia
May lead to destruction of renal
parenchyma
Symptomatology can sometimes be mild
VCUG in pt with
Posterior Urethral
Valves
Posterior Urethral Valves
Place urinary catheter to drain bladder
Obtain VCUG to confirm diagnosis
Urologist to ablate valves – usually with a
transurethral approach
Assess renal function – urine output,
electrolytes, BUN, creatinine
Bladder may be dysfunctional
Some will be OK in neonatal period and go
on to “outgrow” their renal function
Extrophy of the Bladder
May range from epispadias to complete
extrusion of bladder on to abdominal wall
Initial surgical repair is most critical for
best functional outcome
Apply sterile saline and lay saran wrap on
top of exposed bladder, but keep any
irritants away (no gauze, etc)
Extrophy of bladder
2:1 male to female ratio
Symphysis pubis is widely separated
Is a very complicated and prolonged repair
requiring urologist and orthopedist to work
together
Patient immobilized for a week or more
post-op
Phallic reconstruction may be done in later
operation
Cloacal Extrophy
More complex than simple bladder
extrophy
May include: vesico-intestinal fissure,
omphalocele, extrophied bladder,
hypoplastic colon, imperforate anus,
absence of vagina in female, and
microphallus in males.
Series of complex operations needed
Abdominal masses
Renal masses
Ovarian cyst
Tumors
Adrenal hemorrhage
Hydrometrocolpos
Renal Masses
Polycystic kidneys
Multicystic dysplastic kidneys
Renal duplications
Hydronephrosis
Ovarian Cyst
One of the most common abdominal
masses in female fetus and newborn
May cause torsion and necrosis of ovary
Surgical resection if >4cm diameter or
persistent
Tumors
Teratomas are most common.
Sacrococcygeal
About 10% contain a malignant element
Neuroblastoma – 50% of malignant tumors
in neonates. Can resolve spontaneously.
Wilm’s tumor
Sarcoma botryoides – grapelike tumor
arises from edge of vulva or vagina.
Sacrococcygeal teratoma
Sarcoma Botryoides
Hydrometrocolpos
Imperforate hymen (or other vaginal
obstruction) with back up of secretions in
the uterus, which can cause intestinal
obstruction
Hymen will bulge
May have edema and cyanosis of the legs
May cause hydronephrosis
Inguinal Hernia
Frequent in preterm babies, male>female
Usually repair prior to discharge if possible
Monitor for incarceration
Incarcerated hernia can usually be reduced
with sedation and steady firm pressure
Even if reduced, should be repaired as soon
as edema is resolved
Testicular Torsion
70% occur in fetal life
Testes is tender, firm, swollen with a slightly
bluish cast to the scrotum on affected side
Differential dx includes scrotal hematoma
US with doppler flow can be useful
Any possibility of recent torsion – surgery
within 4-6 hrs
Orchiopexy of contralateral side
Neurosurgical
Myelomeningocele
Hydrocephalus
Intracranial hematoma
Myelomeningocele
Saccular outpouching of neural elements
through defect in bone and soft tissues in
posterior thoracic, sacral and/or lumbar
regions (lumbar 80%)
Most common primary neural tube defect
Hydrocephalus in 84%
Arnold-Chiari II malformation in 90%
The Chiari II malformation is a complex
congenital malformation of the brain,
nearly always associated with
myelomeningocele. This condition
includes downward displacement of the
medulla, fourth ventricle, and cerebellum
into the cervical spinal canal, as well as
elongation of the pons and fourth ventricle,
probably due to a relatively small posterior
fossa.
Chiari II malformation. Sagittal T1-weighted MRI of posterior fossa abnormalities in
Chiari II malformation: (1) colpocephaly; (2) beaked tectum; (3) cascade of an inferiorly
displaced vermis behind the medulla; (4) elongated tubelike fourth ventricle; (5) low-lying
torcular herophili; (6) cerebellar hemispheres wrapping around the brainstem anteriorly;
(7) concave clivus; (8) medullary spur; and (9) medullary kink.
Hydrocephalus
Associated with MM
Aqueductal Stenosis – male with X-linked
Post-hemmorhagic – most frequent in
premature population