Transcript Surgical Emergencies In Neonatal Dr.Mohammad Saquib Mallick,FRCS

Surgical Emergencies In
Neonatal
Dr.Mohammad Saquib Mallick,FRCS
Associate Professor and Consultant ,
Division of Pediatric Surgery, Department of Surgery,
College of Medicine and King Khalid University
Hospital, Riyadh
Principles of Neonatal
Surgery
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Types of Newborns:
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Full-term: >38 weeks and weight >
2.5 kg
preterm infant: <38 weeks with
appropriate weight
SGA: >38 weeks and weight< 2.5 kg
VLBW: <32 weeks and <1.5 kg
There are physiologic differences
between all these infants
Principles of Neonatal
Surgery
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Metabolic considerations
1: Thermoregulation
2: Glucose homeostasis
3: Calcium and Magnesium homeostasis
4: Blood volume
5: Jaundice
6: Energy requirement
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Fluid & Electrolytes Concepts
1: water metabolism
Principles of Neonatal Surgery
2: Maintenance needs
3: Monitoring fluid & electrolytes
4: perioperative management
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General considerations
1: GIT decompression
2: Antibiotic therapy
3: Vitamin K 1 mg I/M or I/V
4: Diagnostic study
5: Transport of neonates
High intestinal obstruction in neonate
Oesophageal atresia with/without
Tracheo-esophageal Fistula (TOF)
 Infantile hypertrophy pyloric stenosis
 Duodenal obstruction:
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– Duodenal atresia or web or stenosis
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Annular pancrease
– Ladd band (malrotation)
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Proximal jejunal obstruction:
– Atresia, web, stenosis.
High intestinal obstruction in neonate
Oesophageal atresia & TOF
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Incidence: 1: 5000 live births, 50% associated with anomalies
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Types:
VACTERL
Syndrome
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Symptoms and Signs:
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Excessive salivation
Respiratory Distress
Inability to pass NG tube
Choking and coughing on feeding
High intestinal obstruction in neonate
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Oesophageal atresia &
TOF
Diagnosis – Clinical & CXR
Management: Resuscitation
– Common type
Right thoracotomy
Division and repair of TOF
 Primary anastomosis
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– Pure TOF
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Division and repair
– Isolated atresia
>3 vertebra
Staged surgery (gastrostomy and followed
in 3-6 months by delayed repair. If fails
then need esophageal replacement
(stomach or colon)
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High intestinal obstruction in neonate
Duodenal obstruction
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Divided into:
– Complete (atresia)
– Partial (web, stenosis, ladd band,
annular pancreas))
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Antenatal diagnosis:
– Polyhydramnios
– Dilated stomach and
1st part Duodenum
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Down syndrome 30%
Symptoms and Signs:
– vomiting, bilious 80%
– High gastric aspiration: >30ml
High intestinal obstruction in neonate
Duodenal obstruction
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X-rays:
– Double bobble shadow
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Management:
– Exclude the Volvulus and
resuscitation
– NGT, Vitamin K,
– stabilized before surgery
– Duodeno-duodenostomy
Proximal jejunal
obstruction
Atresia
Web
Stenosis
–Treatment: End to
end anastomosis
Case study
A 3-day old baby boy who presented with
H/O of vomiting which was formula milk
and then green for last 12 hrs. He passed
meconium last night. His mother told that
his abdomen is full and feel firm. No
perinatal problem
 O/E He is active and mildly dehydrated.
Abdomen is distended and non tender
with no mass. PR examination showed
normal anus
 Plain X-rays was a lot of dilated loops with
multiple fluid levels
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Low intestinal obstruction in neonate
Clinical presentation
Low intestinal obstruction in neonateDifferential Diagnosis
Ileal/Colon atresia
 Meconium ileus
 Hirschsprung's Disease,
 Meconium plug syndrome,
 Left micro-colon syndrome,
 Malrotation with volvulus
 ((Anorectal malformation))
 Medical causes
– sepsis, ileus, electrolytes imbalance
Low intestinal obstruction in neonate
Common presentations
Bilious vomiting
 Failure or delayed to pass
meconium
 Abdominal distension
 Multiple fluid levels in plain AXR
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Ileal /Colon atresia
Meconium ileus
Hirschsprung's Disease
Pathology cont..
Due to congenital absence of ganglion
cells in the distal bowel.
 Incidence: 1/4500-5000 live births
 Sex: 4:1 male predominance,
 Age: 96% Full term & 4% premature
 Site: Commonly: rectum/rectosigmoid
Less commonly: total colonic with or
without small intestine
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Hirschsprung's Disease
Diagnosis
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Neonatal:
Delayed or failure to pass meconium with low
intestinal obstruction.
late presentation: *Failure to thrive, *Poor
feeding *Diarrhea with abdominal distension and
occasionally with enterocolitis.
Examination: Abdominal Distension
PR: tight sphincter with gush of loose stool
Malnutrited child, Enterocolitis
Hirschsprung's Disease
Management
At birth
Pull through operation
At 6-9 months of age
*Primary pull-through procedure without colostomy*
Anorectal Malformation
(imperforate anus)
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Incidence 1:5000 live births
Common in boys than
girls(55%-65%)
Low - below levator sling
High - above levator sling
Intermedate - not fit above
Rectovestibular fistula commonest in girls
Rectourtheral fistula commonest in boys
No anal opening
ARM
Management at birth
Posterior sagittal
anorectoplasty (PSARP)
Principles of Neonatal
Surgery
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The newborn suspected of having
intestinal obstruction should be studied
in a logical step by step manner.
It is important that it be definitely
established that the infant has a surgical
problem before surgery is performed.
Resuscitation must be done before
operation
Every condition will be dealt according
Respiratory Distress
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Causes
– Surgical
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Upper airway obstruction
Congenital diaphragmatic hernia
Eventration of Diaphragm
Esophageal atresia with TOF
Congenital lobar emphysema
Congenital cystic adenomatoid malformation
Pulmonary Sequestration
Respiratory Distress
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Congenital Diaphragmatic Hernia
Incidence: 1:2000 to 5000,
female more affected,
prematurity and low BW,
Left side
Diaphragmatic Hernia
Symptoms
None to severe
Polyhydramnios
Presents birth to
after many days
 Signs
Scaphoid abdomen
Audible bowel sound in the chest
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Diaphragmatic Hernia
 Diagnosis:
– Prenatal <25wks, prognosis bad
– Clinical
– CXR
– 10% >after neonatal period
Diaphragmatic Hernia
Diaphragmatic Hernia
 Management
– Reussciataion and
stabilization
– Laparotomy
 Primary
 Patch
by silo or
muscle
– Laparoscopic repair
Eventration of Diaphragm
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Def: Abnormal elevation of diaphragm that
results in paradoxical motion of affected
hemidiaphragm during inspiration and
expiration
Cause:
– Congenital
– Acquired
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Symptoms:
– None
– Resp. distress
– Wheezing, repeated URI, exercise intolerance
Eventration of Diaphragm
 Diagnosis:
– CXR
– Fluoroscopy or
– Real time US
Eventration of Diaphragm
 Management:
–Conservative
–plication
Respiratory Distress
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The newborn suspected of having
respiratory distress should be studied in
a logical step by step manner.
It is important to establish that the
infant has a surgical problem before
surgery is performed.
Resuscitation must be done before
operation
Every condition will be dealt
accordingly
QUESTIONS ?