Surgical Emergencies In Neonatal

Surgical Surgical Emergencies In Emergencies In

Neonatal Neonatal Dr.Mohammad Saquib Dr.Mohammad Saquib

Mallick,FRCSMallick,FRCSAssociate Professor and Consultant , Associate Professor and Consultant ,

Division of Pediatric Surgery, Department of Division of Pediatric Surgery, Department of Surgery, College of Medicine and King Khalid Surgery, College of Medicine and King Khalid

University Hospital, RiyadhUniversity Hospital, Riyadh

Principles of Principles of Neonatal Surgery Neonatal Surgery

Types of Newborns:– 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 Principles of Neonatal Surgery Neonatal Surgery

Metabolic considerations1: Thermoregulation2: Glucose homeostasis3: Calcium and Magnesium homeostasis4: Blood volume5: Jaundice6: Energy requirement

Fluid & Electrolytes Concepts1: water metabolism

Principles of Neonatal Principles of Neonatal Surgery Surgery

2: Maintenance needs

3: Monitoring fluid & electrolytes 4: perioperative management

General considerations1: GIT decompression2: Antibiotic therapy 3: Vitamin K 1 mg I/M or I/V4: Diagnostic study5: Transport of neonates

High intestinal obstruction in High intestinal obstruction in neonateneonate

Oesophageal atresia with/without Oesophageal atresia with/without Tracheo-esophageal Fistula (TOF)Tracheo-esophageal Fistula (TOF)

Infantile hypertrophy pyloric Infantile hypertrophy pyloric stenosisstenosis

Duodenal obstruction:Duodenal obstruction:– Duodenal atresia or web or stenosisDuodenal atresia or web or stenosis

Annular pancreaseAnnular pancrease

– Ladd band (malrotation)Ladd band (malrotation) Proximal jejunal obstruction:Proximal jejunal obstruction:

– Atresia, web, stenosis.Atresia, web, stenosis.

Oesophageal atresia & TOFOesophageal atresia & TOF Incidence: 1: 5000 Incidence: 1: 5000 live births, 50% associated with live births, 50% associated with

anomaliesanomalies

Types: Types:

Symptoms and Signs:Symptoms and Signs:– Excessive salivation Excessive salivation – Respiratory DistressRespiratory Distress– Inability to pass NG tubeInability to pass NG tube– Choking and coughing on feedingChoking and coughing on feeding

High intestinal obstruction in neonate

VACTERLSyndrome

Oesophageal Oesophageal atresia & TOFatresia & TOF

Diagnosis Diagnosis – Clinical & CXR – Clinical & CXR Management: Management: ResuscitationResuscitation

– Common typeCommon type Right thoracotomyRight thoracotomy

Division and repair of TOFDivision and repair of TOF Primary anastomosisPrimary anastomosis

– Pure TOFPure TOF Division and repairDivision and repair

– Isolated atresiaIsolated atresia >3 vertebra>3 vertebra

Staged surgery (gastrostomy and Staged surgery (gastrostomy and followed in 3-6 months by delayed followed in 3-6 months by delayed repair. If fails then need esophageal repair. If fails then need esophageal replacement (stomach or colon)replacement (stomach or colon)


Duodenal obstructionDuodenal obstruction

Divided into:Divided into:– Complete (atresia)Complete (atresia)– Partial (web, stenosis, ladd Partial (web, stenosis, ladd

band, annular pancreas))band, annular pancreas))

Antenatal diagnosis: Antenatal diagnosis: – PolyhydramniosPolyhydramnios– Dilated stomach and Dilated stomach and 11stst part Duodenum part Duodenum

Down syndrome 30%Down syndrome 30% Symptoms and Signs:Symptoms and Signs:

– vomiting, bilious 80%vomiting, bilious 80%– High gastric aspiration: High gastric aspiration:

>30ml>30ml


Duodenal Duodenal obstruction obstruction

X-rays:X-rays:– Double bobble shadowDouble bobble shadow

Management: Management: – Exclude the Volvulus and Exclude the Volvulus and

resuscitationresuscitation– NGT, Vitamin K, NGT, Vitamin K, – stabilized before surgerystabilized before surgery– Duodeno-duodenostomyDuodeno-duodenostomy


Proximal jejunal Proximal jejunal obstructionobstruction

AtresiaAtresiaWebWebStenosisStenosis

–Treatment: End to Treatment: End to end anastomosisend anastomosis

Case studyCase study A 3-day old baby boy who presented A 3-day old baby boy who presented

with H/O of vomiting which was with H/O of vomiting which was formula milk and then green for last 12 formula milk and then green for last 12 hrs. He passed meconium last night. hrs. He passed meconium last night. His mother told that his abdomen is His mother told that his abdomen is full and feel firm. No perinatal problemfull and feel firm. No perinatal problem

O/E He is active and mildly O/E He is active and mildly dehydrated. Abdomen is distended dehydrated. Abdomen is distended and non tender with no mass. PR and non tender with no mass. PR examination showed normal anusexamination showed normal anus

Plain X-rays was a lot of dilated loops Plain X-rays was a lot of dilated loops with multiple fluid levels with multiple fluid levels

Clinical presentationClinical presentationLow intestinal obstruction in neonate

Low intestinal obstruction in neonate-

Differential Diagnosis Ileal/Colon atresia Meconium ileus Hirschsprung's Disease, Meconium plug syndrome, Left micro-colon syndrome, Malrotation with volvulusMalrotation with volvulus ((Anorectal malformation))((Anorectal malformation)) Medical causes-Medical causes-

– sepsis, ileus, electrolytes sepsis, ileus, electrolytes imbalanceimbalance

Common Common presentationspresentations

Bilious vomiting Bilious vomiting Failure or delayed to pass Failure or delayed to pass

meconiummeconium Abdominal distensionAbdominal distension Multiple fluid levels in plain Multiple fluid levels in plain

AXRAXR

Low intestinal obstruction in neonate

Ileal /Colon atresia

Meconium ileus

Hirschsprung's Hirschsprung's Disease Pathology Disease Pathology

cont..cont.. Due to congenital absence of ganglion Due to congenital absence of ganglion

cells in the distal bowel.cells in the distal bowel. Incidence: Incidence: 1/4500-5000 live births 1/4500-5000 live births Sex:Sex: 4:1 male predominance,4:1 male predominance, Age: Age: 96% Full term & 4% premature96% Full term & 4% premature Site: Commonly: Site: Commonly: rectum/rectosigmoid Less commonly: total colonic with or Less commonly: total colonic with or

without small intestinewithout small intestine

Hirschsprung's Disease Hirschsprung's Disease DiagnosisDiagnosis

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 Hirschsprung's Disease Disease

ManagementManagement

At birthAt birth Pull through operationPull through operationAt 6-9 months of ageAt 6-9 months of age

*Primary pull-through procedure without colostomy*

Anorectal Anorectal MalformationMalformation

(imperforate anus)(imperforate anus) Incidence 1:5000 live Incidence 1:5000 live

birthsbirths Common in boys than Common in boys than

girls(55%-65%)girls(55%-65%) Low - below levator slingLow - below levator sling High - above levator slingHigh - above levator sling Intermedate - not fit above Intermedate - not fit above Rectovestibular fistula - Rectovestibular fistula -

commonest in girlscommonest in girls Rectourtheral fistula - Rectourtheral fistula -

commonest in boyscommonest in boys

No anal openingNo anal opening

ARMARM

Management at birth

Posterior sagittal Posterior sagittal anorectoplasty anorectoplasty

(PSARP)(PSARP)

Principles of Neonatal Principles of Neonatal SurgerySurgery

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 accordingEvery condition will be dealt according

Respiratory DistressRespiratory Distress

Causes– Surgical

Upper airway obstruction Congenital diaphragmatic hernia Eventration of Diaphragm Esophageal atresia with TOF Congenital lobar emphysema Congenital cystic adenomatoid

malformation Pulmonary Sequestration

Respiratory DistressRespiratory Distress

Congenital Diaphragmatic HerniaCongenital Diaphragmatic Hernia

Incidence: 1:2000 to 5000,

female more affected,

prematurity and low BW,

Left side

Diaphragmatic Diaphragmatic HerniaHernia

SymptomsNone to severePolyhydramniosPresents birth to after many days

SignsScaphoid abdomenAudible bowel sound in the chest


Diagnosis:– Prenatal <25wks, prognosis

bad– Clinical– CXR– 10% >after neonatal period



Management– Reussciataion and

stabilization– Laparotomy

Primary Patch by silo or

muscle– Laparoscopic repair

Eventration of Eventration of DiaphragmDiaphragm

Def: Abnormal elevation of diaphragm Def: Abnormal elevation of diaphragm that results in paradoxical motion of that results in paradoxical motion of affected hemidiaphragm during affected hemidiaphragm during inspiration and expirationinspiration and expiration

Cause:Cause:– Congenital Congenital – AcquiredAcquired

Symptoms: Symptoms: – NoneNone– Resp. distressResp. distress– Wheezing, repeated URI, exercise intoleranceWheezing, repeated URI, exercise intolerance


Diagnosis:Diagnosis:– CXRCXR– Fluoroscopy or Fluoroscopy or – Real time USReal time US


Management:Management:–ConservativeConservative–plicationplication

Respiratory DistressRespiratory Distress 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 Every condition will be dealt accordinglyaccordingly

QUESTIONS ?QUESTIONS ?

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Surgical Emergencies In Neonatal