Principles of neonatal Surgery

Dr. Abdulrahman Albassam,FRCS (Edin)

professor and Consultant , head section of Pediatric Surgery,

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

Khalid University Hospital, Riyadh

Principles of 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 Neonatal Surgery

High intestinal obstruction in neonate Oesophageal atresia with/without

Tracheo-esophageal Fistula (TOF) Infantile hypertrophy pyloric stenosis Duodenal obstruction:

– Duodenal atresia.(complete)– web or stenosis– Annular pancrease– Ladd band (malrotation)

Proximal jejunal obstruction:– Atresia, web, stenosis.

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

anomalies

Types:

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

High intestinal obstruction in neonate

VACTERLSyndrome

Oesophageal atresia & TOF

Diagnosis – Clinical & CXR Management: Resuscitation

– Common type Right thoracotomyDivision and repair of TOF Primary anastomosis

– Pure TOF Division and repair

– Isolated atresia >3 vertebraStaged surgery (gastrostomy and

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

High intestinal obstruction in neonate

Infantile hypertrophy pyloric stenosis

Incidence: 2-3 per 1000 live births, more in whites

Age: peak 2-5 weeks Sex: 4:1 male

predominance Symptoms and Signs:

– Projectile vomiting, non-bilious

– Failure to thrive– Visible peristalsis– Palpable mass

High intestinal obstruction in neonate

Infantile hypertrophy pyloric

stenosis Diagnosis– Clinical and lab test– Ultrasonography– Contrast meal

Management– Correct dehydration and

acid base with electrolytes– pyloromyotomy either

open or laparoscopic

High intestinal obstruction in neonate

Duodenal obstruction

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

band,annular pancreas)

Antenatal diagnosis: – Polyhydramnios– Dilated stomach and 1st part Duodenum

Down syndrome 30% Symptoms and Signs:

– vomiting, bilious 80%– High gastric aspiration:

>30ml

High intestinal obstruction in neonate

Duodenal obstruction

X-rays:– Double bobble shadow

Management: – Exclude the Volvulus – NGT– stabilized before surgery– Duodeno-duodenostomy

High intestinal obstruction in neonate

Proximal jejunal obstruction

AtresiaWebStenosis

–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

Clinical 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 ((Anorectal malformation)) Medical causes-

– sepsis, ileus, electrolytes imbalance

Common presentations

Bilious vomiting Failure or delayed to pass

meconium Abdominal distension Multiple fluid levels in plain

AXR

Low intestinal obstruction in neonate

Ileal /Colon atresia

Meconium ileus

Hirschsprung's Disease

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

Hirschsprung's Disease Diagnosis

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 Diagnosis

cont.. Radiographic

studies: – Plain AXR, – unprepared

barium enema Rectal biopsy

– Suction– Full thickness

Hirschsprung's Disease

Management

At birth Pull through operationAt 6-9 months of age

*Primary pull-through procedure without colostomy*

Anorectal Malformation

(imperforate anus) Incidence 1:5000 live

births Common in boys than

girls(55%-65%) Low - below levator sling High - above levator slin Rectovestibular fistula -

commonest in girls Rectourtheral fistula -

commonest in boys

Management at birth

Posterior sagittal anorectoplasty

(PSARP)

ARMClosure of Colostomy

Principles of Neonatal Surgery

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