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
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