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Principles of neonatal Surgery Dr. Abdulrahman Albassam, FRCS (Edin) professor and Consultant, head section of Pediatric Surgery, Division of Pediatric.

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Presentation on theme: "Principles of neonatal Surgery Dr. Abdulrahman Albassam, FRCS (Edin) professor and Consultant, head section of Pediatric Surgery, Division of Pediatric."— Presentation transcript:

1 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

2 Principles of Neonatal Surgery l l 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 l l There are physiologic differences between all these infants

3 Principles of Neonatal Surgery High intestinal obstruction in neonate l Oesophageal atresia with/without Tracheo- esophageal Fistula (TOF) l Infantile hypertrophy pyloric stenosis l Duodenal obstruction: –Duodenal atresia.(complete) – web or stenosis –Annular pancrease –Ladd band (malrotation) l Proximal jejunal obstruction: –Atresia, web, stenosis.

4 Oesophageal atresia & TOF l Incidence: 1: 5000 live births, 50% associated with anomalies l Types: l Symptoms and Signs: –Excessive salivation –Respiratory Distress –Inability to pass NG tube –Choking and coughing on feeding High intestinal obstruction in neonate VACTERL Syndrome

5 Oesophageal atresia & TOF l Diagnosis – Clinical & CXR l Management: Resuscitation –Common type l Right thoracotomy Division and repair of TOF l Primary anastomosis –Pure TOF l Division and repair –Isolated atresia l >3 vertebra Staged 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

6 Infantile hypertrophy pyloric stenosis l Incidence: 2-3 per 1000 live births, more in whites l Age: peak 2-5 weeks l Sex: 4:1 male predominance l Symptoms and Signs: –Projectile vomiting, non-bilious –Failure to thrive –Visible peristalsis –Palpable mass High intestinal obstruction in neonate

7 Infantile hypertrophy pyloric stenosis l Diagnosis –Clinical and lab test –Ultrasonography –Contrast meal l Management –Correct dehydration and acid base with electrolytes – pyloromyotomy either open or laparoscopic High intestinal obstruction in neonate

8 Duodenal obstruction l Divided into: –Complete (atresia) –Partial (web, stenosis, ladd band,annular pancreas) l Antenatal diagnosis: –Polyhydramnios – Dilated stomach and 1 st part Duodenum l Down syndrome 30% l Symptoms and Signs: –vomiting, bilious 80% – High gastric aspiration: >30ml High intestinal obstruction in neonate

9 Duodenal obstruction l X-rays: –Double bobble shadow l Management: –Exclude the Volvulus –NGT –stabilized before surgery –Duodeno-duodenostomy High intestinal obstruction in neonate

10 Proximal jejunal obstruction AtresiaWebStenosis –Treatment: End to end anastomosis

11 Case study l 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 l O/E He is active and mildly dehydrated. Abdomen is distended and non tender with no mass. PR examination showed normal anus l Plain X-rays was a lot of dilated loops with multiple fluid levels

12 Clinical presentation Low intestinal obstruction in neonate

13 Low intestinal obstruction in neonate- Differential Diagnosis l l Ileal/Colon atresia l l Meconium ileus l l Hirschsprung's Disease, l l Meconium plug syndrome, Left micro-colon syndrome l ((Anorectal malformation)) l Medical causes- –sepsis, ileus, electrolytes imbalance

14 Common presentations l Bilious vomiting l Failure or delayed to pass meconium l Abdominal distension l Multiple fluid levels in plain AXR Low intestinal obstruction in neonate

15 Ileal /Colon atresia

16 Meconium ileus

17 Hirschsprung's Disease l Due to congenital absence of ganglion cells in the distal bowel. Incidence: 1/ live births Incidence: 1/ live births Sex: 4:1 male predominance, Sex: 4:1 male predominance, Age: 96% Full term & 4% premature Age: 96% Full term & 4% premature l Site: Commonly: l Site: Commonly: rectum/rectosigmoid Less commonly: total colonic with or without small intestine Less commonly: total colonic with or without small intestine

18 Hirschsprung's Disease Diagnosis l l 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. l l Examination: Abdominal Distension PR: tight sphincter with gush of loose stool Malnutrited child, Enterocolitis

19 Hirschsprung's Disease Diagnosis cont.. l l Radiographic studies: – –Plain AXR, – –unprepared barium enema l l Rectal biopsy – –Suction – –Full thickness

20 Hirschsprung's Disease Management At birth Pull through operation At 6-9 months of age *Primary pull-through procedure without colostomy*

21 Anorectal Malformation (imperforate anus) l Incidence 1:5000 live births l Common in boys than girls(55%-65%) l Low - below levator sling l High - above levator slin l Rectovestibular fistula - commonest in girls l Rectourtheral fistula - commonest in boys

22 Management at birth

23 Posterior sagittal anorectoplasty (PSARP)

24 ARM Closure of Colostomy

25 Principles of Neonatal Surgery l l The newborn suspected of having intestinal obstruction should be studied in a logical step by step manner. l l It is important that it be definitely established that the infant has a surgical problem before surgery is performed. l l Resuscitation must be done before operation l Every condition will be dealt according


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