1. Neonatal Surgical Issues (Part 2)
Sue Ann Smith, MD
Neonatologist

2. Anatomic survey (cont)
Intestinal obstructions
Genitourinary
Abdominal masses
Inguinal hernia
Testicular torsion
Neurosurgical

3. Intestinal obstructions
Atresias – duodenal, jejunal, colonic
Meconium ileus
Meconium plug
Hirschsprung’s disease
Imperforate anus
Malrotation with volvulus
Adhesions and strictures

4. Atresias High obstruction of jejunal atresia
Double bubble of duodenal atresia

5. Atresias (cont)
Duodenal atresia associated with trisomy 21, or other anomalies
Hx of polyhydramnios
Delee more than 30-50ml from stomach
Jejunal atresia is rarely associated with other anomalies.
Decompress proximal bowel with repogle tube to low continuous suction

6. Meconium Ileus Obstruction of bowel by thick tenacious meconium
30% of intestinal obstruction in neonates
Frequent cause of meconium peritonitis
Most are associated with cystic fibrosis (but only 15% of infants with CF will have meconium ileus)
Abdominal distention is typically present at birth

7. Meconium Ileus (cont) Diagnosis made with contrast enema
Gastrograffin enema with aggressive hydration can be used to treat some
Operative evacuation of meconium
May require ostomy
Proximal bowel dilated and distal bowel may be very small (microcolon) and require time to dilate with use

8. Meconium plug
Difference between meconium ileus and meconium plug is site and severity of obstruction
Preterm infants, infants of diabetic mothers, IUGR babies, otherwise ill babies
Treatment with glycerin suppositories and warm saline enemas
May require contrast enema to make diagnosis
Normal stooling pattern should follow evacuation of plug

9. Meconium plugs

10. Hirschsprung’s Disease
Colonic agangliosis
Extent can vary from very short segment of rectal tissue to entire colon
Should be considered in any baby who does not pass stool spontaneously by 24 hours of age.
Diagnosis by rectal biopsy to look for ganglion cells

11. Hirschsprung’s Disease (cont)
Barium enema can show transition zone
Short segment disease can be treated with rectal irrigations followed by primary pull through procedure
Longer segment disease requires ostomy followed by pull through when older (months usually).

12. Imperforate Anus
May pass meconium if a rectovaginal or rectourinary fistula exists.
Low imperforate anus: the rectum has descended through the puborectalis sling and exists as a fistula on the perineum.
May see mec on the perineum, may be seen in the rugal folds or scrotum of males and vagina of females.
These fistula may be dilated to temporarily relieve obstruction

14. Imperforate Anus (cont)
High imperforate anus: rectum ends above the puborectalis sling.
No perineal fistula, but may have urinary fistula
Temporary colostomy is necessary in all babies with high imperforate anus.

15. Malrotation with volvulus
Can occur in the fetus – large calcified shadow in midabdomen on x-ray
Sudden onset of bilious emesis in infant – requires rule out
Signs of shock and sepsis can be present
Surgical emergency since intestinal viability is at stake.
UGI to evaluate for position of ligament of Treitz

16. Malrotation
Volvulus

17. Adhesions and strictures
Can occur following any abdominal surgical manipulation.
Can occur following NEC even if initial disease process required only medical treatment.

18. Necrotizing Enterocolitis
This is a whole lecture unto itself
Incidence varies from center to center and from year to year within centers
2-5% of all NICU admissions and 5-10% of VLBW infants
Prematurity is greatest risk factor
Mortality is 9-28% regardless of medical or surgical intervention

19. NEC (cont)
To be continued in future lecture……..?

20. Genitourinary Posterior urethral valves Extrophy of the bladder
Cloacal extrophy

21. Posterior Urethral Valves
Obstruction of urinary flow at level of bladder outlet
Exclusively in males
May lead to oligohydramnios and pulmonary hypoplasia
May lead to destruction of renal parenchyma
Symptomatology can sometimes be mild

22. VCUG in pt with
Posterior Urethral
Valves

24. Posterior Urethral Valves
Place urinary catheter to drain bladder
Obtain VCUG to confirm diagnosis
Urologist to ablate valves – usually with a transurethral approach
Assess renal function – urine output, electrolytes, BUN, creatinine
Bladder may be dysfunctional
Some will be OK in neonatal period and go on to “outgrow” their renal function

25. Extrophy of the Bladder
May range from epispadias to complete extrusion of bladder on to abdominal wall
Initial surgical repair is most critical for best functional outcome
Apply sterile saline and lay saran wrap on top of exposed bladder, but keep any irritants away (no gauze, etc)

27. Extrophy of bladder 2:1 male to female ratio
Symphysis pubis is widely separated
Is a very complicated and prolonged repair requiring urologist and orthopedist to work together
Patient immobilized for a week or more post-op
Phallic reconstruction may be done in later operation

28. Cloacal Extrophy More complex than simple bladder extrophy
May include: vesico-intestinal fissure, omphalocele, extrophied bladder, hypoplastic colon, imperforate anus, absence of vagina in female, and microphallus in males.
Series of complex operations needed

30. Abdominal masses Renal masses Ovarian cyst Tumors Adrenal hemorrhage
Hydrometrocolpos

31. Renal Masses Polycystic kidneys Multicystic dysplastic kidneys
Renal duplications
Hydronephrosis

32. Ovarian Cyst
One of the most common abdominal masses in female fetus and newborn
May cause torsion and necrosis of ovary
Surgical resection if >4cm diameter or persistent

33. Tumors Teratomas are most common.
Sacrococcygeal
About 10% contain a malignant element
Neuroblastoma – 50% of malignant tumors in neonates. Can resolve spontaneously.
Wilm’s tumor
Sarcoma botryoides – grapelike tumor arises from edge of vulva or vagina.

34. Sacrococcygeal teratoma

35. Sarcoma Botryoides

36. Hydrometrocolpos
Imperforate hymen (or other vaginal obstruction) with back up of secretions in the uterus, which can cause intestinal obstruction
Hymen will bulge
May have edema and cyanosis of the legs
May cause hydronephrosis

37. Inguinal Hernia Frequent in preterm babies, male>female
Usually repair prior to discharge if possible
Monitor for incarceration
Incarcerated hernia can usually be reduced with sedation and steady firm pressure
Even if reduced, should be repaired as soon as edema is resolved

40. Testicular Torsion 70% occur in fetal life
Testes is tender, firm, swollen with a slightly bluish cast to the scrotum on affected side
Differential dx includes scrotal hematoma
US with doppler flow can be useful
Any possibility of recent torsion – surgery within 4-6 hrs
Orchiopexy of contralateral side

41. Neurosurgical
Myelomeningocele
Hydrocephalus
Intracranial hematoma

42. Myelomeningocele
Saccular outpouching of neural elements through defect in bone and soft tissues in posterior thoracic, sacral and/or lumbar regions (lumbar 80%)
Most common primary neural tube defect
Hydrocephalus in 84%
Arnold-Chiari II malformation in 90%

43. The Chiari II malformation is a complex congenital malformation of the brain, nearly always associated with myelomeningocele. This condition includes downward displacement of the medulla, fourth ventricle, and cerebellum into the cervical spinal canal, as well as elongation of the pons and fourth ventricle, probably due to a relatively small posterior fossa.

44. Chiari II malformation
Chiari II malformation. Sagittal T1-weighted MRI of posterior fossa abnormalities in Chiari II malformation: (1) colpocephaly; (2) beaked tectum; (3) cascade of an inferiorly displaced vermis behind the medulla; (4) elongated tubelike fourth ventricle; (5) low-lying torcular herophili; (6) cerebellar hemispheres wrapping around the brainstem anteriorly; (7) concave clivus; (8) medullary spur; and (9) medullary kink.

48. Hydrocephalus Associated with MM
Aqueductal Stenosis – male with X-linked
Post-hemmorhagic – most frequent in premature population