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 High intestinal obstruction in neonate 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 VACTERL Syndrome

Oesophageal atresia & TOF High intestinal obstruction in neonate Oesophageal atresia & TOF Diagnosis – Clinical & CXR Management: Resuscitation Common type Right thoracotomy Division and repair of TOF Primary anastomosis Pure TOF Division and repair Isolated atresia >3 vertebra Staged surgery (gastrostomy and followed in 3-6 months by delayed repair. If fails then need esophageal replacement (stomach or colon)

Infantile hypertrophy pyloric stenosis 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

Infantile hypertrophy pyloric stenosis 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

Duodenal obstruction Divided into: Antenatal diagnosis: 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

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

Proximal jejunal obstruction Atresia Web Stenosis 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 presentation Low intestinal obstruction in neonate Clinical presentation

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

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 operation At 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)

ARM Closure 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