1. Common Neonatal Emergencies. Dr. Mohammad Saquib Mallick,FRCS Dr. Mohammad Saquib Mallick,FRCS Consultant Pediatric Surgeon Consultant Pediatric Surgeon

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. Common Neonatal Emergencies l l The newborn suspected of having surgical emergency should be studied in a logical step by step manner. l l It is important to establish 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 accordingly

4. Principles of Neonatal Surgery l l Metabolic considerations 1: Thermoregulation 2: Glucose homeostasis 3: Calcium and Magnesium homeostasis 4: Blood volume 5: Jaundice 6: Energy requirement l l Fluid & Electrolytes Concepts 1: water metabolism

5. Principles of Neonatal Surgery 2: Maintenance needs 3: Monitoring fluid & electrolytes 4: perioperative management l l General considerations 1: GIT decompression 2: Antibiotic therapy 3: Vitamin K 1 mg I/M or I/V 4: Diagnostic study 5: Transport of neonates

6. Common Neonatal Emergencies l Congenital Diaphragmatic Hernia Bochdalek Hernia Incidence: 1:2000 to 5000, female more affected, prematurity and low BW, Left side

7. Diaphragmatic Hernia l l Symptoms: None to severe ( Onset may be immediate or may be delayed up to 48 hrs.) l l Tachypnea, grunting respiration, cynosis, chest retraction. l l Signs Scaphoid abdomen Audible bowel sound in the chest

8. Diaphragmatic Hernia l l Diagnosis: – –Prenatal <25wks, prognosis bad – –Clinical – –CXR – –10% >after neonatal period

9. Diaphragmatic Hernia

10. l l Management – –Reussciataion and stabilization l Endotracheal Intubation l Orogastric or nasogastric decompression l Echocardiography

11. Diaphragmatic Hernia l l Surgery: – –Laparotomy l l Primary l l Patch by silo or muscle – –Laparoscopic repair

12. Eventration of Diaphragm l Def: Abnormal elevation of diaphragm that results in paradoxical motion of affected hemidiaphragm during inspiration and expiration l Cause: –Congenital –Acquired l Symptoms: –None –Resp. distress –Wheezing, repeated URI,

13. Eventration of Diaphragm l Diagnosis: –CXR –Fluoroscopy or –Real time US

14. Eventration of Diaphragm l Management: –Conservative –plication

15. Respiratory Distress l l Pneumothorax: The collection of air in the pleural cavity in neonates. Causes: Hyaline membrane disease Meconium aspiration Pulmonary hemorrhage Traumatic Rupture of cong.lung cyst

16. Respiratory Distress l l Diagnosis: Clinical Radiological

17. Respiratory Distress

18. l l Treatment: 1, Decompression by inserting chest tube 2, Treat the cause

19. Oesophageal atresia & TOF l Incidence: 1: 5000 live births, 50% associated with anomalies l Types: VACTERL Syndrome

20. Oesophageal atresia & TOF Symptoms and Signs: –Excessive salivation –Respiratory Distress –Inability to pass NG tube –Choking and coughing on feeding

21. 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)

22. Common Neonatal Emergencies l Neonatal Intestinal Obstraction

23. High intestinal obstruction in neonate High intestinal obstruction in neonate Pyloric Atresia: l Duodenal obstruction: –Duodenal atresia or web or stenosis l Annular pancrease –Ladd band (malrotation) l Proximal jejunal obstruction: –Atresia, web, stenosis.

24. 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

25. Duodenal obstruction l X-rays: –Double bobble shadow

26. Duodenal obstruction l Management: –Exclude the Volvulus and resuscitation –NGT, Vitamin K, –stabilized before surgery –Duodeno-duodenostomy High intestinal obstruction in neonate

27. Proximal jejunal obstruction l Normally present within 24 to 48 hrs after birth with Bilious vomiting and Bilious vomiting and Abdominal distention Abdominal distention

28. Proximal jejunal obstruction AtresiaWebStenosis –Treatment: End to end anastomosis

29. Clinical presentation Low intestinal obstruction in neonate

30. 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 Malrotation with volvulus l ((Anorectal malformation)) l Medical causes- –sepsis, ileus, electrolytes imbalance

31. 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

32. Ileal /Colon atresia

33. Meconium ileus

34. Hirschsprung's Disease Pathology cont.. l Due to congenital absence of ganglion cells in the distal bowel. Incidence: 1/4500-5000 live births Incidence: 1/4500-5000 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

35. 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

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

37. 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 sling l Intermedate - not fit above l Rectovestibular fistula - commonest in girls l Rectourtheral fistula - commonest in boys

38. No anal opening

39. ARM

40. Management at birth

41. Posterior sagittal anorectoplasty (PSARP)

43. QUESTIONS ? QUESTIONS ?

44. 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

45. Respiratory Distress in Neonates Respiratory Distress in Neonates Dr.Mohammad Saquib Mallick, FRCS Consultant Paediatric Surgeon, Consultant Paediatric Surgeon, King Fahd Medical City. Riyadh

46. Respiratory Distress l l Causes – –Surgical l l Upper airway obstruction l l Congenital diaphragmatic hernia l l Eventration of Diaphragm l l Esophageal atresia with TOF l l Pneumothorax l l Congenital lobar emphysema l l Congenital cystic adenomatoid malformation l l Pulmonary Sequestration

47. Respiratory Distress l l Congenital Lobar Emphysema: “ massive over distension of a lobe or a segment of the lung that causes compression of normal lungs and medistinum“

48. Respiratory Distress Etiology; air trapping due to abnormalities in the bronchial cartilages. bronchial cartilage may be absent, hypoplastic, or dysplastic