1. Surgical Emergencies In Neonatal
Dr.Mohammad Saquib Mallick,FRCS
Associate Professor and Consultant ,
Division of Pediatric Surgery, Department of Surgery, College of Medicine and King Khalid University Hospital, Riyadh

2. 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

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

4. Principles of Neonatal Surgery
2: Maintenance needs
3: Monitoring fluid & electrolytes : perioperative management
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

5. High intestinal obstruction in neonate
Oesophageal atresia with/without Tracheo-esophageal Fistula (TOF)
Infantile hypertrophy pyloric stenosis
Duodenal obstruction:
Duodenal atresia or web or stenosis
Annular pancrease
Ladd band (malrotation)
Proximal jejunal obstruction:
Atresia, web, stenosis.

6. 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

7. 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)

8. 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

9. Duodenal obstruction X-rays: Management: Double bobble shadow
High intestinal obstruction in neonate
Duodenal obstruction
X-rays:
Double bobble shadow
Management:
Exclude the Volvulus and resuscitation
NGT, Vitamin K,
stabilized before surgery
Duodeno-duodenostomy

10. Proximal jejunal obstruction
Atresia
Web
Stenosis
Treatment: End to end anastomosis

11. 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

12. Clinical presentation
Low intestinal obstruction in neonate
Clinical presentation

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

14. 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

15. Ileal /Colon atresia

16. Meconium ileus

17. Hirschsprung's Disease Pathology cont..
Due to congenital absence of ganglion cells in the distal bowel.
Incidence: 1/ 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

18. 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

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

20. Anorectal Malformation (imperforate anus)
Incidence 1:5000 live births
Common in boys than girls(55%-65%)
Low - below levator sling
High - above levator sling
Intermedate - not fit above
Rectovestibular fistula - commonest in girls
Rectourtheral fistula - commonest in boys

21. No anal opening

22. ARM

23. Management at birth

24. Posterior sagittal anorectoplasty (PSARP)

25. 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

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

27. Respiratory Distress Congenital Diaphragmatic Hernia
Incidence: 1:2000 to 5000,
female more affected,
prematurity and low BW,
Left side

28. Diaphragmatic Hernia
Symptoms None to severe Polyhydramnios Presents birth to after many days
Signs Scaphoid abdomen Audible bowel sound in the chest

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

30. Diaphragmatic Hernia

31. Diaphragmatic Hernia Management Reussciataion and stabilization
Laparotomy
Primary
Patch by silo or muscle
Laparoscopic repair

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

33. Eventration of Diaphragm
Diagnosis:
CXR
Fluoroscopy or
Real time US

34. Eventration of Diaphragm
Management:
Conservative
plication

35. Respiratory Distress
The newborn suspected of having respiratory distress should be studied in a logical step by step manner.
It is important to establish that the infant has a surgical problem before surgery is performed.
Resuscitation must be done before operation
Every condition will be dealt accordingly

36. QUESTIONS ?