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
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 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.

4. 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

5. 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)

6. 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

7. 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

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
NGT
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
((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
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 Diagnosis cont..
Radiographic studies:
Plain AXR,
unprepared barium enema
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)
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

22. Management at birth

23. Posterior sagittal anorectoplasty (PSARP)

24. ARM Closure of Colostomy

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