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Surgical Emergencies In Neonatal

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. Principles of Neonatal Surgery. Types of Newborns:

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Surgical Emergencies In Neonatal

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  1. Surgical Emergencies In Neonatal Dr.MohammadSaquibMallick,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 considerations1: Thermoregulation 2: Glucose homeostasis 3: Calcium and Magnesium homeostasis 4: Blood volume 5: Jaundice 6: Energy requirement • Fluid & Electrolytes Concepts1: water metabolism

  4. Principles of Neonatal Surgery 2: Maintenance needs 3: Monitoring fluid & electrolytes4: 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. 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 VACTERLSyndrome

  7. 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. 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. 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. 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. 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: 1/4500-5000 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

  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 • SymptomsNone to severePolyhydramniosPresents birth to after many days • SignsScaphoid abdomenAudible 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 ?

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