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NEONATAL SURGICAL EMERGENCIES

The neonatal period is the first 28 days ofpost-delivery life.

The fetus is dependent on the mother forall its requirements of

oxygen, fluid, metabolites and warmth

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Anorectal malformations

The emergencies are related to:

Dehydration- Intestinal obstructions

Exposure- Anterior abdominal wall defects(Gastroschisis)

Hypoxia Dysplastic lungs (CDH)

Ischaemia- Midgut volvulus

Perforation-

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What is the emergency ?

How to recognize patients

Intestinal obstruction

Intermittent, persistent vomiting

Risk of aspiration of vomitus

Dehydration - Unable to feed

Vomiting Bile is pathognomonic.

Increasing abdominal distension

Antenatal dilated bowel loops / Polyhydramnios.

Associated congenital anomaliesAbdominal X-ray

No passage of stool

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Proximal Jejunal Atresia Type IIIb, SGADuodenal Atresia, Oesophageal Atresia, Fallots Tetralogy

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Double Bubble

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What is the pathologyFoetus starts with completely patent GIT tube

Developmental & Embolic lesions give rise to gut lesion

Atresias Vs Stenoses & Volvulus.

Management options

Prevent complications. N/g tube & regular aspiration

IV FluidsWarmth & Oxygen

Make diagnosis Clinically & investigations

Surgical treatment

Post-Operative care

ICUTPNfurther SurgeryOutcome

Other anomalies

Intestinal obstruction

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Gastroschisis

How to recognize patients

Narrow paraumbilical defect with protruding bowel loops.

-bowel lies Rt of the normal umbilicus-no covering to the bowel-premature child.

Antenatal diagnosis by ultrasound should be standard.

Distinguish condition from Exomphalos by the;

The bowel herniates through the anterior abdominal wall

The exposed bowel -

Looses heat & fluid neonatal Stress

=Inflammed - has become short & thick cant Feed.

Bacterial exposure infection & septicaemia.

Prone to Trauma & Ischaemia - obstruction

What is the emergency?

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Gastroschisis

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What is the pathology

Theories of causation.Involution of vein @ 4-5thweek gestation

Rupture of an exomphalos

Young mothers of +/- 21 years of age.

World-wide increaseManagement optionsAntenatal diagnosis & discussion with parents

Primary bowel reduction AnalgesiaEvacuation of bowel contents

Abdominal wall stretchA need for Silo and gradual reduction

Total parenteral nutrition, venous access, sepsis.

Gastroschisis

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Pulmonary Dysplasia

What is the emergency?

Newborn becomes increasingly dyspnoeic

Attempts to mask ventilate worsens conditionHypoxia may become irreversible

(Congenital Diaphragmatic Hernia)

How to recognize patientsAntenatal u/s mediastinal shift

CXR

Scaphoid abdomen

Hypoxia < 8 hours

Difficulty in breathing

Associated anomalies

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What is the pathologyHypoplastic, AbN lung(s)

Inability to ventilate adequately

Hypoxia

Fetal shunt reopens

Fetal circulation bypassing lung

Management options

Antenatal Maternal Dexamethazone

- Tracheal occlusion (Lig./Balloon/Clip)

Referral to specialist hospital

Fetal surgery(JPS,1997;32(4):834-8)

Post-delivery - N/g tube, CXR

Closure Open Sx / Thoracoscopically

Low pressure Ventilation,

Pulmonary Dysplasia(Congenital Diaphragmatic Hernia)

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Midgut Malrotation

Periods of well being, N feeding

Vomitus is Bilious, may be intermittent, scanty

Contrast X-ray may show obstructed, volved gut.

Midgut loop ( from duodenum to middle of Colon) is volved

Twisted portion of gut may obstruct its own blood supplyPresentation due to vomiting or abdominal pain

What is the emergency?

How to recognize patients

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What is the pathology

AbN fixation of bowel at beginning of 2ndtrimester

Results in abnormally narrow fixation of bowel mesentryThe above 2 allow for rotation of midgut loop

How are they treatedRe-hydration IV fluids

Urgent surgical total derotation of midgut.

Midgut Malrotation

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Oesophageal Atresia c.

TacheoOesophageal Fistula

Midgut Malrotation

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Ano-Rectal malformations

These children are unable to pass meconium

Rectal distension leads to loss of functionColon perforates at either caecum or rectum

This malformation has frequently assoc. congenital abN.

What is the emergency?

How to recognize patients

Males Females

LOW

HIGH

40% 60%

60% 40%

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What is the pathology

This is a foetal developmental anomaly

The primitive Cloacal membrane has notdivided into anal and urogenital channels

The earlier the developmental process fails

the worse the childs potential continence

Ano-Rectal malformations

Management options

Primary anoplasty / Defunctioning ColostomyAnoRectoplasty Posterior / Anterior / Laparoscopic.

Management aims to optimise sphincteric function

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Anorectal malformations

The emergencies discussed:

Intestinal obstructions

Gastroschisis

Dysplastic lungs (CDH)

Midgut volvulus

Thank you !