1. Surgical disorders in Newborn
Dr. Abhijeet Deshmukh

2. • Fetal surgical disorders:
Polyhydramnios:
- 1:1000 births
Causes:
1. GI obstruction
2. Abdominal wall defects
Omphalocele, gastroschisis, diaphragmatic
hernia, tight nuchal cord

3. • Oligohydramnios:
Renal dysgenesis/ agenesis
• Meconium peritonitis:
Antenatal perforation of GIT
Intestinal obstruction

4. • Fetal ascites:
Urinary tract anomalies – Posterior
urethral valve, thoracic duct obstruction,
hepatic/portal vein obstruction

5. • Postnatal surgical disorders:
A. Respiratory distress:
- Diaphragmatic hernia
- Coanal atresia
- Laryngeal clefts
- Tracheal agenesis
- Oesophageal atresia
- Congenital lobar emphysema
- Cystic adenomatoid malformation of lung

6. B. Scaphoid abdomen
- Diaphragmatic hernia
- EA without TEF
C. Excessive mucus & salivation
- EA with/ without TEF
D. Abdominal distention
- Pneumoperitonium
Causes are : NEC, bowel wall ischemia,
instrumentation, TEF

7. E. Vomiting:
1. Bilious emesis :
Can be a life threatening emergency
20% require immediate surgical
intervention
Causes:
- Malrotation with/ without volvulus
- Duodenal/jejunal/ileal/colonic atresias

8. - Annular pancreas
- Hirschprung disease
- Preduodenal portal veins
- Peritoneal bands
- Persistent omphalomesenteric duct
- Duodenal duplication
- Decreased motility of intestine

9. 2. Nonbilious emesis:
- Excessive feeding
- Milk intolerance
- Sepsis
- Lesions above ampulla of Veter
> Pyloric stenosis
> Upper duodenal stenosis
> Annular pancreas

10. F. Failure to develop transient stools:
- volvulus
- Malrotation
G. Hematemesis/ Hematochezia:
- Nonsurgical conditions :
> Milk intolerance
> Instrumentation
> Swallowed maternal blood

11. - Surgical conditions:
> NEC (most frequent in premature infants)
> Gastric/duodenal ulcers (stress/steroids)
> Coagulation disorders (DIC/ Vit K def.)
> Volvulus
> GI obstructions
> Intussuception
> Polyps/ hemangiomas

12. > Meckel diverticulum
> Duplication of small intestine
H. Abdominal mass :
- GU abnormalities
- Hepatosplenomegaly
- Tumors
I . Birth trauma:
- Fractured clavicle
- IC haemorrhages
- Spinal cord transection

13. Lesions causing Respiratory distress
A. EA and TEF:
- 85% association
- Absence of stomach bubble
• Postnatal presentation
- Excessive salivation & vomiting soon after
birth
- Scaphoid abdomen

14. • Diagnosis:
- Inability to pass NG tube
- Confirmed by X ray : coiled catheter ,
distended upper oesophagus after pushing
air.
• Other associated anomalies:
- Vertebral defects
- Imperforate anus
- Cardiac defects
- Renal dysplasia
- Limb anomalies

15. • Management:
- Oro-nasal suction
- Head end elevation -45 degree
- Immediate gastrostomy tube placement.

16. Tracheo Esophageal Fistula (TEF)

17. • Incidence: 1:4000 live births
• M > F (25:3)
• 10-40% are preterm
• Antenatal history: polyhydramnios (60%)
• Etiology: failure in mesenchymal separation
of upper foregut

18. • Clinical Presentation
choking on 1st feed
coughing
cyanosis
excessive salivation
aspiration pneumonia

19. • Diagnosis
• Inability to pass a suction catheter into the
stomach
• CXR: Coiled orogastric tube in the cervical
pouch, air in the stomach and intestine

20. Esophageal Atresia Tracheoesophageal Fistula

21. • 5 Types (Gross and Vogt)
7.7% 4.2% 0.8% 86% 0.7% 0.7%

22. • 35-65% have associated anomalies
V Vertebral anomalies or VSD
A Anorectal malformation
C Cardiac anomalies (common)
T TEF
E Esophageal atresia
R Renal abnormalities
L Limb/radial malformation

23. Laboratory studies
CBC
Electrolytes
Glucose
Calcium
ABGs

24. - NPO
- IVF & Antibiotics
- Ensure availability of blood in the OT
- Optimize volume status and metabolic state
- Intubation preferably in the operating room under
controlled situation
- Echo

25. • Surgical repair
• Ligation of fistula
• Esophageal repair
– Chest tube placement and closure of
thoracic cavity

26. Diaphragmatic Hernia

27. - Most difficult of all neonatal emergencies
- Most common site is left hemithorax.
- Incidence 1 : 4000 live births
- Associated with trisomies 13 & 18, 45 XO
Goldenhar syndrome,
Backwith- Wiedmann synd.
Pierre robin synd.
Goltz-Gorlin synd.
Rubella synd.

28. Classification
• Absent diaphragm : rare
• Diaphragmatic hernia
80% posterolateral L >R
(Bochdalek)
2% anterior (Morgagni)
15 - 20% paraesophageal
• Eventration (15 - 20%)

29. • Symptoms :
- Cyanosis at birth
- Respiratory distress
- Scaphoid abdomen
- Decreased / absent breath sounds on
hernial side
- Shift of cardiac sounds opposite to the
hernia

30. • Diagnosis:
1. Antenatal diagnosis –
- Often undetected as it occurs mostly after
16 wks.
- Presence of liver in the thorax asso with
increased severity & poor prognosis

31. 2. Postnatal diagnosis:
X ray : cardiothymic shift
- loops of bowel in the chest
- mediastinal shift
- absent lung markings

32. • Treatment:
- Immediate intubation
- Bag & mask is contraindicated
- immediate NG tube insertion & continuous
suction.
- Low pressure ventilation - to avoid damage
to contra lateral lung.
- Surgical repair with reduction of intestine into
abdominal cavity.

33. Extracorporeal Membrane Oxygenation
(ECMO)
• Use: controversial
• Allows the lungs to develop & restructure
• Expensive

34. Criteria for ECMO
• Gestational age ≥ 34 wks
• Weight ≥ 2000 grams
Predicted mortality ≥ 80%

35. • Associated anomalies (20-50%) :
cardiovascular 13 - 23%
CNS 28%
gastrointestinal 20%
genitourinary 15%

36. Anorectal malformations

37. Frequency
• 1 : 5000 live births

38. TYPES
• HIGH TYPE
• LOW TYPE

39. Clinical Findings
• High type :
– A flat perineum & lack of a midline gluteal fold
– Absence of an anal dimple
• Low type :
– the presence of meconium at the perineum,
– A bucket-handle malformation
– Anal membrane (through which meconium is visible).

40. INVERTOGRAM
16-24 hours

41. A flat perineum

42. A flat perineum-GIRL

43. Perineal fistula

44. bucket-handle malformation

45. Associated malformations
Genitourinary :
- Absent, dysplastic, or horseshoe
kidneys
- Vesicoureteral reflux
- Hydronephrosis
- Hypospadias
- Bifid scrotum

46. Skeletal System :
• Partial or complete lumbosacral agenesis
• Hemivertebrae
• Agenesis of thoracic vertebrae
• Scoliosis
• Hemisacrum or scimitar sacrum
• Asymmetric sacrum
• Posterior protruding sacrum
• Agenesis of the coccyx

47. Spinal anomalies :
• Tethered cord
• Dural sac stenosis
• Narrow spinal canal
• Myelomeningocele, meningocele
• Intraspinal teratoma
• Neurogenic bladder

48. Gastrointestinal and Cardiovascular
Systems
• VATER and VACTERL associations:
– Esophageal atresia
– Duodenal atresia
– Ventricular or atrioseptal defects
– Tetrology of Fallot
– Hirschsprung's disease

49. Surgical therapy
• Colostomy
• Definitive repair

50. Colostomy Newborn boys
• Rectobulbar urethral fistula
• Rectoprostatic urethral fistula
• Rectovesical fistula
• Imperforate anus without fistula
• Rectal atresia

51. Newborn girls
Colostomy -
• Rectovestibular fistula
• Imperforate anus without fistula
• Persistent cloaca
• Rectal atresia
• Rectovaginal fistula

54. COLOSTOMY

55. Definitive repair
• Anoplasty : Indications
– Rectoperineal fistula - girls & boys
– Covered anus
– Bucket-handle malformation

56. • posterior sagittal ARP
• Laprotomy

57. PSARP

58. Outcome after surgery
• Altered bowel habits in most of the cases
• 50% - few episodes of accidental soilage
• Few of them require major adjustments in lifestyle
secondary to fecal incontinence, chronic
constipation, and odor.

59. Necrotizing Enterocolitis
(NEC)

60. • Life-threatening intestinal inflammation or injury
• Caused by bacterial invasion of previously injured
or ischemic bowel wall
• Incidence: 5 -10% in infants <1500g birth weight
• Mortality rate: 10 - 30%

61. • Single most important factor
PREMATURITY
• Can occur in:
LBW infants
Full term infants
Fed and unfed infants

62. • Other factors
- ischemia
- bacterial infection
- GI endotoxemia
- enteral feeding
- use of hyperosmolar formula
- congenital heart disease
- umbilical arterial catheterization
- exchange transfusion

63. Early signs
- ↑ gastric residuals with feedings
- temperature instability
- poor feeding
- bilious vomiting
- lethargy
- mucoid or bloody stool
- apnea and bradycardia

64. • Late Signs
• Hemodynamic instability
• Anemia
• Thrombocytopenia
• Coagulopathy, DIC
• Prerenal azotemia
• Metabolic acidosis

65. Physical Exam
distended and tender abdomen
Labs:
CBC
electrolytes and glucose
platelets and coagulation profile
DIC profile
ABG

66. Abdominal X-ray
• signs of bowel obstruction
• Ileus with edematous bowel
• Pneumatosis intestinalis or
intramural air (arrow)
• Air in portal vein
• pneumoperitoneum

67. Medical Management
• No enteral feedings for 10-14 days
• NGT on intermittent suction
• Hydration and correction of electrolytes
• Ventilatory support
• Antibiotics
• Blood and platelet transfusion if needed

68. • Surgical Indications
Absolute Indications
1) bowel perforation
2) intestinal gangrene

69. • Relative Indications
– metabolic acidosis
– respiratory failure
– oliguria, hypovolemia
– thrombocytopenia
– leucopenia, leukocytosis
– air in the portal vein
– bowel wall edema
– persistent dilated bowel loops

70. • Non-Surgical Indications
severe GI hemorrhage
abdominal tenderness
intestinal obstruction
gasless abdomen with ascites

71. Thank You!