Surgical emergencies in newborn

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Surgical emergencies in newborn

  1. 1. Surgical disorders in Newborn Dr. Abhijeet Deshmukh
  2. 2. • Fetal surgical disorders: Polyhydramnios: - 1:1000 births Causes: 1. GI obstruction 2. Abdominal wall defects Omphalocele, gastroschisis, diaphragmatic hernia, tight nuchal cord
  3. 3. • Oligohydramnios: Renal dysgenesis/ agenesis• Meconium peritonitis: Antenatal perforation of GIT Intestinal obstruction
  4. 4. • Fetal ascites: Urinary tract anomalies – Posterior urethral valve, thoracic duct obstruction, hepatic/portal vein obstruction
  5. 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. 6. B. Scaphoid abdomen- Diaphragmatic hernia- EA without TEFC. Excessive mucus & salivation- EA with/ without TEFD. Abdominal distention- Pneumoperitonium Causes are : NEC, bowel wall ischemia, instrumentation, TEF
  7. 7. E. Vomiting:1. Bilious emesis : Can be a life threatening emergency 20% require immediate surgical interventionCauses:- Malrotation with/ without volvulus- Duodenal/jejunal/ileal/colonic atresias
  8. 8. - Annular pancreas- Hirschprung disease- Preduodenal portal veins- Peritoneal bands- Persistent omphalomesenteric duct- Duodenal duplication- Decreased motility of intestine
  9. 9. 2. Nonbilious emesis:- Excessive feeding- Milk intolerance- Sepsis- Lesions above ampulla of Veter > Pyloric stenosis > Upper duodenal stenosis > Annular pancreas
  10. 10. F. Failure to develop transient stools:- volvulus- MalrotationG. Hematemesis/ Hematochezia:- Nonsurgical conditions : > Milk intolerance > Instrumentation > Swallowed maternal blood
  11. 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. 12. > Meckel diverticulum > Duplication of small intestineH. Abdominal mass :- GU abnormalities- Hepatosplenomegaly- TumorsI . Birth trauma:- Fractured clavicle- IC haemorrhages- Spinal cord transection
  13. 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. 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. 15. • Management: - Oro-nasal suction - Head end elevation -45 degree - Immediate gastrostomy tube placement.
  16. 16. Tracheo Esophageal Fistula (TEF)
  17. 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. 18. • Clinical Presentation choking on 1st feed coughing cyanosis excessive salivation aspiration pneumonia
  19. 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. 20. Esophageal Atresia Tracheoesophageal Fistula
  21. 21. • 5 Types (Gross and Vogt)7.7% 4.2% 0.8% 86% 0.7% 0.7%
  22. 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. 23. Laboratory studies CBC Electrolytes Glucose Calcium ABGs
  24. 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. 25. • Surgical repair • Ligation of fistula • Esophageal repair – Chest tube placement and closure of thoracic cavity
  26. 26. Diaphragmatic Hernia
  27. 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. 28. Classification• Absent diaphragm : rare• Diaphragmatic hernia 80% posterolateral L >R (Bochdalek) 2% anterior (Morgagni) 15 - 20% paraesophageal• Eventration (15 - 20%)
  29. 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. 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. 31. 2. Postnatal diagnosis:X ray : cardiothymic shift- loops of bowel in the chest- mediastinal shift- absent lung markings
  32. 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. 33. Extracorporeal Membrane Oxygenation (ECMO)• Use: controversial• Allows the lungs to develop & restructure• Expensive
  34. 34. Criteria for ECMO• Gestational age ≥ 34 wks• Weight ≥ 2000 grams Predicted mortality ≥ 80%
  35. 35. • Associated anomalies (20-50%) : cardiovascular 13 - 23% CNS 28% gastrointestinal 20% genitourinary 15%
  36. 36. Anorectal malformations
  37. 37. Frequency• 1 : 5000 live births
  38. 38. TYPES• HIGH TYPE• LOW TYPE
  39. 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. 40. INVERTOGRAM 16-24 hours
  41. 41. A flat perineum
  42. 42. A flat perineum-GIRL
  43. 43. Perineal fistula
  44. 44. bucket-handle malformation
  45. 45. Associated malformationsGenitourinary : - Absent, dysplastic, or horseshoe kidneys - Vesicoureteral reflux - Hydronephrosis - Hypospadias - Bifid scrotum
  46. 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. 47. Spinal anomalies :• Tethered cord• Dural sac stenosis• Narrow spinal canal• Myelomeningocele, meningocele• Intraspinal teratoma• Neurogenic bladder
  48. 48. Gastrointestinal and Cardiovascular Systems• VATER and VACTERL associations: – Esophageal atresia – Duodenal atresia – Ventricular or atrioseptal defects – Tetrology of Fallot – Hirschsprungs disease
  49. 49. Surgical therapy• Colostomy• Definitive repair
  50. 50. Colostomy Newborn boys• Rectobulbar urethral fistula• Rectoprostatic urethral fistula• Rectovesical fistula• Imperforate anus without fistula• Rectal atresia
  51. 51. Newborn girls Colostomy -• Rectovestibular fistula• Imperforate anus without fistula• Persistent cloaca• Rectal atresia• Rectovaginal fistula
  52. 52. COLOSTOMY
  53. 53. Definitive repair• Anoplasty : Indications – Rectoperineal fistula - girls & boys – Covered anus – Bucket-handle malformation
  54. 54. • posterior sagittal ARP• Laprotomy
  55. 55. PSARP
  56. 56. 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.
  57. 57. Necrotizing Enterocolitis(NEC)
  58. 58. • 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%
  59. 59. • Single most important factor PREMATURITY• Can occur in: LBW infants Full term infants Fed and unfed infants
  60. 60. • Other factors - ischemia - bacterial infection - GI endotoxemia - enteral feeding - use of hyperosmolar formula - congenital heart disease - umbilical arterial catheterization - exchange transfusion
  61. 61. Early signs - ↑ gastric residuals with feedings - temperature instability - poor feeding - bilious vomiting - lethargy - mucoid or bloody stool - apnea and bradycardia
  62. 62. • Late Signs • Hemodynamic instability • Anemia • Thrombocytopenia • Coagulopathy, DIC • Prerenal azotemia • Metabolic acidosis
  63. 63. Physical Exam distended and tender abdomenLabs: CBC electrolytes and glucose platelets and coagulation profile DIC profile ABG
  64. 64. Abdominal X-ray• signs of bowel obstruction• Ileus with edematous bowel• Pneumatosis intestinalis or intramural air (arrow)• Air in portal vein• pneumoperitoneum
  65. 65. 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
  66. 66. • Surgical IndicationsAbsolute Indications1) bowel perforation2) intestinal gangrene
  67. 67. • Relative Indications – metabolic acidosis – respiratory failure – oliguria, hypovolemia – thrombocytopenia – leucopenia, leukocytosis – air in the portal vein – bowel wall edema – persistent dilated bowel loops
  68. 68. • Non-Surgical Indications severe GI hemorrhage abdominal tenderness intestinal obstruction gasless abdomen with ascites
  69. 69. Thank You!

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