The document discusses various neonatal surgical issues, including anatomical surveys and conditions affecting head, neck, chest, abdomen, and abdominal wall. Key topics include choanal atresia, tracheo-esophageal fistula, congenital diaphragmatic hernia, and associated surgical management strategies. It emphasizes the importance of pre-operative assessments, operative management, and post-operative care to address these complex congenital conditions.

1. Neonatal Surgical Issues
Neonatal Surgical Issues
(Part 1)
(Part 1)
Sue Ann Smith, MD
Sue Ann Smith, MD
Neonatologist
Neonatologist

2. An anatomic survey
An anatomic survey
 Head and Neck lesions
Head and Neck lesions
 Chest lesions
Chest lesions
 Abdomen
Abdomen
Abdominal wall defects and infection
Abdominal wall defects and infection

3. The Nose
The Nose
 Choanal atresia – bilateral atresia
Choanal atresia – bilateral atresia
 Respiratory distress resolves with crying
Respiratory distress resolves with crying
 Treat with oral airway until surgical repair
Treat with oral airway until surgical repair
 CT scan often used in surgical planning
CT scan often used in surgical planning
 ENT surgeons make opening in bony plate and stent
ENT surgeons make opening in bony plate and stent
open during healing
open during healing
 Nasolacrimal duct cysts – large and bilat
Nasolacrimal duct cysts – large and bilat
 Respiratory distress resolves with crying
Respiratory distress resolves with crying
 Treat with oral airway
Treat with oral airway
 Can usually be seen with otoscope
Can usually be seen with otoscope

4. Robin sequence
Robin sequence
 AKA Pierre Robin syndrome
AKA Pierre Robin syndrome
 Hypoplastic mandible with U-shaped
Hypoplastic mandible with U-shaped
midline cleft palate
midline cleft palate
Respiratory and feeding difficulties
Respiratory and feeding difficulties
Position prone, may require nasopharyngeal
Position prone, may require nasopharyngeal
tube, oral airway, LMA, or endotracheal tube
tube, oral airway, LMA, or endotracheal tube
Mandibular distraction is now treatment of
Mandibular distraction is now treatment of
choice at OHSU
choice at OHSU

6. The Unusual
The Unusual
 Laryngotracheal clefts
Laryngotracheal clefts
 Laryngeal webs
Laryngeal webs
 Tracheal agenesis – frequently lethal
Tracheal agenesis – frequently lethal
 Neck masses
Neck masses
Foregut duplication cyst
Foregut duplication cyst
lymphangioma
lymphangioma

7. Normal Larynx
Laryngeal Web

10. Congenital Chest Lesions
Congenital Chest Lesions
 Tracheo-esophageal fistula
Tracheo-esophageal fistula
 Diaphragmatic Hernia (briefly)
Diaphragmatic Hernia (briefly)
 Congenital lobar emphysema
Congenital lobar emphysema
 Cystic adenomatoid malformation
Cystic adenomatoid malformation
 Vascular rings
Vascular rings

11. Tracheo-Esophageal Fistula (TEF)
Tracheo-Esophageal Fistula (TEF)
 Esophageal atresia with TEF is most
Esophageal atresia with TEF is most
common (85%).
common (85%).
Diagnosis may be suspected antenatal with
Diagnosis may be suspected antenatal with
absence of stomach bubble and
absence of stomach bubble and
polyhydramnios. (*Caution: also seen with
polyhydramnios. (*Caution: also seen with
conditions that lead to poor swallowing)
conditions that lead to poor swallowing)
Often associated with other anomalies:
Often associated with other anomalies:
VATER and chromosomal
VATER and chromosomal

13. Tracheo-Esophageal Fistula (TEF)
Tracheo-Esophageal Fistula (TEF)
(cont)
(cont)
 Presentation: excessive salivation and
Presentation: excessive salivation and
intolerance of feedings.
intolerance of feedings.
 Diagnosis: inability to pass catheter into
Diagnosis: inability to pass catheter into
stomach.
stomach.
 Pre-op Management: avoid mechanical
Pre-op Management: avoid mechanical
ventilation (if possible), catheter to suction
ventilation (if possible), catheter to suction
in the esophageal pouch, elevate head of
in the esophageal pouch, elevate head of
bed.
bed.

14. Operative management
Operative management
 Ligation of fistula at trachea.
Ligation of fistula at trachea.
 Mobilization of distal esophageal segment
Mobilization of distal esophageal segment
with primary anastamosis to proximal
with primary anastamosis to proximal
pouch.
pouch.
 NG tube left in place to stent open
NG tube left in place to stent open
anastamosis while healing.
anastamosis while healing.
 Chest tube left in for serous drainage
Chest tube left in for serous drainage
usually.
usually.

15. Post-operative Management
Post-operative Management
 Careful airway management to prevent
Careful airway management to prevent
trauma to the fistula ligation site in the
trauma to the fistula ligation site in the
trachea.
trachea.
 Prior to feedings, must make sure that the
Prior to feedings, must make sure that the
esophageal anastamosis does not leak.
esophageal anastamosis does not leak.
(swallow study)
(swallow study)
 Often have on going feeding problems.
Often have on going feeding problems.
May need dilation procedures periodically
May need dilation procedures periodically

16. Other “TEFs”
Other “TEFs”
 Esophageal atresia without TEF – very rare
Esophageal atresia without TEF – very rare
 H-Type TEF-also rare.
H-Type TEF-also rare.
Diagnosis usually after the neonatal period with
Diagnosis usually after the neonatal period with
frequent pneumonias or respiratory distress
frequent pneumonias or respiratory distress
related to feedings
related to feedings

17. Congenital Diaphragmatic Hernia
Congenital Diaphragmatic Hernia
(CDH)
(CDH)
 Most commonly on left side
Most commonly on left side
 Incidence 1:2000 to 1:5000
Incidence 1:2000 to 1:5000
 Often associated with other malformations
Often associated with other malformations
 Frequently diagnosed prenatally
Frequently diagnosed prenatally
 Avoid bag-mask PPV
Avoid bag-mask PPV

18. Pre-op CDH
Pre-op CDH
 Delayed surgical repair – usually after 72
Delayed surgical repair – usually after 72
hrs of age
hrs of age
 NG drainage tube to keep bowel
NG drainage tube to keep bowel
decompressed
decompressed
 Treat aggressively for pulmonary
Treat aggressively for pulmonary
hypoplasia and Persistent Pulmonary
hypoplasia and Persistent Pulmonary
Hypertension – including ECMO(?).
Hypertension – including ECMO(?).
 Surfactant therapy is now controversial
Surfactant therapy is now controversial

20. Post-Op CDH
Post-Op CDH
 “
“Anatomy is destiny”
Anatomy is destiny”
 Survival continues to be around 40-50%.
Survival continues to be around 40-50%.
 Feeding difficulties
Feeding difficulties

21. Congenital lobar emphysema
Congenital lobar emphysema
 Lesions that cause air trapping, with
Lesions that cause air trapping, with
compression of surrounding tissue
compression of surrounding tissue
 Most common in left upper, right middle
Most common in left upper, right middle
and right upper lobes
and right upper lobes
 Usually attempt low volume ventilation.
Usually attempt low volume ventilation.
Sometimes selective intubation of other
Sometimes selective intubation of other
bronchus
bronchus
 May require surgical resection
May require surgical resection

23. Congenital Cystic Adenomatoid
Congenital Cystic Adenomatoid
Malformation (CCAM)
Malformation (CCAM)
 May be confused with CDH
May be confused with CDH
 Abnormal lung tissue that forms fluid filled
Abnormal lung tissue that forms fluid filled
cysts. May be large cysts, or many small
cysts. May be large cysts, or many small
cysts and solid areas
cysts and solid areas
 Space occupying lesion
Space occupying lesion
 May cause shifting of mediastium
May cause shifting of mediastium
 May spontaneously regress in fetus
May spontaneously regress in fetus
 May require surgical removal
May require surgical removal

25. Vascular Rings
Vascular Rings
 Uncommon
Uncommon
 Signs include stridor, vomiting and difficulty
Signs include stridor, vomiting and difficulty
swallowing.
swallowing.
 Barium swallow can be diagnostic, but may
Barium swallow can be diagnostic, but may
need chest MRI.
need chest MRI.
 Sometimes may need cardiac
Sometimes may need cardiac
catheterization
catheterization

27. The Abdomen
The Abdomen
 Abdominal wall
Abdominal wall
defects
defects
infection
infection
 Bowel
Bowel
Obstructions
Obstructions

28. Gastroschisis
Gastroschisis
 Abdominal wall defect to right of umbilicus with
Abdominal wall defect to right of umbilicus with
no covering over intestines
no covering over intestines
 Rarely associated with other anomalies
Rarely associated with other anomalies
 Most babies are SGA and born to young
Most babies are SGA and born to young
mothers (why?)
mothers (why?)
 10% will have intestinal atresias
10% will have intestinal atresias
 Rarely will have significant infarction of most of
Rarely will have significant infarction of most of
small bowel (i.e. lethal)
small bowel (i.e. lethal)
 Most will have “meconium” stained amniotic fluid
Most will have “meconium” stained amniotic fluid
(really bile)
(really bile)

30. Gastroschisis Pre-op
Gastroschisis Pre-op
 Empty stomach (usually lots of bilious fluid)
Empty stomach (usually lots of bilious fluid)
 NG tube for decompression
NG tube for decompression
 Place in bowel bag or wrap in warm saline
Place in bowel bag or wrap in warm saline
soaked gauze and saran wrap
soaked gauze and saran wrap
 Support the bowel so as to maintain
Support the bowel so as to maintain
perfusion
perfusion

31. Gastroschisis (post-op)
Gastroschisis (post-op)
 Primary closure is attempted
Primary closure is attempted
 May require silo with slow return of
May require silo with slow return of
intestine into small abdominal cavity
intestine into small abdominal cavity
 Maintain perfusion
Maintain perfusion
 Feeding difficulties are main post-op
Feeding difficulties are main post-op
problem
problem
 At risk for adhesions throughout life
At risk for adhesions throughout life

32. Omphalocele
Omphalocele
 Abdominal wall defect at umbilicus with
Abdominal wall defect at umbilicus with
covering (sac may rupture)
covering (sac may rupture)
 Frequently associated with other
Frequently associated with other
anomalies
anomalies
 Giant omphaloceles: respiratory issues
Giant omphaloceles: respiratory issues
with misshaped chest and airway malacias
with misshaped chest and airway malacias

35. Omphalocele
Omphalocele
 Decompress stomach initially
Decompress stomach initially
 Careful eval for other anomalies
Careful eval for other anomalies
 Intact sac may defer operation for years
Intact sac may defer operation for years
“
“paint” membrane with betadine to toughen
paint” membrane with betadine to toughen
into a “rind”
into a “rind”
 Ruptured sac – repair similar to
Ruptured sac – repair similar to
gastroschisis
gastroschisis

36. Omphalitis
Omphalitis
 Presentation – erythema/induration of the
Presentation – erythema/induration of the
periumbilical area with purulent discharge
periumbilical area with purulent discharge
from umbilical stump.
from umbilical stump.
 Can spread extensively to abdominal wall
Can spread extensively to abdominal wall
or develop necrotizing fasciitis.
or develop necrotizing fasciitis.
 Both gram + and gram neg bacteria
Both gram + and gram neg bacteria
implicated
implicated
 Full sepsis evaluation
Full sepsis evaluation
 Oxacillin/nafcillin and gent
Oxacillin/nafcillin and gent

40. Normal Larynx (upside down) Laryngeal Web (also upside down)