Neonatal Surgical Issues Part 2

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Neonatal Surgical Issues(Part 2)

• Sue Ann Smith, MD
• Neonatologist

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Anatomic survey (cont)

• Intestinal obstructions
• Genitourinary
• Abdominal masses
• Inguinal hernia
• Testicular torsion
• Neurosurgical

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Intestinal obstructions

• Atresias duodenal, jejunal, colonic
• Meconium ileus
• Meconium plug
• Hirschsprungs disease
• Imperforate anus
• Malrotation with volvulus
• Adhesions and strictures

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Atresias
High obstruction of jejunal atresia
Double bubble of duodenal atresia
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Atresias (cont)

• Duodenal atresia associated with trisomy 21, or
  other anomalies
• Hx of polyhydramnios
• Delee more than 30-50ml from stomach
• Jejunal atresia is rarely associated with other
  anomalies.
• Decompress proximal bowel with repogle tube to
  low continuous suction

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Meconium Ileus

• Obstruction of bowel by thick tenacious meconium
• 30 of intestinal obstruction in neonates
• Frequent cause of meconium peritonitis
• Most are associated with cystic fibrosis (but
  only 15 of infants with CF will have meconium
  ileus)
• Abdominal distention is typically present at birth

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Meconium Ileus (cont)

• Diagnosis made with contrast enema
• Gastrograffin enema with aggressive hydration can
  be used to treat some
• Operative evacuation of meconium
• May require ostomy
• Proximal bowel dilated and distal bowel may be
  very small (microcolon) and require time to
  dilate with use

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Meconium plug

• Difference between meconium ileus and meconium
  plug is site and severity of obstruction
• Preterm infants, infants of diabetic mothers,
  IUGR babies, otherwise ill babies
• Treatment with glycerin suppositories and warm
  saline enemas
• May require contrast enema to make diagnosis
• Normal stooling pattern should follow evacuation
  of plug

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Meconium plugs
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Hirschsprungs Disease

• Colonic agangliosis
• Extent can vary from very short segment of rectal
  tissue to entire colon
• Should be considered in any baby who does not
  pass stool spontaneously by 24 hours of age.
• Diagnosis by rectal biopsy to look for ganglion
  cells

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Hirschsprungs Disease (cont)

• Barium enema can show transition zone
• Short segment disease can be treated with rectal
  irrigations followed by primary pull through
  procedure
• Longer segment disease requires ostomy followed
  by pull through when older (months usually).

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Imperforate Anus

• May pass meconium if a rectovaginal or
  rectourinary fistula exists.
• Low imperforate anus the rectum has descended
  through the puborectalis sling and exists as a
  fistula on the perineum.
• May see mec on the perineum, may be seen in the
  rugal folds or scrotum of males and vagina of
  females.
• These fistula may be dilated to temporarily
  relieve obstruction

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Imperforate Anus (cont)

• High imperforate anus rectum ends above the
  puborectalis sling.
• No perineal fistula, but may have urinary fistula
• Temporary colostomy is necessary in all babies
  with high imperforate anus.

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Malrotation with volvulus

• Can occur in the fetus large calcified shadow
  in midabdomen on x-ray
• Sudden onset of bilious emesis in infant
  requires rule out
• Signs of shock and sepsis can be present
• Surgical emergency since intestinal viability is
  at stake.
• UGI to evaluate for position of ligament of Treitz

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Malrotation
Volvulus
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Adhesions and strictures

• Can occur following any abdominal surgical
  manipulation.
• Can occur following NEC even if initial disease
  process required only medical treatment.

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Necrotizing Enterocolitis

• This is a whole lecture unto itself
• Incidence varies from center to center and from
  year to year within centers
• 2-5 of all NICU admissions and 5-10 of VLBW
  infants
• Prematurity is greatest risk factor
• Mortality is 9-28 regardless of medical or
  surgical intervention

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NEC (cont)

• To be continued in future lecture..?

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Genitourinary

• Posterior urethral valves
• Extrophy of the bladder
• Cloacal extrophy

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Posterior Urethral Valves

• Obstruction of urinary flow at level of bladder
  outlet
• Exclusively in males
• May lead to oligohydramnios and pulmonary
  hypoplasia
• May lead to destruction of renal parenchyma
• Symptomatology can sometimes be mild

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VCUG in pt with Posterior Urethral Valves
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Posterior Urethral Valves

• Place urinary catheter to drain bladder
• Obtain VCUG to confirm diagnosis
• Urologist to ablate valves usually with a
  transurethral approach
• Assess renal function urine output,
  electrolytes, BUN, creatinine
• Bladder may be dysfunctional
• Some will be OK in neonatal period and go on to
  outgrow their renal function

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Extrophy of the Bladder

• May range from epispadias to complete extrusion
  of bladder on to abdominal wall
• Initial surgical repair is most critical for best
  functional outcome
• Apply sterile saline and lay saran wrap on top of
  exposed bladder, but keep any irritants away (no
  gauze, etc)

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Extrophy of bladder

• 21 male to female ratio
• Symphysis pubis is widely separated
• Is a very complicated and prolonged repair
  requiring urologist and orthopedist to work
  together
• Patient immobilized for a week or more post-op
• Phallic reconstruction may be done in later
  operation

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Cloacal Extrophy

• More complex than simple bladder extrophy
• May include vesico-intestinal fissure,
  omphalocele, extrophied bladder, hypoplastic
  colon, imperforate anus, absence of vagina in
  female, and microphallus in males.
• Series of complex operations needed

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Abdominal masses

• Renal masses
• Ovarian cyst
• Tumors
• Adrenal hemorrhage
• Hydrometrocolpos

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Renal Masses

• Polycystic kidneys
• Multicystic dysplastic kidneys
• Renal duplications
• Hydronephrosis

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Ovarian Cyst

• One of the most common abdominal masses in female
  fetus and newborn
• May cause torsion and necrosis of ovary
• Surgical resection if 4cm diameter or persistent

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Tumors

• Teratomas are most common.
• Sacrococcygeal
• About 10 contain a malignant element
• Neuroblastoma 50 of malignant tumors in
  neonates. Can resolve spontaneously.
• Wilms tumor
• Sarcoma botryoides grapelike tumor arises from
  edge of vulva or vagina.

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Sacrococcygeal teratoma
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Sarcoma Botryoides
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Hydrometrocolpos

• Imperforate hymen (or other vaginal obstruction)
  with back up of secretions in the uterus, which
  can cause intestinal obstruction
• Hymen will bulge
• May have edema and cyanosis of the legs
• May cause hydronephrosis

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Inguinal Hernia

• Frequent in preterm babies, malefemale
• Usually repair prior to discharge if possible
• Monitor for incarceration
• Incarcerated hernia can usually be reduced with
  sedation and steady firm pressure
• Even if reduced, should be repaired as soon as
  edema is resolved

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Testicular Torsion

• 70 occur in fetal life
• Testes is tender, firm, swollen with a slightly
  bluish cast to the scrotum on affected side
• Differential dx includes scrotal hematoma
• US with doppler flow can be useful
• Any possibility of recent torsion surgery
  within 4-6 hrs
• Orchiopexy of contralateral side

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Neurosurgical

• Myelomeningocele
• Hydrocephalus
• Intracranial hematoma

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Myelomeningocele

• Saccular outpouching of neural elements through
  defect in bone and soft tissues in posterior
  thoracic, sacral and/or lumbar regions (lumbar
  80)
• Most common primary neural tube defect
• Hydrocephalus in 84
• Arnold-Chiari II malformation in 90

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• The Chiari II malformation is a complex
  congenital malformation of the brain, nearly
  always associated with myelomeningocele. This
  condition includes downward displacement of the
  medulla, fourth ventricle, and cerebellum into
  the cervical spinal canal, as well as elongation
  of the pons and fourth ventricle, probably due to
  a relatively small posterior fossa.

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Chiari II malformation. Sagittal T1-weighted MRI
of posterior fossa abnormalities in Chiari II
malformation (1) colpocephaly (2) beaked
tectum (3) cascade of an inferiorly displaced
vermis behind the medulla (4) elongated tubelike
fourth ventricle (5) low-lying torcular
herophili (6) cerebellar hemispheres wrapping
around the brainstem anteriorly (7) concave
clivus (8) medullary spur and (9) medullary
kink.
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Hydrocephalus

• Associated with MM
• Aqueductal Stenosis male with X-linked
• Post-hemmorhagic most frequent in premature
  population

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