Neonatal Surgical Issues Part 1

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Neonatal Surgical Issues(Part 1)

• Sue Ann Smith, MD
• Neonatologist

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An anatomic survey

• Head and Neck lesions
• Chest lesions
• Abdomen
• Abdominal wall defects and infection

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The Nose

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

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Robin sequence

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

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The Unusual

• Laryngotracheal clefts
• Laryngeal webs
• Tracheal agenesis frequently lethal
• Neck masses
• Foregut duplication cyst
• lymphangioma

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Normal Larynx
Laryngeal Web
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Congenital Chest Lesions

• Tracheo-esophageal fistula
• Diaphragmatic Hernia (briefly)
• Congenital lobar emphysema
• Cystic adenomatoid malformation
• Vascular rings

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Tracheo-Esophageal Fistula (TEF)

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

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Tracheo-Esophageal Fistula (TEF) (cont)

• Presentation excessive salivation and
  intolerance of feedings.
• Diagnosis inability to pass catheter into
  stomach.
• Pre-op Management avoid mechanical ventilation
  (if possible), catheter to suction in the
  esophageal pouch, elevate head of bed.

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Operative management

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

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Post-operative Management

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

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Other TEFs

• Esophageal atresia without TEF very rare
• H-Type TEF-also rare.
• Diagnosis usually after the neonatal period with
  frequent pneumonias or respiratory distress
  related to feedings

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Congenital Diaphragmatic Hernia (CDH)

• Most commonly on left side
• Incidence 12000 to 15000
• Often associated with other malformations
• Frequently diagnosed prenatally
• Avoid bag-mask PPV

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Pre-op CDH

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

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Post-Op CDH

• Anatomy is destiny
• Survival continues to be around 40-50.
• Feeding difficulties

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Congenital lobar emphysema

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

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Congenital Cystic Adenomatoid Malformation (CCAM)

• May be confused with CDH
• Abnormal lung tissue that forms fluid filled
  cysts. May be large cysts, or many small cysts
  and solid areas
• Space occupying lesion
• May cause shifting of mediastium
• May spontaneously regress in fetus
• May require surgical removal

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Vascular Rings

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

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The Abdomen

• Abdominal wall
• defects
• infection
• Bowel
• Obstructions

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Gastroschisis

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

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Gastroschisis Pre-op

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

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Gastroschisis (post-op)

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

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Omphalocele

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

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Omphalocele

• Decompress stomach initially
• Careful eval for other anomalies
• Intact sac may defer operation for years
• paint membrane with betadine to toughen into a
  rind
• Ruptured sac repair similar to gastroschisis

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Omphalitis

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

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