Neonatal surgical

Emergencies

Dr Prashant Jain

Sr Consultant Ped. Surgery & Ped Urology

Dr BLKSS Hospital

Gastro-Intestinal

Abdominal wall defects

Respiratory distress

Intestinal Obstruction

Bilious Vomiting

Abdominal distension

Failure to pass meconium

Neonatal Intestinal Obstruction

Bilious Vomiting

+/- fail to pass meconium

Abdominal Distension

+/- Bilious vomiting

+/- fail to pass meconium

Upper GI Obstruction

Duodenal Atresia

Malrotation

Jejunal/ileal/colonic atresia

Meconium ileus

Anorectal malformation

Hirschsprung’s Disease

Small or large bowel

PASSAGE OF MECONIUM

• CANNOT RULE OUT OBSTRUCTION

• CAN PASS EVEN IN CASES OF ATRESIA

Causes

Intestinal atresia

Malrotation with or without Midgut volvulus

Meconium ileus

Meconium Peritonitis

Ano-Rectal Malformation

Hirschsprung’s Disease

CASE

Term male child 2.7 Kg

discharged after delivery

Passed meconium

Antenatal history normal

Presented at day 5 with

yellowish vomiting

Admitted and managed

conservatively

Again presented after 8 days with bilious vomiting

MALROTATION WITH MID GUT VOLVULUS

Exploratory Laparotomy

Malrotation is a TRUE SURGICAL EMERGENCY

• X-Ray

• Upper GI study

• USG

Normal

Acute Intestinal Obstruction Recurrent abdominal pain and vomiting

Malrotation Volvulus

CASE

Bilious vomiting

Antenatal scan:

Polyhydramnios

Down’s Syndrome

Duodenal Atresia

Double Bubble

Bilious vomiting/aspirates

Mild upper abdominal

distension

Antenatal H/O of

Polyhydramnios

D/D: Jejunal Atresia

Triple Bubble

CASE

• Bilious vomiting/aspirates

• Progressive abdominal

distension

Multiple air fluid level

Ileal Atresia

• Ileal atresia

• NEC

• Total colonic

aganglionosis

• Meconium Ileus

D/D

CASE

Colonic Atresia

CASE

Intestinal Atresia

CASE

• Abdominal distension

from birth

• Antenatal scan: Echogenic

and dilated bowel

• X-ray

Abdominal distension since birth

Meconium ileus

Meconium peritonitis/ascites

Abdominal lump

Ascites

Meconium Ileus

• Gastrograffin enema

Exploration

CASE

Term male Newborn

Antenatal scan s/o

echogenic bowel

Bilious aspirates &

not passed meconium

Abdominal distension

since birth

Meconium Peritonitis

Ano-Rectal Malformation

Vestibular Fistula Anteriorly placed anus

Bucket Handle deformity

Anocutaneous Fistula

Ano-Rectal Malformation

Perineal Examination

Fistula

Anoplasty or Pull through after 3mths

No Fistula

24 hrs

Cross table Xray

Colostomy

Pull through after 3 months

Aganglionosis can extend to variable distance

• Short segment – Classical

Rectosigmoid (60-70%)

• Long Segment (15-20%)

• Total colonic

aganglionosis (5-10%)

• Ultrashort segment

Hirschsprung’s Disease

Presentation

• Characteristically disease of full term newborn

• History of constipation dating back to newborn

period

• 95% of newborns defecate in first 24 hrs

of life

• Abdominal distension

• Poor feeding

• Failure to thrive

Investigations

• Barium Enema

• Rectal Biopsy

Definitive Pull through

for Hirschsprung’s Disease

• Single stage at age 3-6 months

• Two stage at 6-12 months after

colostomy

Primary Laparoscopic Assisted

Pull through

Respiratory Distress

• Day 1, Term 39 wks,

delivered in Sonepat

• Antenatal scan:

Polyhydramnios

• Respiratory distress

• Intubated and transferred

in BLK

A new born with

respiratory distress

CONGENITAL DIAPHRAGMATIC HERNIA

Congenital Diaphragmatic Hernia

Minimal Barotrauma • Conventional Ventilation • High frequency ventilation • ECMO

Cardio-Pulmonary Stabilisation

(Pulmonary Hypoplasia + Hypertension)

Invasive & Noninvasive monitoring

Day 1

• Respiraory acidosis (Ph 7.26/PO2 118/Pco2 47/Hco3 20.1)

• Assisted control ventilation

– Fio2 100%

– PIP/PEEP: 15/5

• Dopamine and Adrenaline (Mean 50mm Hg)

• Cardiac Echo: Mild Pulmonary Hypertension

Day 2

• One episode of desaturation

• Respiratory acidosis

• Shifted on HFO

MAP 14

Fio2 100%

Delta P 30

• Stable

Day 3

• Desaturated

• Rt Pneumothorax- Drained

• Stable

Day 4(CDH Repair)

Post Operative Course

• Stable on ventilator (PSV)

• Had collpase/ consolidation of Rt Lung….managed conservatively

• Extubated on POD 9

• Discharged on POD 13

• Asymptomatic now at 3 months

A new born with respiratory distress

Cystic adenomatoid malformation

Air filled cystic spaces: Congenital Cystic Adenomatoid Malformation

Respiratory distress

CONGENITAL LOBAR EMPHYSEMA

CDH CCAM Pneumatocoel

pneumothorax

CLE CLE