Neonatal Surgery Dr. Ehab M.

Oraby

Contents
Neonatal Surgery .......................................................................................................................................... 2
II- Golden Rules ................................................................................................................................. 8
Esophageal atresia ...................................................................................................................................... 10
CHPS ............................................................................................................................................................ 13
Intestinal Atresia ......................................................................................................................................... 15
Malrotation & Midgut Volvulus .................................................................................................................. 16
Meconium ileus........................................................................................................................................... 17
Necrotizing Enterocolitis ............................................................................................................................. 18
Hirshsprung’s Disease ................................................................................................................................. 19

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Neonatal Surgery Dr. Ehab M. Oraby

Neonatal Surgery
By: Dr. Ehab M. Oraby
I- Surgical Examination of Neonates:

a. Fontanelles: Open or closed

Normally fontanelle diameter 3

fingers at birth, 2 fingers at 6
months, one finger at 1 year old, and
closed after 18 months old.

b. Eye:

a Hypertelorism: increased distance between both eyes.

b Coloboma

c Epicanthus

c. Mouth: Cleft lip, Cleft palate, Micrognathia, Macroglossia

d. Neck: Web, Cystic hygroma

e. Chest: Pectus excavatum, Pigeon chest

f. Abdomen: Umbilical hernia, Exomphalos major, exomphalos minor,

Prune belly syndrome, Inguinal hernia

g. Genitalia: Hypospadias, Undescended testis

h. Anus: Imperforate anus

i. Limbs: Genu varus, Genu vulgus

j. Back spines: Spina bifida, Meningocele, Scoliosis

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II- Golden Rules

a. Neonatal Cyanosis

i. cardiac ii. Pulmonary

iii. Diaphragmatic hernia

iv. Esophageal atresia

b. Neonatal Frothy saliva: Considered esophageal atresia until prove otherwise

c. Baby with persistent bilious vomiting: is considered Intestinal Obstruction until

prove otherwise.

d. Intestinal Obstruction presentation:

i. Vomiting ii.

Visible peristalsis iii.

Colic iv.

Constipation

v. Distension vi.

Dehydration

e. Approach to Vomiting:

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Esophageal atresia

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Neonatal Surgery Dr. Ehab M. Oraby

Varieties of anomalies

a. Pure esophageal atresia

b. Esophageal atresia with proximal trachea-esophageal fistula
c. Esophageal atresia with distal trachea-esophageal fistula (the
commonest)
d. Esophageal atresia with proximal & distal trachea-esophageal
fistula
e. Only trachea-esophageal fistula

N.B) Esophageal atresia: is a member of VACTERL syndrome:

V: Vertebral
A: Anus
C: Cardiac
T: Trachea
E: Esophagus
R: Renal
L: Limbs

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Neonatal Surgery Dr. Ehab M. Oraby

• Presentation:

➢ Antenatal:

 Polyhydraminos ➢ Dilated esophageal pouch

➢ At birth:

 Atresia→ frothy saliva

 No fistula→ scaphoid abdomen

 Fistula→ chocking, cyanosis, pneumonia and abdominal distension.

 Distal fistula→ acid pneumonia

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Neonatal Surgery Dr. Ehab M. Oraby

CHPS
(Congenital hypertrophic pyloric stenosis)

Incidence:
• 8:1000

• M/F= 4/1

• More in first born male baby

• After Erythromycin Presentation:

• Age: 3-6 weeks

• Persistent non bilious vomiting

• After vomiting→ Voracious appetite

• No fever

• Dehydrated

• Visible epigastric peristalsis

• Palpable pylorus “olive nodule”.

Treatment:
➢ Pyloromyotomy operation.

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Neonatal Surgery Dr. Ehab M. Oraby

Duodenal Obstruction
• Anomalies:
o Atresia
o Stenosis
o Web
o Annular Pancreas
o Duplication cyst

Presentation:
• Vomiting “ Bilious or Non-Bilious”
• X-Ray: double bubble
• DD: malrotation and midgut volvulus → ill baby with tender abdomen
• Other anomalies → Down syndrome, cardiac anomalies.
• Treatment: Bypass operation “bypass the obstruction”.

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Neonatal Surgery Dr. Ehab M. Oraby

Intestinal Atresia
• Incidence:
o 1/2000 – 1/5000 live birth.
o Male = female.
o At any point of intestine.
• Cause: In-utero mesenteric vascular
accident.

• Presentation
o Bilious vomiting with
progressive distension.
• X-Ray: bowel distension + air-fluid level.
• Contrast enema → microcolon

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Neonatal Surgery Dr. Ehab M. Oraby

Malrotation & Midgut Volvulus

Anomaly:
• Cecum at epigastrium.

• Peritoneal band between cecum and lateral abdominal wall “Ladd’s band” obstructing
duodenum.

• Narrow mesenteric pedicle → Volvulus

Treatment:

1- Cutting Ladd’s 2- Cutting other 3- Cecum in left iliac fossa

band adhesions +
appendectomy

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Neonatal Surgery Dr. Ehab M. Oraby

Meconium ileus

➢ Viscid meconium → Failure to pass meconium:

→ Intestinal obstruction

→ persistent bilious vomiting

→ distension Management:

• Non-Complicated:

o Enema with water soluble contrast → success if contrast pass to terminal

ileum.

• Complicated:

o Exploration.

o Enterotomy.

o Irrigation and wash of meconium.

o Then closure or temporary ileostomy.

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Necrotizing Enterocolitis

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Hirshsprung’s Disease
Embryology:

• Neural crest cells are precursors of intestinal ganglia cells.

• Migration of neural crest cells occur from cephalad to caudad.

• Migration from mid transverse colon to anus take more prolonged time →
more vulnerable to migration defects.

• Migration occurs under control of certain genes (RET receptor gene)

Presentation:
→ Classic early presentation (Neonatal presentation):
• Failure to pass meconium within 48 hours
• Distension, bilious vomiting ± enterocolitis (toxicity + tender abdomen).
• PR: foul propulsion, foul odour liquid stool.
→Late presentation (20%):
• Beyond neonatal period.
• Constipation & Long history of laxatives and enemas
• Chronic distension.
• F.T.T.

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Neonatal Surgery Dr. Ehab M. Oraby

Diagnosis:
• Barium enema: contrast enema
in non-prepared colon, heavily
loaded with stool to clearly
demonstrate the diagnostic
transitional zone. Distally
stenotic segment, proximal
dilated segment, and transitional
zone in between.
• Biopsy: full thickness biopsy to
detect absence of ganglia.
• Manometric study.

Treatment:
Principle: Resection of aganglionic segment and re-anastomosis
Operation:
Soave operation,
Swenson operation
or Duhamel operation

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