Neonatal Surgical Issues

(Part 1)

Sue Ann Smith, MD

Neonatologist
 An anatomic survey
 Head and Neck lesions
 Chest lesions
 Abdomen
 Abdominal wall defects and infection
 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
 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
 The Unusual
 Laryngotracheal clefts
 Laryngeal webs
 Tracheal agenesis – frequently lethal
 Neck masses
 Foregut duplication cyst
 lymphangioma
Normal Larynx
Laryngeal Web
 Congenital Chest Lesions
 Tracheo-esophageal fistula
 Diaphragmatic Hernia (briefly)
 Congenital lobar emphysema
 Cystic adenomatoid malformation
 Vascular rings
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
 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.
 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.
 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
 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
 Congenital Diaphragmatic Hernia
(CDH)
 Most commonly on left side
 Incidence 1:2000 to 1:5000
 Often associated with other malformations
 Frequently diagnosed prenatally
 Avoid bag-mask PPV
 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
 Post-Op CDH
 “Anatomy is destiny”
 Survival continues to be around 40-50%.
 Feeding difficulties
 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
 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
 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
 The Abdomen
 Abdominal wall
 defects
 infection

 Bowel
 Obstructions
 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)
 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
 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
 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
 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
 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
Normal Larynx (upside down) Laryngeal Web (also upside down)