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Neonatal Surgical Issues (Part 1)

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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 ... – PowerPoint PPT presentation

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Title: Neonatal Surgical Issues (Part 1)


1
Neonatal Surgical Issues(Part 1)
  • Sue Ann Smith, MD
  • Neonatologist

2
An anatomic survey
  • Head and Neck lesions
  • Chest lesions
  • Abdomen
  • Abdominal wall defects and infection

3
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

4
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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6
The Unusual
  • Laryngotracheal clefts
  • Laryngeal webs
  • Tracheal agenesis frequently lethal
  • Neck masses
  • Foregut duplication cyst
  • lymphangioma

7
Normal Larynx
Laryngeal Web
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10
Congenital Chest Lesions
  • Tracheo-esophageal fistula
  • Diaphragmatic Hernia (briefly)
  • Congenital lobar emphysema
  • Cystic adenomatoid malformation
  • Vascular rings

11
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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13
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.

14
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.

15
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

16
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

17
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

18
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

21
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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23
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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27
The Abdomen
  • Abdominal wall
  • defects
  • infection
  • Bowel
  • Obstructions

28
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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30
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

31
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

32
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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35
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

36
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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40
Normal Larynx (upside down)
Laryngeal Web (also upside down)
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