Neonatal Surgical Emergencies
R.H. Overbaugh M.D.
Abdominal Wall Defects
• Omphalocele
– def: Abnormal development of gut prior to 3rd wk of gestation, preventing later return of midgut into abdominal cavity Incidence: 1/4000-6000 Types: 1.Epigastric 2.Hypogastric 3.Classic
• Classic Omphalocele: Avascular sac composed of fused layers of amnion and peritoneum • Sac Contents: liver, spleen, small intestine • umbilical cord inserted into apex of sac • Diagnosis: Antenatal Ultrasound • Obstetric Management: Elective C-section
Preoperative Management
– Nasogastic decompression – Airway protection, intubation immediately after delivery – Iv fluid recussitation, with potential for massive 3rd space and evaporative loss – Protection of “intact” sac: warm saline soaked dressing to prevent heat and fluid loss
Operative Management
• One stage repair vs. Silo formation (staged) • Anesthetic management
– – – – Awake intubation after NG decomp. Must ensure adequate abdominal relaxation avoid nitrous aggressive volume replacement with balanced salt or albumin
Anesthetic Management
• One stage Closure: may cause severe dec in pulmonary compliance.
– Abdominal compartment syndrome – decreed lower extremity blood flow – Post op intubation with gradual vent wean
Associated Abnormalities
• Cardiac:
– – – – TOF 33% ASD 19% Rarely, VSD, PS,Coarctation, PDA Genetic Abnormalities
• Trisomy 21, 18, 13 • Beckwith-Wiedemann • Turner’s
Associated Cond.
• Diaphragmatic Hernia • Bladder anolmalties
Gastrochisis
• Cause: occurs from interruption of omphalomesenteric artery • located toward right of umbilicus • lacs protective membrane/Sac • 15% of patients have concomitant malrotation or segemental atresia • Not associated with chromosomal Abnl.
Duodenal Atresia
• Definition: Interruption of the duodenal lumen by the diaphragm • Incidence: 1/5000 pregnancies • Onset 24-48hrs after birth • Diagnosis: Bile stained emesis after delivery, with severe abdominal distention • Radiographic: “Double Bubble” sign
Perioperative Management
• Immediate NG Decompression • Fluid and electrolyte replacement: Hypochloremic metabolic alkalosis • Awake intubation vs. RSI • Avoid Nitrous Oxide
Associated Anolmalties
• 20-30 % have trisomy 21 • Often associated with volvulus, malrotation, and abdominal wall defects • Increased incidence of cardiac abnormalities: ASD, VSD, AV canal.
Hypertrophic Pyloric Stenosis
• Definition: Hypertrophy of muscularis layer of gastric pyloris • Incidence: 1/500, male sex predominates, age 4-6 wks at initial presentation • Symptomology: Protracted, projectile vomiting. • Diagnosis: Palpable olive-shaped mass between midline and RUQ
Pyloric Stensosis
• Medical NOT Surgical Emergency !!! • Metabolic Derangement: Hypokalemic, Hypochloremic , metabolic alkalosis, hypocalcemia • Prerenal azotemia---- hypovolemic shock--metabolic acisosis
Treatment
• Preoperative: volume resuscitation, and electrolyte replacement. • Surgical Management: Pyloromyotomy • Anesthetic Management:
– Orogastric decompression in lateral position with lg bore OG tube-red robin catheter. – Rapid Sequence Induction and Intubation (No Mask Induction) – Extubate when fully awake