Neonatal Surgical Issues
(Part 1)
Sue Ann Smith, MD
Neonatologist
An anatomic survey
Head and Neck lesions
 Chest lesions
 Abdomen
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Abdominal wall defects and infection
The Nose
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Choanal atresia – bilateral atresia
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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
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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
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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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The Unusual
Laryngotracheal clefts
 Laryngeal webs
 Tracheal agenesis – frequently lethal
 Neck masses
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Foregut duplication cyst
 lymphangioma
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Normal Larynx
Laryngeal Web
Congenital Chest Lesions
Tracheo-esophageal fistula
 Diaphragmatic Hernia (briefly)
 Congenital lobar emphysema
 Cystic adenomatoid malformation
 Vascular rings
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Tracheo-Esophageal Fistula (TEF)
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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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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.
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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.
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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
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Other “TEFs”
Esophageal atresia without TEF – very rare
 H-Type TEF-also rare.
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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
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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
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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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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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The Abdomen
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Abdominal wall
defects
 infection
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Bowel
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Obstructions
Gastroschisis
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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
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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
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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
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“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
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Normal Larynx (upside down)
Laryngeal Web (also upside down)