Neonatal Surgical Issues
(Part 2)
Sue Ann Smith, MD
Neonatologist
Anatomic survey (cont)
Intestinal obstructions
 Genitourinary
 Abdominal masses
 Inguinal hernia
 Testicular torsion
 Neurosurgical

Intestinal obstructions
Atresias – duodenal, jejunal, colonic
 Meconium ileus
 Meconium plug
 Hirschsprung’s disease
 Imperforate anus
 Malrotation with volvulus
 Adhesions and strictures

Atresias
High obstruction of jejunal atresia
Double bubble of duodenal atresia
Atresias (cont)

Duodenal atresia associated with trisomy
21, or other anomalies
Hx of polyhydramnios
 Delee more than 30-50ml from stomach

Jejunal atresia is rarely associated with
other anomalies.
 Decompress proximal bowel with repogle
tube to low continuous suction

Meconium Ileus
Obstruction of bowel by thick tenacious
meconium
 30% of intestinal obstruction in neonates
 Frequent cause of meconium peritonitis
 Most are associated with cystic fibrosis
(but only 15% of infants with CF will have
meconium ileus)
 Abdominal distention is typically present at
birth

Meconium Ileus (cont)
Diagnosis made with contrast enema
 Gastrograffin enema with aggressive
hydration can be used to treat some
 Operative evacuation of meconium
 May require ostomy
 Proximal bowel dilated and distal bowel
may be very small (microcolon) and
require time to dilate with use

Meconium plug
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Difference between meconium ileus and
meconium plug is site and severity of obstruction
Preterm infants, infants of diabetic mothers,
IUGR babies, otherwise ill babies
Treatment with glycerin suppositories and warm
saline enemas
May require contrast enema to make diagnosis
Normal stooling pattern should follow evacuation
of plug
Meconium plugs
Hirschsprung’s Disease
Colonic agangliosis
 Extent can vary from very short segment
of rectal tissue to entire colon
 Should be considered in any baby who
does not pass stool spontaneously by 24
hours of age.
 Diagnosis by rectal biopsy to look for
ganglion cells

Hirschsprung’s Disease (cont)
Barium enema can show transition zone
 Short segment disease can be treated with
rectal irrigations followed by primary pull
through procedure
 Longer segment disease requires ostomy
followed by pull through when older
(months usually).

Imperforate Anus
May pass meconium if a rectovaginal or
rectourinary fistula exists.
 Low imperforate anus: the rectum has
descended through the puborectalis sling
and exists as a fistula on the perineum.

May see mec on the perineum, may be seen
in the rugal folds or scrotum of males and
vagina of females.
 These fistula may be dilated to temporarily
relieve obstruction

Imperforate Anus (cont)
High imperforate anus: rectum ends above
the puborectalis sling.
 No perineal fistula, but may have urinary
fistula
 Temporary colostomy is necessary in all
babies with high imperforate anus.

Malrotation with volvulus
Can occur in the fetus – large calcified
shadow in midabdomen on x-ray
 Sudden onset of bilious emesis in infant –
requires rule out
 Signs of shock and sepsis can be present
 Surgical emergency since intestinal
viability is at stake.
 UGI to evaluate for position of ligament of
Treitz

Malrotation
Volvulus
Adhesions and strictures
Can occur following any abdominal
surgical manipulation.
 Can occur following NEC even if initial
disease process required only medical
treatment.

Necrotizing Enterocolitis
This is a whole lecture unto itself
 Incidence varies from center to center and
from year to year within centers


2-5% of all NICU admissions and 5-10% of
VLBW infants
Prematurity is greatest risk factor
 Mortality is 9-28% regardless of medical or
surgical intervention

NEC (cont)

To be continued in future lecture……..?
Genitourinary
Posterior urethral valves
 Extrophy of the bladder
 Cloacal extrophy

Posterior Urethral Valves
Obstruction of urinary flow at level of
bladder outlet
 Exclusively in males
 May lead to oligohydramnios and
pulmonary hypoplasia
 May lead to destruction of renal
parenchyma
 Symptomatology can sometimes be mild

VCUG in pt with
Posterior Urethral
Valves
Posterior Urethral Valves
Place urinary catheter to drain bladder
 Obtain VCUG to confirm diagnosis
 Urologist to ablate valves – usually with a
transurethral approach
 Assess renal function – urine output,
electrolytes, BUN, creatinine
 Bladder may be dysfunctional
 Some will be OK in neonatal period and go
on to “outgrow” their renal function

Extrophy of the Bladder
May range from epispadias to complete
extrusion of bladder on to abdominal wall
 Initial surgical repair is most critical for
best functional outcome
 Apply sterile saline and lay saran wrap on
top of exposed bladder, but keep any
irritants away (no gauze, etc)

Extrophy of bladder
2:1 male to female ratio
 Symphysis pubis is widely separated
 Is a very complicated and prolonged repair
requiring urologist and orthopedist to work
together
 Patient immobilized for a week or more
post-op
 Phallic reconstruction may be done in later
operation

Cloacal Extrophy
More complex than simple bladder
extrophy
 May include: vesico-intestinal fissure,
omphalocele, extrophied bladder,
hypoplastic colon, imperforate anus,
absence of vagina in female, and
microphallus in males.
 Series of complex operations needed

Abdominal masses
Renal masses
 Ovarian cyst
 Tumors
 Adrenal hemorrhage
 Hydrometrocolpos

Renal Masses
Polycystic kidneys
 Multicystic dysplastic kidneys
 Renal duplications
 Hydronephrosis

Ovarian Cyst
One of the most common abdominal
masses in female fetus and newborn
 May cause torsion and necrosis of ovary
 Surgical resection if >4cm diameter or
persistent

Tumors

Teratomas are most common.
Sacrococcygeal
 About 10% contain a malignant element

Neuroblastoma – 50% of malignant tumors
in neonates. Can resolve spontaneously.
 Wilm’s tumor
 Sarcoma botryoides – grapelike tumor
arises from edge of vulva or vagina.

Sacrococcygeal teratoma
Sarcoma Botryoides
Hydrometrocolpos
Imperforate hymen (or other vaginal
obstruction) with back up of secretions in
the uterus, which can cause intestinal
obstruction
 Hymen will bulge
 May have edema and cyanosis of the legs
 May cause hydronephrosis

Inguinal Hernia
Frequent in preterm babies, male>female
 Usually repair prior to discharge if possible
 Monitor for incarceration

Incarcerated hernia can usually be reduced
with sedation and steady firm pressure
 Even if reduced, should be repaired as soon
as edema is resolved

Testicular Torsion
70% occur in fetal life
 Testes is tender, firm, swollen with a slightly
bluish cast to the scrotum on affected side
 Differential dx includes scrotal hematoma
 US with doppler flow can be useful
 Any possibility of recent torsion – surgery
within 4-6 hrs
 Orchiopexy of contralateral side

Neurosurgical
Myelomeningocele
 Hydrocephalus
 Intracranial hematoma

Myelomeningocele
Saccular outpouching of neural elements
through defect in bone and soft tissues in
posterior thoracic, sacral and/or lumbar
regions (lumbar 80%)
 Most common primary neural tube defect
 Hydrocephalus in 84%
 Arnold-Chiari II malformation in 90%
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The Chiari II malformation is a complex
congenital malformation of the brain,
nearly always associated with
myelomeningocele. This condition
includes downward displacement of the
medulla, fourth ventricle, and cerebellum
into the cervical spinal canal, as well as
elongation of the pons and fourth ventricle,
probably due to a relatively small posterior
fossa.
Chiari II malformation. Sagittal T1-weighted MRI of posterior fossa abnormalities in
Chiari II malformation: (1) colpocephaly; (2) beaked tectum; (3) cascade of an inferiorly
displaced vermis behind the medulla; (4) elongated tubelike fourth ventricle; (5) low-lying
torcular herophili; (6) cerebellar hemispheres wrapping around the brainstem anteriorly;
(7) concave clivus; (8) medullary spur; and (9) medullary kink.
Hydrocephalus
Associated with MM
 Aqueductal Stenosis – male with X-linked
 Post-hemmorhagic – most frequent in
premature population
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