Premature Infant & Neonatal Surgery

Overview

Neonates who are premature or extremely unwell may require surgery soon after birth to correct congenital malformations or anomalies. Neonatal surgery is done on newborns shortly after birth. It is often used to treat diseases that cannot be detected or treated while the baby is still in the womb. It may also be used to address problems that arise shortly after delivery. Premature babies frequently require neonatal surgery to fix developmental abnormalities.

Depending on the problem being treated, there are several types of fetal and neonatal operations. These procedures range from minimally invasive laparoscopic to more invasive open surgical approaches.

The conditions that are found in pregnancy scans are often a result of a baby not developing properly. For example, exomphalos is one of the conditions that is operated on by neonatal surgeons. This condition is caused by the incorrect development of the tummy wall, causing the bowel to remain on the outside of the baby’s body. Again, the severity of this can range from minor to complex.

Another condition usually treated by neonatal surgery is gastroschisis, which occurs when a hole develops in the belly wall near to the umbilical cord, enabling the intestines to float freely in the amniotic fluid and come into touch with the baby's pee and feces, causing irritation. Hence, surgery is needed to ensure the bowel is returned to the abdominal cavity and the hole closed.

Preoperative Care of the Neonate

On admission, the preoperative surgical neonate is given a thorough history and physical examination. It is critical to pay attention to airway, respiratory, cardiac, and renal problems that may affect surgery. A complete blood count with differential, a basic metabolic panel, coagulation investigations, and cross match blood screening should all be performed prior to surgery.

Preoperative airway care includes determining the necessity for intubation and mechanical ventilation, as well as using chest radiography to check endotracheal tube location, measure lung volumes, and evaluate cardiomegaly. Endotracheal intubation is frequently done by the newborn critical care physician, however pediatric anesthesia may prefer this role at times; hence, communication is essential.

Other preoperative objectives include improving breathing and oxygenation, correcting aberrant electrolytes and pH levels, and providing appropriate perfusion. Preoperative lab tests should alert doctors to anemia and thrombocytopenia, which should be rectified with a newborn hematocrit of 30-35% and platelet count more than 100,000. Prior to surgery, coagulation tests should be normalized using fresh frozen plasma and cryoprecipitate as needed. Consider vitamin K supplementation in situations of liver impairment. If sepsis is suspected, consider and treat disseminated intravascular coagulation. If sepsis is suspected, surgery should be postponed.

Prior to surgery, adequate intravenous access is required. The requirement for a central venous line should be identified and discussed in advance with the anesthesiologist and pediatric surgeon. If percutaneous central venous line insertion fails, a surgical central venous line may be required. The kind of operation, estimated recovery period, and anticipated length of time to restore bowel function should all be considered when deciding the necessity for central line placement. If the neonate is projected to be nil per os (NPO) for more than 2 - 5 days and cannot tolerate enough enteral volumes for proper nutrition, central line access should be investigated.

The disease process, surgery, and kind of therapy all influence the choice of intravenous fluid replacement. Maintenance fluids and, if required, fluid and electrolyte replacement to address deficiencies and for surgical circumstances with predicted fluid loss should be included in intravenous fluids. When compared to muscle mass and fat, newborns have an excess of total body water. Extracellular fluid levels are higher in premature infants. After delivery, there is a fluid shift from the extracellular compartment, resulting in salt and water diuresis within 48 to 72 hours and physiological weight loss throughout the first week of life.

Inadequate diuresis is linked to an increased risk of morbidities such as pulmonary edema, tissue edema, symptomatic patent ductus arteriosus, necrotizing enterocolitis (NEC), and chronic lung disease. Because of their poor cardiac contractility, newborns are especially susceptible to hypovolemia. Maintenance fluid replacement should allow for a loss of extracellular fluid diuresis throughout the first week of life while maintaining normal intravascular volume and tonicity as measured by heart rate, urine output, electrolytes, and acid/base status.

When Neonatal Surgery is Indicated?

Neonatal surgery is used to treat many different neonatal conditions, such as the following:

Abdominal Wall Defects

Organs such as the stomach and intestines grow outside the abdomen during the early stages of normal fetal development. The organs within the abdomen move as a fetus grows. Sometimes the abdomen may not completely close around these organs. This is referred to as an abdominal wall defect.

Two of the most common forms of abdominal wall defects are addressed below:

• Gastroschisis. Gastroschisis occurs when the organs protrude through a hole near the belly button. In severe cases, the liver may also push outside the body.
• Omphalocele. In omphalocele, the organs also protrude through the belly button. A thin membrane or sac covers the organs. Usually, babies born with omphalocele also have additional genetic abnormalities or conditions.

Management

After the baby is born, the exposed intestines are covered with a sterile bandage to keep them wet and protected, and fluids and antibiotics are administered by vein. To drain digestive fluid that accumulates in the stomach, a long, thin tube is introduced through the nose and implanted in the stomach or intestine (nasogastric tube).

To replace the intestines in the abdomen and repair the hole, surgery is necessary. Surgery to fix the defect is performed as soon as possible after delivery, if possible. However, the skin of the abdominal wall is frequently stretched for a few days before surgery to ensure that adequate tissue is present to cover the incision. 

To fix a large defect, physicians may need to generate skin flaps. If there is a substantial piece of intestine protruding from the belly, it is wrapped in a protective covering (called a silo) and gradually pushed back into the abdomen over several days or weeks. The hole is surgically closed after all of the intestines have returned to the abdomen.

Bowel Atresia

Babies born with bowel atresia have an intestinal obstruction. Fetal imaging is frequently used to diagnose this problem before delivery. Babies with intestinal obstructions may require surgery soon after birth.

The infant was stabilized before to surgery by inserting a nasogastric (NG) tube through the nose. To keep the stomach empty, this tube utilizes mild suction. Intravenous (IV) lines are also used to ensure that neonates receive nutrients and keep hydrated.

Management

Treatment for intestinal atresia include removing the obstruction (atresia) and repairing the affected portion of the intestine. The procedure is not an emergency and is usually performed when the infant is two or three days old.

The kind of your baby's operation will be determined by the individual problems in his or her intestine. In most cases, the atresia is removed and the intestine is repaired by stitching the two ends together.

The procedure is performed under general anesthesia. Your kid will then be returned to the NICU. Your infant may require a breathing machine (ventilator) for many days.

Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) occurs when a baby is born with a hole in the diaphragm (the horizontal muscle that separates the chest from the abdomen). When this muscle is stretched, the stomach and intestines might shift towards the chest, affecting lung function and development.

Babies with CDH may require assistance with breathing, blood pressure, and cardiac support, including extracorporeal membrane oxygenation (ECMO). The surgeons may potentially do surgery just after your kid is born.

Management

Repairing a diaphragmatic hernia after delivery is not an emergency procedure and is normally performed once the infant has stabilized in the first week of life. Following repair, these kids will require intense care for several weeks, if not months.

The surgeon evaluates the severity and specific location of the hernia during the procedure. The hernia will be corrected in one of three methods based on these results. If the opening in the diaphragm is tiny and there is enough diaphragmatic muscle, the hole can be sewed up. This is known as an initial repair.

If the diaphragm opening is big or a major section of the diaphragm is missing, the surgeon will need to use more tissue or material to fix the hole. Patch repairs are frequently performed with a synthetic biocompatible substance.

In other cases, the surgeon will seal the diaphragm hole using a muscle flap—the internal oblique or latissimus dorsi from the infant's abdomen/back. This is known as a muscle flap repair. Infants may be candidates for a minimally invasive thoracoscopic repair in certain conditions. At the time of the procedure, the surgeon will determine the sort of repair needed and the material to be utilized.

Esophageal Atresia

Esophageal atresia (EA) is a disorder that affects the swallowing tube of a newborn (esophagus). The esophagus helps food flow from the mouth to the stomach. Part of the swallowing tube does not form normally in esophageal atresia. Babies with the disease may have difficulty breathing and cannot transfer food to their stomach.

Management

Because esophageal atresia can be fatal, the infant must be treated as soon as possible. In newborns with this problem, doctors conduct surgery to connect the esophagus to the stomach.

Babies that are otherwise healthy have surgery just a few days after birth. Babies who have additional health conditions or disabilities at birth may need to wait for esophageal atresia surgery. If your baby needs to wait for surgery, they will be fed through an IV (a thin tube put into a vein) until the procedure is performed.

Tracheoesophageal Fistula

Tracheoesophageal fistula (TEF) is an abnormal connection between the esophagus and trachea. Babies with TEF can still swallow, but food or breastmilk may leak through the fistula into their lungs. The hole must be closed so that the baby can eat normally.

Management

Surgeons have found extremely effective treatments for TEF and recurrent TEF that do not result in additional recurrence. If your infant develops TEF without esophageal atresia (EA), doctors can typically fix it with a single quick procedure during the first day or two of life. This technique has also been helpful for children who have recurrent TEF. To guarantee the greatest possible outcome, the technique is tailored to your kid. Your child's doctor will do the following during this surgery:

1. Make a small incision in your child's neck or back, depending on the location of the TEF.
2. Divide the fistula, closing the connection between the esophagus and the trachea.
3. Remove the pouch from the back of the trachea where the TEF originated. This is done with bronchoscopy guidance, so that the surgeons can see the repair from the inside of the airway.
4. Repair the hole in the esophagus, which is often necessary to correct an area of narrowing in the esophagus that may be present.
5. Correct tracheaomalacia, if present, with a posterior tracheopexy. This is done with bronchoscopy to ensure a good result.
6. Rotate the esophagus away from the trachea so the TEF does not come back.

If your baby has TEF and EA, our doctors will take the same procedure as described above and then join the two ends of the esophagus, if they are near enough. If this is not possible, our surgeons will examine the best ways to lengthen the esophagus enough to allow for the repair. If your child has TEF and long-gap EA, which means that the two detached ends of the esophagus are far apart, they will need to undergo a procedure known as the Foker process. 

Hirschsprung’s disease

Hirschsprung's disease is an uncommon disorder in which poop becomes lodged in the bowels. It primarily affects infants and young children.

The colon normally squeezes and relaxes repeatedly to push feces forward, a process controlled by your neurological system.

The nerves that govern this movement are absent from a region at the end of the intestine in Hirschsprung's disease, allowing feces to pile up and cause a blockage.

If not recognized and treated promptly, this can cause severe constipation and, in rare cases, a dangerous bowel infection known as enterocolitis.

However, the issue is typically detected shortly after birth and corrected as soon as possible with surgery.

Symptoms of Hirschsprung's disease are usually noticeable from soon after a baby is born, although occasionally they're not obvious until a child is a year or two old.

Management

Hirschsprung's disease is usually treated with surgery to bypass or eliminate the section of the colon that lacks nerve cells. There are two options for doing this: a pull-through surgery or an ostomy operation.

Pull-through surgery

The lining of the diseased section of the colon is removed during this treatment. The regular part is then withdrawn from the interior of the colon and connected to the anus. This is normally accomplished through the anus utilizing minimally invasive (laparoscopic) techniques.

Ostomy surgery

In children who are very ill, surgery might be done in two steps.

First, the aberrant piece of the colon is removed, and the upper, healthy portion of the colon is attached to a hole in the child's belly made by the surgeon. Stool subsequently exits the body through the opening into a bag that is attached to the end of the intestine that protrudes through the abdominal hole (stoma). This gives the bottom section of the colon time to recover.

Anorectal malformations

Anorectal malformations are congenital deformities of the anus or rectum of a newborn that interfere with regular stool passage. The condition is known as imperforate anus when the anus is fully occluded.

The anus in children with anorectal abnormalities may be absent, occluded by a thin or thick layer of tissue, or narrower than usual. The anus may be normal while the rectum is blocked or narrowed in rare circumstances.

Many infants with anorectal abnormalities have a fistula, or abnormal route, from the rectum to another region of the body, such as the perineum, or the skin between the anus and the sex organs, urethra, bladder, or vagina.

In some children with anorectal malformations, the rectum and the urinary tract have the same opening. This abnormality is called a cloaca.

Management

1. Pull-through procedure. This procedure is known as posterior sagittal anorectoplasty (PSARP), sometimes known as the Pea Procedure. During this procedure, your baby's rectum will be relocated and an anal opening will be established. This operation is performed under general anesthesia on full-term, healthy newborns in their first days of life. A few weeks following surgery, your doctor will advise you to do anal dilations, an after-care technique designed to prevent the new opening from constricting or scarring closed.
2. Colostomy. In rare circumstances, a colostomy may be required before to the pull-through surgery. It is frequently performed if your baby is small, premature, has other medical issues, or has a complicated anorectal malformation. A colostomy is a surgical surgery that redirects the large intestine to an abdominal orifice. A colostomy is often just temporary and will be removed. It does not impair your child's ability to eat or defecate; rather, it permits your youngster to feed and develop before undergoing corrective surgery later. The nursing staff and other health care experts who work with your child's surgeon are available to assist you in learning how to care for your child's colostomy.

Postoperative Care of the Neonate

Face-to-face contact between the senior physician caring for the newborn following surgery, the surgeon, and the anesthesiologist should begin with postoperative treatment. The neonatologist should be informed of any major events that occurred during the surgery, the type of surgery performed, the anesthesia the neonate received during the surgery and in recovery (especially if paralytic agents were used), and the volume and type of fluids or blood products given during the operation.

In the postoperative phase, temperature homeostasis is critical. Neonates having surgical operations in the operating room are more vulnerable to thermal instability. Postoperative neonatal hypothermia increases the incidence of unfavorable respiratory outcomes, including the requirement for respiratory and cardiac treatments, as compared to normothermic neonates. Hypothermia can also cause protein catabolism, hypokalemia, and changes in glucose metabolism. Warm temperature regulating blankets, reducing skin exposure, and warming operating rooms are all postoperative therapies.

Immediate postoperative labs should include hemoglobin/hematocrit measurements. If blood loss exceeds 15% and has not previously been restored during surgery, doctors should consider replacing with packed red blood cells. Electrolytes should be examined immediately after surgery and monitored every 6 hours for invasive procedures and every 8-12 hours for less invasive procedures for the first 24 hours.

If there is no arterial line access, blood pressure should be checked at least every hour. Until demonstrated differently, hypotension in the postoperative phase is considered an indication of hypovolemia. Skin perfusion should be monitored, which can be accomplished via NIRS or the perfusion index of pulse oximetry. Postoperatively, all tubes and drains should be routinely examined for patency, function, and how securely they are linked to the patient. Sumps, chest tubes, wound drains, and Foley catheters should all be monitored. To avoid infection with chronic foreign bodies, both the ileus and the improvement in outputs should be eliminated as soon as possible.

Prevention of infection is important. White blood cell count, C-reactive protein trend and bandemia should be monitored and blood cultures obtained if concern for infection rises. Be especially cautious of hygienic precautions when handling tubes, drains and any wound dressing changes. The need for postoperative antibiotic coverage should be discussed between the neonatal clinician and surgeon.

Conclusion

Neonatal surgery includes a spectrum of surgical procedures performed on newborn babies. Newborn babies will require surgery if the condition is life-threatening; however, some disorders that are operated on are very minor issues.

Some of these issues will have been found in regular scans prior to delivery, while others may not be recognized until after birth or will develop in the weeks after birth.