Newborn surgery Robert Macháček The main issues of newborn surgery are inflammatory illnesses, injuries, tumours and the most important congenital developmental defect by which suffer approximately ?% of all newborns. The main issues of newborn surgery are inflammatory illnesses, injuries, tumours and the most important congenital developmental defect by which suffer approximately 2% of all newborns. Dividing of newborn surgery •Newborn neurosurgery •Neck surgery •Thoracic surgery •Cardiac surgery •Abdomen chirurgy •Urinology •Musculoskeletal system surgery Classification of CDD •Simple abnormality • •Malformation (development of organ or tissue was stopped or was abnormally exerted – e.g. defect of atrial septum, cleft lip, …) •Disruption (external factor consequences – Cocaine – vascular supply of exerted structures supression – enteric atresia) •Deformation (mechanical entrapment of organ - pes equinovarus with oligohydramnion) •Dysplasia (abnormal cell organization to the tissues – multicystic renal dysplasia) • •Multiple anomaly • •Sequences (consequences of cascade of developmental changes activated by one anomaly or by mechanical entrapment – Pierre Robin Sequence – primarily, lower jaw anomaly leads to the lack of space for tongue development which expels cranially and gothic palate up to cleft palate is being created) •Syndrome (multiple malformation pathogenetically connected with one cause – e.g. Down´s syndrome chromosome aberration) •Association (nonrandom occurence of types of malformations which are not pathogenetically connected • - e.g. VACTERL association during omphalocele • Serious CDD - cardiovascular 1% - CNS 1% - GIT 0,4% - Limbs 0,2% - Urinogenital 0,4% Less serious 10% preauricular excrescence lacrimal canaliculus stenosis umbilical hernia hydrocele hollow in sacral area syndactyly of 2nd and 3rd toe supernumerary nipple … „You are not definitely healthy because the medicine is so advanced that there no longer exists a healthy human.“ Causes of CDD •Genetic 30-40% •Chromosomal •Disfuction of one gene •Multifactorial • •External environment influence 5-10% •Drugs and chemicals •Infection •Physical factors • •Unknown 50% C:\Users\Jirku\Pictures\prezentace\otazník.jpg C:\Users\Jirku\Pictures\prezentace\atomový výbuch.png C:\Users\Jirku\Pictures\prezentace\DNA.png CDD Prognosis •Depends on the type of the defect, not always estimated • •In general, at serious VVV is not encouraging • • 25% dies at the early infantile age • 25% proves after-mental or physical disability • 50% has acceptable or good prognosis during right therapy • • Anatomical differences (find 10 differences) Anatomical differences • • • • • uf… • • • • • • • • •Head – great, facial part to cerebral part 1:8, • floating sutures, fontanelle •Chest – without noticable sulcus, chest/abdomen crossing is not sensible, ball shape heart, thymus, more mediastinum in thoracic cavity •Abdonem – the biggest width in the liver level, great livers, canal gallbladder, higher position of caecum, large intestine dilated by meconium, larger adrenal gland, small omentum, musculature is not noticeable externally, transverse dermal sulcus in lower area, panniculus adiposus in pubic area • Limbs – relatively short • •Significantly smaller measurement •Delicate fragile tissue •Blood loss ! •Thermoregulation ! •Restricted options of vascular access •Small manipulative space • • •Special technical equipment in the workplace •Informed team of doctors and paramedical staff •Specific surgery technique •Specific postoperative care • We are having a baby it could happen to you as well We are having a baby it could happen to you as well C:\Users\82034\Pictures\těhotenský test.jpg We are having a baby it could happen to you as well C:\Users\82034\Pictures\vyděšená tvář.jpg We are having a baby it could happen to you as well C:\Users\82034\Pictures\svatba.jpg We are having a baby it could happen to you as well C:\Users\82034\Pictures\těhotná.jpg •Labour in 40 t.g., ph 3050/50cm •AS 8-9-10 •Postnatal adaptation in normal •4 cm defected abdominal wall, which prolapse skin livid intestinal villis clenched to solid adhesions •Suspicious eventration of fetus intestinal villis prenatally according to the US • • 20.t.g – US screening • C:\Users\82034\Pictures\sono omphalocele.png C:\Users\82034\Pictures\otazník.jpg Gastroschisis , omphalocele •Labour in 40 t.g., ph 3050/50cm •AS 8-9-10 •Postnatal adaptation in normal •4 cm defected abdominal wall, which prolapse skin livid intestinal villis clenched to solid adhesions •Suspicious eventration of fetus intestinal villis prenatally according to the US • 20.t.g – US screening • C:\Users\82034\Pictures\sono omphalocele.png •gastroschisis •Defected abdominal wall from funis (90%dx) •Changing intestinal wall (both anatomically and functionally) • • •omphalocele •Defected abdominal wall in umbilical cord area •30-70% + VACTERL •Anatomy and function of intestine in normal • • F:\Fotky\Zeman Jan 1.JPG F:\Fotky\P8011350.JPG Gastroschisis+omphalocele therapy •Loop reposition to the abdominal cavity and its closure •Small defects - primordial closure •Great defects with small abdominal cavity – often surgeries with progressive organ reposition • (due to abdominal compartment sy.) • •Conservative procedure with unstable newborns only – temporary hanged omphalocele bag packing with physiological saline after stabilized surgery state. Gastroschisis 1st stage • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2082411.JPG Gastroschisis 1st stage • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2082415.JPG Gastroschisis 2nd stage • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2142458.JPG Gastroschisis 2nd stage • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2142462.JPG Gastroschisis 3rd stage • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2192484.JPG Gastroschisis 3rd stage • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2192486.JPG Gastroschisis final state after two weeks • C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2082414.JPG C:\Users\82034\Desktop\Medici\Fotky\gastroschiza fotky Cetl\P2192487.JPG Omphalocele one time surgery • F:\Fotky\Zeman Jan 1.JPG F:\Fotky\Zeman Jan 3.JPG Gastroschisis one time surgery • F:\Fotky\P8011350.JPG F:\Fotky\P8011351.JPG We are having a baby it could happen to you as well C:\Users\82034\Pictures\těhotná.jpg • •Labour in 39tg, ph3500g/50 cm •AS 9,5,4 •Progressive poor breathlessness and cyanosis •Heavily breathless newborn after 15 minutes •Weak bilateral breathing •The state is getting worse after breathing with mask • C:\Users\82034\Pictures\Brániční kýla.png C:\Users\82034\Pictures\otazník.jpg Diaphragmatic hernia • •Labour in 39tg, ph3500g/50 cm •AS 9,5,4 •Progressive poor breathlessness and cyanosis •Heavily breathless newborn after 15 minutes •Weak bilateral breathing •The state is getting worse after breathing with mask C:\Users\82034\Pictures\Brániční kýla.png Diaphragmatic hernia •Malformation affects diaphragm development •The hole to which are organs transformed from the abdominal cavity to the chest cavity •Lungs development endangered •Sinistrous 85%, right-hand, bilateral •True, false 80-90% •Noticeable prenatally on US, MRI • Diaphragmatic hernia • C:\Users\82034\Pictures\brániční kýla schema.jpg Diaphragmatic hernia • C:\Users\82034\Pictures\brániční kýla rtg.jpg Diaphragmatic hernia • C:\Users\82034\Pictures\prenatální MR brániční kýla.jpg Diaphragmatic hernia •Clinical signs • •Progressive aggravation of respiratory insufficiency •Serious dyspnoea •Heart sounds transfered to the other side •Intestinal peristalsis in thoracic cavity Diaphragmatic hernia •Therapy •Immediate treatment of respiratory insufficiency •Immediate intubation •NG tube •Intravenous cannula •Airway, Breathing and Circulation monitoring •Deaden the newborn •Transport to the child surgery workplace • Diaphragmatic hernia •Therapy • •Creating septum between the thoracic and abdominal cavity • •Small defects – simple suture defect •Great defects – synthetic material diaphragm compensation (Gore-Tex membrane) Diaphragmatic hernia • C:\Users\82034\Pictures\PB062108.JPG Diaphragmatic hernia Diaphragmatic hernia • C:\Users\82034\Pictures\P1110643.JPG We are having a baby it could happen to you as well C:\Users\82034\Pictures\těhotná.jpg • C:\Users\82034\Pictures\nedonošenec1.jpg C:\Users\82034\Pictures\nedonošenec.jpg •Labour in 32.tgSC, ph 1060g/40cm •AS 5,8,9 •Ventilated for 4 days due to RDS •Detected hypotension, circulatory support by dopamine for 48 hours •ATB therapy , clin. and lab. signs of sepsis regression after 72 hours •Fed by tube + parent. nutrition •12th day of aggravation state, billowing abdomen, tachycardia, apneic intermission, impure blood in stool, hypotension F:\Fotky\P7081899.JPG X-ray • C:\Users\82034\Pictures\NEC rtg.jpg C:\Users\82034\Pictures\pneumoperitoneum.jpg C:\Users\82034\Pictures\otazník.jpg Necrotizing enterocolitis • C:\Users\82034\Pictures\NEC rtg.jpg C:\Users\82034\Pictures\NEC rtg1.jpg C:\Users\82034\Pictures\pneumoperitoneum.jpg Necrotizing enterocolitis •One of the most serious GIT newborns disease •Affects mostly immature newborns with pH under 1500g (10-20% affects mature newborns with risk factors – Congenital Heart Defect…, exceptionally full term infant without CDD) •Causes – multifactorial. • -immature GIT ischemic reaction (perinat. asphyxia, pneumopathie, • shock, ductus arteriosus patens, polycythemia, …) • -food loading of unsuitable composition (cow milk proteins, hyperosmolar food) • -imune systém immature • - bacterial infection – nosocomial flora colonization •Terminal ileum and proximal colon frequently affected, however, the whole intestines necrosis might happen (up to 20% of patients) Necrotizing enterocolitis clinical count •Mild course • •Temporary food intolerance •Abdomen distension •Rectum occult bleeding • • • •Peracute course • •Fully spread sepsis with apnea count •Bradycardia •Unstable temperature •Unstable circulation •Massive enterorrhagia •Shock • Stage Systemic symptoms GIT symptoms X-ray symptoms 1A – suspected NEC Unstable temperature, bradycardia, mild apnea, lethargy Gastric residuum, mild abdomen distension, vomiting, occult bleeding Mild loop diletation up to subileus 1B – suspected NEC The same Clearly red rectum blood The same 2A – confirmed NEC, mild alteration The same The same + deaf peristalsis, +/- sensitive abdomen ileus, pneumatosis intestinalis 2B - confirmed NEC, middle alteration The same + mild metab. acidosis, mild trombocytopenia The same + clear abdomen pain, +/- abdomen wall cellulitis or right lowe quadrant resistance The same + gas v port. bed, +/- ascites 3A – advanced NEC, serious alteration, intestine infarction The same+ hypotension bradycardia,deep apnea, DIC, neutropenia The same + diffuse peritonitis signs, breakthrough pain and abdomen distension The same + overt ascites 3B – advanced NEC, serious alteration, perforated intestine The same The same The same + pneumoperitoneum Necrotizing enterocolitis •Diagnosis •Clinical finding •Lab tests–neutropenia, trombocytopenia, inflammation messenger growth, metabol. acidosis, hyperglycemia •Imaging methods –X-ray (sub-ileus, pneumatosis intestini, gas in portal bed, pneumoperitoneum) • US (ascites) Necrotizing enterocolitis •Thrapy •Mild form – nursing intervention – ATB, discontinued enteral nutrition, GIT decompression by NG tube, TIBC •From 2B stage – surgical treatment – abdomen revision, affected intestine removal, primordial anastomosis (rather exceptionally), stoma •Drainage abdominal cavity succesive by second look surgery at unstable patients in critical state or during pancolitis only. Necrotizing enterocolitis abdomen distension • F:\Fotky\P7081899.JPG Necrotizing enterocolitis pneumatosis intestini • F:\Fotky\PC080595.JPG Necrotizing enterocolitis caecum necrosis + colon ascendens • F:\Fotky\PB233290.JPG Necrotizing enterocolitis primary anastomosis • F:\Fotky\PB243292.JPG Necrotizing enterocolitis pancolitis • F:\Fotky\P9052970.JPG Necrotizing enterocolitis stoma • F:\Fotky\PICT0628.JPG We are having a baby it could happen to you as well C:\Users\82034\Pictures\těhotná.jpg •Spont. labour, 2500g/47cm •Respiratory insufficiency progression after labour •Billowing abdomen, meconium is not gone •Anus created normally, RR can be inserted for 5 cm, no meconium impression •Sono finding of small amount of floating liquid in abdominal cavity F:\Fotky\P6052818.JPG C:\Users\82034\Pictures\otazník.jpg Meconium ileus •Spont. labour, 2500g/47cm •Respiratory insufficiency progression after labour •Billowing abdomen, meconium is not gone •Anus created normally, RR can be inserted for 5 cm, no meconium impression •Sono finding of small amount of floating liquid in abdominal cavity F:\Fotky\P6052818.JPG Meconium ileus •Affects 10-15% of newborns with cystic fibrosis (mucoviscidosis) •Rigid meconium similar like rubber arises because of exocrine gland affect •Termin. ileum as the most frequent obstruction • • Meconium ileus newborns meconium passages casebook Simple meconium ileus Termin. ileum obstruction by meconium viscosity, CF+ Complicated meconium ileus Intestine obstruction by meconium viscosity, CF+, intestine artresia at the same time, volvulus, stenosis, perforation, intestine necrosis, peritonitis Meconium plugs syndrome Rectosigma obstruction by meconium, another disease unproven Immaturity ileus Termin. Ilea obstruction by meconium, children with less than 1500g Intestine innervation dysfunction M.Hirschsprung, totální aganglionosis, intestine hypoperistalsis Other causes Congenital hypothyroidism, mother´s narcotic abusus Meconium ileus •Clinical count • •No meconium leaving •1st-2nd day of vomiting and progressive abdomen distesion •Sometimes palpable indefinite resistance in the right hypogastrium •Progressive ileus and sepsis Meconium ileus •Diagnosis •Abdomen X-ray in eyesight – ileu count, sometimes noticeable meconium shadows •Irrigography – narrow colon count (microcolon) •Sono – distended small bowel loops, termin. ileum distended by content without liquid •Elevated chloride values in sweat •Genetic examination CF • Meconium ileus •„Dry“ ileus X-ray •Irrigography - microcolon C:\Users\82034\Pictures\mekoniový suchý ileus.png C:\Users\82034\Pictures\mekoniový ileus irrigo.jpg Meconium ileus •Therapy •Simple form – conservative – clysis (alternatively with mucolytic), start with feeding after clearance by GIT (special milks + pancreat. enzymes substitution) •Complicated forms – surgical th. – in case of concervat. th. failure or at či GIT perforation – the most frequent temporar stoma. Meconium ileus • F:\Fotky\ileus mekoniovy\P3250101.JPG Meconium ileus • F:\Fotky\ileus mekoniovy\P3250102.JPG Meconium ileus • F:\Fotky\mekoniovy ileus\Meconiovy_ileus_perforace2.JPG Meconium ileus • F:\Fotky\mekoniovy ileus\Meconiovy_ileus_perforace4.JPG We are having a baby it could happen to you as well C:\Users\82034\Pictures\těhotná.jpg C:\Users\82034\Pictures\těhotenské břicho.jpg Is it going to be smooth? • C:\Users\82034\Pictures\tunel.jpg Sometimes not… • C:\Users\82034\Pictures\Klešťový porod1.jpg C:\Users\82034\Pictures\vakuumextraktor.png C:\Users\82034\Pictures\kleště.png Newborn´s labour injury •Risk factors • •Immature fetus •Breech birth •Instrumental delivery •Great fetus delivery, cephalopelvic disproportion •Rapid delivery •Slacken delivery •Abnormally positioned fetus •CDD of fetus • Newborn´s labour injury •Soft tissue injury (petechia, cephalhaematoma, subconjuctival • and retinal haemorrhage, • m.sternocleidomastoideus injury) • •Skeleton injury (skull, long bones) • •CNS and periph. nerves injury(epidural, subdural or • subarachnoid bleeding, n. facialis palsy, • brachial plexus palsy) • •Intra-abdominal injury (liver and spleen tear, suprarenal bleeding) Newborn´s labour injury •Clinical symptoms •Depends on the location of the injury •From slight behavioural change to difficult life endangering state •Painful manipulation •Hematoma •Limb disfigurement •Painful manipulation with LA •Asymmetry in collar bone area •Palpable resistance in left collar bone area C:\Users\82034\Pictures\fr. klíčku.jpg C:\Users\82034\Pictures\otazník.jpg Clavicle fracture •Painful manipulation with LA •Asymmetry in collar bone area •Palpable resistance in left collar bone area • C:\Users\82034\Pictures\fr. klíčku.jpg Clavicle fracture • C:\Users\82034\Pictures\fr klíčku rtg.jpg Clavicle fracture • C:\Users\82034\Pictures\zlomenina klíčku.jpg Thigh bone fracture - callus Thigh bone fracture– one month after Thigh bone fracture Humerus fracture Humerus fracture •Prolonged vag. delivery with shoulder dystocia •Fetus size and parturient passage disproportion •Restricted mobility of LA •Pronated position of LA C:\Users\82034\Pictures\otazník.jpg C:\Users\82034\Pictures\zlomenina klíčku.jpg Brachial plexus paresis •Prolonged vag. delivery with shoulder dystocia •Fetus size and parturient passage disproportion •Restricted mobility of LA •Pronated position of LA • C:\Users\82034\Pictures\zlomenina klíčku.jpg Brachial plexus paresis • C:\Users\82034\Pictures\duchenne-erb-paralysis-4677_3.jpg C:\Users\82034\Pictures\paréza brach. plexu.png Brachial plexus paresis •At labour of great fetuses together with abnormal position •Superior type - 90% of paresis, C5-6 injury, UL poorly hangs in adduction and inner shoulder rotation, prehension reflex is possible to equip, n.phrenicus paresis and unilateral diaphragm paresis attend with C4 injury at the same time •Inferior type – 10% of paresis, C7-8 injury, distal part affected, pressured fingers, arm can be livid, Horner´s syndrome at the same time with Th1 • • • C:\Users\82034\Pictures\plexus brachialis - schema.jpg Brachial plexus paresis •Therapy • •Pat. in neurologist´s and RHB doctor´s care •Start of RHB in time (if no other Cl – e.g. colar bone fr., ABC functions unstable •Exercising according to neurophysiology – connection between movement and nervous system – Vojta´s method •Well conducted exercising for 4x day •Baby crying – suppression of personal freedom manifestation, no pain •If the elevation of UL fails within a period of next 3 months – mostly never successful •90% of the disabled in 1 year is without neurological deficiency • • The goal of our work is being sincerely interested in our entrust patients, have a friendly relationship with them, treat them with kindness. Give them their health back and save their lives. •Thank you for your attention C:\Users\82034\Pictures\romská rodina.png