Surgical Emergencies in the Newborn University of North Carolina at Chapel Hill

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Surgical Emergencies in the Newborn

  • University of North Carolina at Chapel Hill

  • Pediatric Surgery Division

  • Patty Lange

  • Last revised 4/15/06


  • Types

    • Airway/Respiratory
    • Intestinal Obstruction
    • Intestinal Perforation
  • Signs

    • Respiratory distress
    • Abdominal distension
    • Peritonitis
    • Pneumoperitoneum


  • Neck Masses

  • Thoracic masses/pulmonary lesions

    • Congenital lobar emphysema
      • Overdistension of one or more lobes (nl histological lung)
    • Congenital cystic adenomatous malformation
      • Multicystic mass of lung tissue, proliferation of bronchial structures at the expense of alveoli
    • Pulmonary agenesis
      • Absence of lung
    • Congenital diaphragmatic hernia
    • Tracheoesophageal fistula

Cystic Hygroma

  • Multiloculated cystic spaces lined by endothelial cells

    • Separated by fine walls containing numerous smooth muscle cells
    • Result of maldevelopment of lymphatic spaces
  • Incidence about 1 in 12,000 births

    • 50-65% appear at birth, 85-90% appear by age 2
    • Neck-75%, Axilla 20%; can be seen in mediastinum, retroperitoneum, pelvis, groin
    • Nuchal/post cervical CH’s have been associated with chromosomal abnormalities—high mortality rate

Cystic Hygroma

  • Complications

    • Respiratory—large hygromas can extend into oropharynx and trachea
    • Inflammation/Infection
    • Hemorrhage
  • Treatment

    • Dependent on size, location, symptoms/complications
    • Some pts require emergent surgery due to airway compromise
    • Best treatment is complete excision
    • Aspiration typically not effective due to rapid refilling of fluid
    • Sclerotherapy—Bleomycin, OK-432 (no longer available in US), doxycycline, fibrin glue

Cystic Hygroma

Cystic Hygroma

Congenital Lobar Emphysema

  • Postnatal overdistension of one or more lobes of histologically normal lung

    • Probably due to cartilaginous deficiency in the tracheobronchial tree
    • Obstruction causing the overdistension may be due to
      • 1—chondromalacia of bronchi
      • 2—extrinsic pressure on bronchus by anomalous pulmonary vein or abnormally large PDA
      • 3—idiopathic
  • Location

Congenital Lobar Emphysema

  • Diagnosis

    • Usually can be made by plain CXR; Chest CT and V/P scans may be helpful
  • Treatment

    • May require urgent surgical decompression with lobectomy
    • Selective bronchial intubation
    • Sometimes see spontaneous resolution—need close observation

Congenital Lobar Emphysema

Congenital Cystic Adenomatous Malformation (CCAM)

  • Mass of cysts lined by ciliated cuboidal or columnar pseudostratified epithelium

  • Three types

    • I—few large cysts >2cm; thick walls, normal alveoli between the cysts; ciliated pseudostratified columnar epithelium
    • II—numerous small cysts <1cm, thin muscular coat, large alveolar-like structures between the cysts; ciliated cuboidal to columnar epithelium; assoc w/other congenital anomalies
    • III—bulky firm masses of folded ciliated and non-ciliated cuboidal epithelium and thick layer of smooth muscle; often occupy the entire lobe or lobes of lung
  • More common on the left side, 2% bilateral


  • Diagnosis

    • CT scan allows differentiation of types
    • Some can be diagnosed on prenatal US
  • Treatment

    • Surgical excision, typically anatomical lobe resection, due to risk of infection, malignant transformation
    • Some are performing fetal aspiration


Congenital Diaphragmatic Hernia

  • Intro

    • 1 in 200-5000 live births, females >males
    • Etiology unknown
    • Large percentage of fetuses are stillborn
    • Still high mortality of those that make it to birth
  • DX

  • Treatment

    • Respiratory support
    • ECMO
    • Primary closure or patch closure when pt stable

Tracheoesophageal Fistula and Esophageal Atresia

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