Chapter 37: Neonatal Surgery – Respiratory distress, obstructions, NEC, biliary atresia, abdominal wall defects

Causes of respiratory distress in newborn · Duodenal obstruction · Small bowel obstruction · Meconium plug syndrome · Hirschsprung disease · Urological problems · Exomphalos/gastroschisis · Sacrococcygeal teratoma · Anorectal anomalies · NEC · Biliary atresia
🩺 Core principles: Respiratory distress → rule out airway, lung, surgical causes (CDH, TEF, CCAM). Bilious vomiting = intestinal obstruction until proven otherwise. NEC: pneumatosis intestinalis, portal vein gas. Biliary atresia: conjugated hyperbilirubinemia, need Kasai portoenterostomy before 60 days.

📘 Neonatal Surgery: key conditions

🫁 Respiratory distress (surgical causes)
Congenital diaphragmatic hernia (CDH) – scaphoid abdomen, mediastinal shift. Tracheoesophageal fistula (TEF) – frothing, feeding cyanosis. CCAM, lobar emphysema.
🍽️ Duodenal obstruction
Bilious vomiting (if post‑ampullary). Double bubble on X-ray. Atresia, annular pancreas, malrotation.
🔄 Small bowel obstruction
Jejunal/ileal atresia, meconium ileus (cystic fibrosis), malrotation with volvulus. Distended loops, bilious aspirates.
💩 Meconium plug / small left colon
Delayed passage of meconium, abdominal distension. Contrast enema diagnostic (plugs). Often transient.
🧬 Hirschsprung disease
Failure to pass meconium, chronic constipation, enterocolitis. Suction rectal biopsy (absence of ganglion cells).
🚽 Urological problems
Posterior urethral valves (PUV) – dribbling, palpable bladder, hydronephrosis. Prune belly syndrome. Vesicostomy.
🛡️ Abdominal wall defects
Exomphalos (omphalocele) – central membrane‑covered, associated anomalies. Gastroschisis – right of cord, no membrane, bowel exposed.
🍂 Biliary atresia & NEC
Biliary atresia: conjugated jaundice, pale stools, dark urine; Kasai operation <60 days. NEC: prematurity, feeding intolerance, pneumatosis, surgery if perforation.
📊 Imaging pearls: Double bubble → duodenal atresia. Ground‑glass opacity + mediastinal shift → CDH. Suction rectal biopsy gold standard for Hirschsprung.

🔍 Approach to surgical neonate

1
Respiratory distress evaluation – Scaphoid abdomen, mediastinal shift (CDH). Frothing, inability to pass orogastric tube (TEF). CXR, upper pouch study.
2
Bilious vomiting – Stop feeds, pass orogastric tube, abdominal X-ray. Double bubble → duodenal atresia. Distended loops → possible malrotation/volvulus (urgent upper GI).
3
Delayed meconium (>48h) + distension – Consider Hirschsprung, meconium plug, meconium ileus. Rectal exam (explosive stool → plug). Contrast enema; rectal biopsy for Hirschsprung.
4
Abdominal wall defect – Omphalocele (central, membrane) → rule out cardiac/genetic anomalies. Gastroschisis (right, no sac) → bowel edema, staged reduction.
5
Conjugated hyperbilirubinemia – Fractionated bilirubin, rule out biliary atresia (ultrasound absent gallbladder, triangular cord sign). Liver biopsy, cholangiogram, Kasai procedure.

📋 Stepwise management of neonatal surgical conditions

1
CDH (preoperative) – Orogastric decompression, avoid bag‑mask ventilation (bowel distension), high‑frequency ventilation, ECMO. Surgical repair after stabilization.
2
TEF (esophageal atresia) – Replogle tube suction, head elevated, prevent aspiration. Surgical ligation of fistula + anastomosis.
3
Intestinal obstruction (atresia/volvulus) – IV fluids, correction of electrolytes, broad‑spectrum antibiotics. Resection and anastomosis (or Ladd procedure for malrotation).
4
Hirschsprung disease – Rectal irrigations, definitive pull‑through (Swenson, Duhamel, Soave). Preoperative optimization.
5
NEC (surgical indications) – Pneumoperitoneum, clinical deterioration, portal vein gas, failed medical therapy. Laparotomy, resection, ostomy.
6
Biliary atresia – Kasai portoenterostomy before 60 days (better prognosis). Postoperative supportive care, liver transplantation if failure.
⚡ Critical reminders: Bilious vomiting = surgical emergency. NEC: abdominal X-ray every 6-12h. Biliary atresia: time is liver.

🧠 Reflex prompts – neonatal surgery

🫁 Scaphoid abdomen + respiratory distress?
Congenital diaphragmatic hernia (CDH).
🥄 Double bubble sign?
Duodenal obstruction (atresia, web, annular pancreas).
💩 Delayed passage of meconium (>48h)?
Hirschsprung disease, meconium plug syndrome.
🛡️ Omphalocele vs gastroschisis?
Omphalocele: central, membrane, associated anomalies. Gastroschisis: right, no sac.
🍂 Conjugated jaundice + pale stools?
Biliary atresia (Kasai <60 days).
📸 Gold standard for Hirschsprung?
Suction rectal biopsy (absence of ganglion cells).