>	PHYSIOLOGICAL CONSIDERATIONS
>	SURGICAL PROBLEMS IN NEONATES
>	SURGICAL PROBLEMS IN YOUNG CHILDREN

While there are many types of congenital anomalies, only a few of them are common. Some require urgent surgical attention while others should be left alone until the child is older. However, resuscitation cannot await referral and you may need to perform essential life-saving interventions prior to referral of the child for definitive surgery.

Intestinal obstruction

Any newborn with abdominal distension, vomiting or no stool output, has a bowel obstruction until proven otherwise.

Bile stained (green) vomiting can be a sign of a life threatening condition. A peristaltic wave across the abdomen can sometimes be seen just before the child vomits:

::	Place a nasogastric tube
::	Start intravenous fluids
::	Keep the child warm
::	Transfer the child, if possible.

If transfer is not possible, perform a laparotomy (see pages 6–1 to 6–4) to rule out midgut volvulus which can result in gangrene of the entire small intestine. Under ketamine anaesthesia, untwist the bowel. Close the abdomen and, when the child is stable, refer for definitive management.

Hypertrophic pyloric stenosis

Non-bilious (not green) vomiting can be caused by hypertrophic pyloric stenosis. This condition is caused by enlargement of the muscle that controls stomach emptying (pylorus). In a relaxed infant, a mass is palpable in the upper abdomen at the midline or slightly to the right of the midline.

The condition most commonly occurs in male infants 2–5 weeks of age. It is treated with pyloromyotomy. Infants with pyloric stenosis commonly present with dehydration and electrolyte imbalances. Intravenous fluid resuscitation is required urgently:

::	Use normal saline (20 ml/kg bolus) and insert a nasogastric tube
::	Repeat the fluid boluses until the infant is urinating and vital signs have corrected to normal (2 or 3 boluses may be required).

Once the fluid and electrolyte abnormalities have been corrected, provide for maintenance for ongoing losses and transfer the patient for urgent management by a qualified surgeon.

Oesophageal atresia

Failure of oesophageal development is often associated with a fistula from the oesophagus to the trachea. The newborn presents with drooling or regurgitation of the first and subsequent feeds. Choking or coughing on feeding is frequent. An X-ray with a nasogastric tube coiled up in an air filled pouch is diagnostic.

Keep the infant warm and nurse in the 30° head up position. Place a sump drain in the oesophageal pouch and administer intravenous fluids calculated according to weight. The child will inevitably get pneumonia, so give antibiotics. Refer the stable infant to a paediatric surgeon.

Abdominal wall defects

Defects of the abdominal wall occur at or beside the umbilicus:

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In omphalocoele, there is a transparent covering over the extruding bowel

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In gastroschisis, the bowel is exposed: – If the bowel is strangulated in a gastroschisis, make an incision in the full thickness of the abdominal wall to increase the size of the opening and relieve the obstruction – Apply a sterile dressing and then cover with a plastic bag to prevent fluid loss; exposed bowel can lead to rapid fluid loss and hypothermia – Transfer the baby urgently to a qualified surgeon. Anorectal anomalies

Imperforate anus can occur in a variety of forms. The diagnosis should be made at birth by examining the anus. There may be no opening at all. In other instances, a tiny opening discharging a little meconium may be seen at the base of the penis or just inside the vagina.

Delay in diagnosis may cause severe abdominal distension, leading to bowel perforation. Place a nasogastric tube, start intravenous fluids and transfer the child to a surgeon. A transverse loop colostomy is the emergency treatment of anorectal obstruction. Arrange for repair of the anomaly by a qualified surgeon on an elective basis.

Meningomyelocele (spina bifida)

Meningomyelocele is the name given to a small sac that protrudes through a bony defect in the skull or vertebrae. The most common site is the lumbar region. It may be associated with neurological problems (bowel, bladder and motor deficits in the lower extremities) and hydrocephalus. These patients should always be referred:

::	Hydrocephalus will progress without a shunt being placed
::	Meningitis occurs if the spinal defect is open.

The defect should be covered with sterile dressings and treated with strict aseptic technique until closure.

Cleft lip and palate

Cleft lip and palate may occur together or separately. A baby with a cleft palate may have difficulty sucking, leading to malnutrition. An infant with cleft lip or palate who is not growing normally should be fed with a spoon. The operation for a cleft lip is best done at 6 months of age and cleft palate at 1 year. Urgent referral is not required.

Congenital orthopaedic disorders

Disability can be avoided with early treatment of two of the most common congenital orthopedic disorders:

::	Talipes equinovarus (club foot)
::	Congenital hip dislocation.

Talipes equinovarus (club foot)

Club foot is a deformity that may be bilateral. It can often be corrected by early treatment (see pages 19–3 to 19–4).

Dislocation of the hip

All children should be screened for this problem at birth. The diagnosis is suggested by clinical examination:

::	When the dislocation is unilateral: – The limb is short – There is limited abduction when the hip is flexed – The skin crease at the back of the hip appears asymmetrical
::	When the flexed hip is abducted, a click can often be felt as the dislocated femoral head enters the acetabulum (Ortolani’s sign).

In some regions of the world, this problem is uncommon because infants are carried on the mother’s back.

See pages 19–1 to 19–2 for treatment.