Surgical Emergencies of the Newborn JAMES D. CURTIS, '64
INTRODUCfiON Conditions that create surgical emergencies in newborn infants, mainly con genital malformations of the alimentary tract, are rare. However, recent advance 路 in pre- and post-operative management, anesthesiology, and surgical technic have improved mortal ity figures so considerably that diagnosis has become of utmos1 importance. This paper will consider the diagnosis of some of these anomalies in order as they appear, from birth until the first few days of life. 1. O MPHALOCELE
An omphalocele is a translucent sac, lined by amniotic membrane and peritonenum, protruding from the anterior abdominal wall at the base of the umbilicus at birth and containing intestines, liver, and possibly other abdominal organs. The intestines have failed to return to the abdominal cavity in embryonic life due to spatial disproportion or a primary defect in the anterior abdominal wall. The wall of the sac is thin and avasbilar and hence prone to perforation, drying, necrosis and infection. Evisceration and peritonitis are logical sequelae. In 20 % of cases the sac ruptures before birth or during delivery. D elay in treatment allows swallowed air to inflate the intestines, making reduction more difficult. D iagnosis is obvious at birth. Fifty-nine per cent have associated congenital anomalies, especially malrotation of the midgut, but many are of minor importance. 2. MALFORMATIONS OF ANUS
AND RECTUM Arrest at various stages of development of the primitive gut can result in various types and degrees of ano-rectal abnormalities: (1) anal stenosis, (2) membranous imperforate anus, (3) imperforate anus with a rectal pouch ending blindly some distance above it, and ( 4) blind rectal pouch with a normal anus and lower rec-
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tum. The third type is the commonest (90 % ) and is usually associated with fistulae to the perineum, the male urinary tract, or the female genital tract. Excessive fusion, failure or development of the urogenital septum, and failure of anal migration have been incriminated. Forty per cent have other abnormalities. T he diagnosis should be made by the obstetrician at delivery or by a nurse when she attempts to obtain the rectal temperature. However, diagnosis may be missed at this stage and signs and symptoms that vary with the type and degree of malformation follow. Most (75 % ) have complete obstruction and present with abdominal distention, failure to pass stools, and failure to feed or vomiting. Fistulae may follow decompression and passage of some stools but with difficulty. D iagnosis is made by thorough inspection and examination and confirmed by x-ray. A dimple or small perineal ridge may be seen in the third type. With imperforate anal membrane the meconium stains the membrane and causes it to bulge when the baby strains or cries. Fistulae may evade detection, especially those communicating with the urinary tract. Micro scopic examination of the urine may be helpful. Local probing often delineates perineal and vaginal fistulae. Radiography is performed with the infant inverted to allow colonic gas to reach the distal end. A lead marker is taped to U.W.O . MEDICAL JouRNAL