152 DeLaware Srave Mepican JourxXar,

CERTAIN ASPECTS OF SURGERY
OF THE NEWBORN *«
C. Kvererr Koop, M, D.,**
Philadelphia, Pa,

To those who interest. themselves primar-
iy in the surgical problems of infaney and
childhood, there seems to be no end to new
ideas which ean be developed in the opera-
tive and post-operative care of children, which
lead to smoother con ralescenee, decreased
morbidity, and lower mortality rates. In the
field of pediatric surgery, however, the chal-
lenge still lies in the surgical management
ot those congenital anomalies which are in-
compatible with life, but which are amenable
to surgical correction.

There are four such problems which might
be included in this group without question.
They are omphalocele, atresia of the esophagus
with or without tracheoesophageal fistula,
atresia of the bowel and imperforate anus.
To this group I would also add meconium
ileus and diaphragmatic hernia. Meconium
ileus should be added because of the distres-
sing mortality this problem carries with it
about the country, and diaphragmatie hernia
because its mortality, although not one hun-
dred per cent, is so close to it as to be inelud-
ed in this series.

The management of omphalocele was mod-
erately efficient as outlined by Ladd and
Gross' some years ago, but an even superior
method is that described more recently by
Gross*, wherein the membranes of the ompha-
locele are not dissected free, but rather are
covered by skin which ean be loosened from
surrounding structures and stretched over the
surface of the membrancous covering of the
abdominal viscera. We have made but one
slight improvement on this technique. In
large omphaloceles where disproportion be-
tween the protruding viscera and available
skin is great, it is possible to compress the
abdominal viscera by rolling the membran-
eous covering in much the same way that one
would roll down the top of a paper bag after
bringing the two sides together, and then to
approximate the skin edges while holding the
viscera, thus tightly compressed. Omphalo-
celes extending from the xiphoid to the pubis,
which otherwise might not. be correctible by

* Read before the Medical Society of Delaware, Wil-

mington, October 9, 1951. . ;
** Surgeon-in-Chief, Children's Hospital.

JUNE, 1952

surgical means, can be closed in this fashion.

In reference to problems of atresia of the
bowel, recovery still seems to be proportional
to the age of the patient, the surgical care
exercised at the time of operation, and the
exeelUcney of post-operative care.

Meconium ileus, diagnosed early by the
signs of vomiting, distention, viseid seeretion,
and shadows resembling feces on X-Tay ¢xam-
ination of the abdomen is beg successfully
treated insofar as the obstructive problem is
concerned by a variety of surgical approaches
with a decreasing mortality. Whether one
performs a temporary ileostomy or resects
the affected portion of the bowel, the use of
pahereatie enzymes and preserved duodenal
Juice are of great help in establishing the
passage of stools.

In the treatment of diaphragmatic hernias,
we have abandoned the abdominal approach
and routinely operate transthoracieally.* Tn
the thoracic approach it is possible to open
the chest of a distressed infant in a matter of
a minute or two, and to eviscerate. the ab-
dominal organs from the thoracic cavity, at
which moment the baby becomes a satisfac-
tory patient from the poiut of view of cardiac
and respiratory reserve. The collapsed lung
ean expand, the heart is no longer compres-
sed, and the mediastinum may sluit back to
its normal position. The surgeon need then
be inno hurry, but can at his leisure replaee
the abdominal viscera into the peritoneal eay-
ity through the diaphragmatie defect; the
chest is then closed in the usual fashion alter
suturing the diaphragm, and the infant re-
turned to his erib with a chest wound which
he seems much better able to handle than a
arge abdominal wound behind which are
more abdominal contents than the peritoneal
cavity can eonveniently aceommodate. We
have done fourteen diaphragmatic repairs by
this technique with one death, and that in a
child with premature ossification of the skull
and subdural and epidural hematomas.

Having thus disposed of four problems with
little more than a word, I would like to turn
our attention to the two remaining problems:
atresia of the esophagus, and imperforate
anus, and outline a method of management
for each which we have found satisfactory
and which in each instance seems to be sume-
JUNE, 1952

what at variance with the usual techniques
employed.

In the management of atresia of the esopha-
gus our earlier method of management was
that. used by most, a retro-pleural approach
through the posterior mediastinum, at which
time the tracheoesophageal fistula was ligated
and an end-to-end anastomosis carried out
between the blind pouch above and the open
esophagus below. On the day after this pro-
cedure a gastrostomy was done, feedings were
delayed for a period of five to ten days, and
frequently post-operative dilatations of the
esophageal anastomosis were necessary in
order to permit the passage of food through
the sutured esophagus. This method of man-
agement had many faults. The operative pro-
cedure was long, it was difficult to stay out
of the pleural eavity, the hospitalization was
prolonged, and economic loss to the family
was great. There was always the risk of re-
vurgitated gastrostomy feedings, the need of
two operations, and the delayed nutrition of
the patient. Finally, the problem of esopha-
geal dilatations and the occasional necessity
for surgical closure of the gastrostomy was
time-consuming. In addition, the patients
irequently developed edema post-operatively,
which in those children who died, at times
approached a generalized anasarea. Under
this technique we felt that we had done all
that we could to improve our management,
and the mortality was over fifty per cent.

At the present time, we have altered our
method of earing for these children in this
manner: instead of using a retro-pleural ap-
proach, we operate transpleurally and reduce
the operative time from a period of twa to
five hours, to an average operating time of an
hour and fifteen minutes. No gastrostomy
is carried out following operation if we have
reasonable assurance that the suture line is
tight. On the morning of the second post-
operative day the patient is fed glucose water
and his formula is increased rapidly to some-
thing similar to that given to most newborn
infants. By this method, not only is anes-
thesia and operating time decreased, but only
one operation is necessary, hospitalization is
shorter, the eeonomic loss to the family is
less, nutrition is maintained, and surprisine-
ly enough, esophageal dilatations do not ap-
pear to be necessary as frequently as hereto-

DELAWARE Strate Mipican Journal 153

fore, Edema is now seldom seen because we
maintain these children on no salt) (except
that contained in blood transfusions) for the
first three post-operative days, and then limit
Muids to approximately 60 ce lh/day.

Iv one excludes patients with a seeond
anomaly incompatible with life and patients
with multiple congenital defects, whieh in
themselves carry a high mortality, the mor-
tality is surprisingly low. Out of 20 such
patients we have had 15 survivals. our was-
trostomies were done in this group and two
patients needed dilatations of the esophagus.
This method seems to us to be a rational ap-
proach to the problem of atresia of the esopha-
gus, not only in the hands of the pediatric
surgeon, but also in the hands of the tharacie
surgeon who only occasionally deals with such
problems. The risks are less, the procedure
easier, and the results better,

The problems resulting from the improper
management of imperforate anus have long
been a burden to us. Beeause this is the most
common of the congenital anomalies ineom-
patible with life, a laree number of sureeons
encounter the lesion and operation is earried
out by many unfamiliav with the end results
of this variety of surgery. Most patients with
imperforate anus are divided into two types:
Those in whom the blind rectal pouch ean he
reached from below, and those in whom the
distance between the anus and the eolon. ig
too great to be bridged by a perineal opera-
tion, in whom a colostomy seems the proced-
ure of choice. This is a satisfactory: classifi-
cation of patients, but the seleetion of oper-
ative procedures for each is frequently un-
Wise,

First, and most dangerous, is the common
attempt to bridge too wide a wap between
anus and colon by the perineal approach,
When such is done it is possible to bring
colon mucosa to perineal skin for a suture
line, hut this is done at the expense of nerve
and blood supply to adjacent areas, Such
suture lines, under great tension, do not hold,
and there develops in a matter of days after
operation a rectal canal surrounded by fat
and muscle and Hned with eranulation tissue.
This in turn hecomes a tight, relatively long
stricture which ean make the patient a rectal
eripple for the rest af his days. Not only are
these strietures very difficult to correct but
154 DELAWARE Strate MepicaL JOURNAL

frequently their correction leads to incontin-
ence. If they are not corrected, obstructive
megacolon may ensue.

The second variety of mistake is made in
those patients in whom a colostomy seems
necessary. The colostomy is carried out in
the sigmoid colon, thereby utilizing the re-
dundant loop of colon which should be left
free to provide bowel to construct pelvic
colon, rectum, and anal canal at the time of
definitive operation. These two errors can be
eliminated by never attempting to bridge a
gap between colon and anus which is greater
than 1.5 em., and when a colostomy seems
indicated, by placing it in the right side of
the transverse colon in order to leave as
much distal colon as possible for use at the
time of definitive operation.

We attempt to divide all of our imperforate
anus cases into three groups as to operative
procedure. First, patients with a blind gap
of 1.5 em. or less are approached through the
perineum, and an anus constructed which
usually has some sphincter. Secondly, pa-
tients who weigh less than four and a half
pounds, or who present some other medical
problem which contraindicates major surgery,
have a colostomy performed im the right trans-
verse colon. These two methods could be car-
ried out satisfactorily in almost any commun-
ity where surgery is practiced.

At the Children’s Hospital of Philadel-
phia, we have added a third category of oper-
ation, believing that we have sufficiently
good anesthesia, nursing, and house officer
care to warrant such type of work. Those
with a gap between anus and colon of more
than 1.5 em. have a definitive operation car-
ried out at the time of admission to the hos-
pital. A combined abdomino-perineal type of
approach is carried out with the abdomen be-
ing opened first and the blind end of colon
secured and exteriorized. The patient is
draped in such a way that one leg is outside
the drapes and in the operative field. A small
seetion of skin and skin only is excised from
ihe region of the anus, the external sphincter
cleanly divided, and a small hemostat is in-
serted into the perineal body. This aperture
is gradually enlarged until it is possible to
reach up into the true pelvis, and bring down
through the perineal canal thus made the
blind loop of colon and exteriorize it through

JUNE, 1952

the newly formed anus. These children are
taken care of once and for all, and the only
thing that remains to be done to them is to
have the excess colon trimmed off by a very
minor procedure just before discharge from
the hospital.®

Patients of three days of age or less tole-
rate this extensive surgery without difficulty.
It is of interest to note, however, that if such
an operation is not carried out in this very
early neonatal period, it becomes one of the
most shocking procedures one can undertake
in pediatric surgery, and therefore, by exper-
ienece we have learned that if this cannot be
accomplished early, one should do a colostomy
and then at a later date, after the age of
three or four months, perform the definitive
operation by the combined abdomino-perineal
approach just described. When patients are
eared for by the three techniques outlined
there should be no rectal strictures. Tight
anuses can be dilated in infancy, resulting in
a cosmetically acceptable anus, and a well-
functioning lower bowel. Such patients take
longer to train for stool habit than normal
babies, but they usually can be made into
satisfactory citizens from the point of view
of bowel function.

I will not go into the many problems of
fistulae between the colon and the urinary
tract, which so frequently complicate this con-
genital defect. They can be managed satis-
factorily during the procedures outlined. We
have operated on almost forty of these young-
sters in the last four years with one death
and one failure. Several premature babies
have died from other congenital anomalies
before surgery was undertaken. The smallest
baby we successfuly treated weighed two
pounds, twelve ounces. None are now rectal
cripples nor need look forward to that exist-
ence in the future. In the same period of
time we have treated a large number of pa-
tients secondarily who had previous surgery
at the time of birth, surgery which was not
carried out according to the principles here
stated. We think that the proper manage-
ment of such patients could eliminate the
very serious problems we see of fecal incon-
tinenee, megacolon and rectal stricture fol-
lowing surgery of imperforate anus.

We believe that much can yet be done to
improve the technique of operative proced-
June, 1952

ure and post-operative management of pa-
tients with atresia of the esophagus and im-
perforate anus. We realize that a low mor-
tality rate in a small series of patients may
be misleading and that we have had a par-

ticularly good succession of patients in both
categories. Tlowever, we do believe also that

some of the improved mortality is due to
careful attention to detail based upon correct-
ible errors of the past, and suggest that the
method of management outlined for each of

DELAWARE State MepicaL JOURNAL 155

these conditions warrants trial in other ped-
iatric installations.
1740 Bainbridge Street

REFERENCES

1. Ladd, W. E., and Gross, R. E.:| Abdominal Surgery
of Infancy and Childhood. Philadelphia: W. B.
Saunders Co., 1941.

2. Gross, R, .: New Method for Surgical Treatment
of Large Omphaloceles, Surgery 24:277, (Aug.) 1948.

3. Koop, C. E., and Johnson. J.: Transthoracic Re-
pair of Diaphragmatic Hernia in Infancy. In press.

4. Rhoads, J. E., Pipes, R. L., and Randall, J. P::

Simultaneous Abdominal and Perineal Approach in

Operations for Imperforate Anus with Atresia of

ao and Rectosigmold, Ann. Surg., 127:572, (March)

Koop, C. E.:| The Management of Imperforate Anus,

Penn. Med. Jour. 53:248 (March) 1950,

en