CERTAIN ASPECTS OF SURGERY OF THE NEWBORN" TO those who illt,c~rc~st themsclvcs l)rim:lr- ily in the surgical problrms of infancy :llld childhood, there swms to be 110 entl to IICW ideas which can be dcvclopc~l in the ol)era- tive and post-operative care 01' children, which lead to smoother convalcsccncc~, decreased morbidity, :\nd lower mort:rIit,y rates. In the field Of pediatric surgery, ho\vevcr, the chill- leiige still lies in tlic surgical managc~mcnt oi those congenital allom:l tics whicll are in- compatible with life, but which are amenable to surgical corrcct,ion. There arc l'our such problems which might be included in this group wit,hout question. They are ompl~aloccle, atresi;r OF thr esol)llagus with or witho& trnchrorsol)h;Iaeal fistula, atresia of the bowel and imprrforatc ;L~IIIS. To this group I would also add mcconinm ileus and diaghragmatic hernia. Rleconium ileus should be added because of the tlistres- sing mortality this problem carries with it about the country, ilnd (li;r~)l~r;i~nlati(: bclrllia because its mortality, alt~horqh not onv hun- dred per cent, is so close to it as to be includ- ed in this series. The management of omphalocc~le was mod- erately efficient as outlined by liadd anti Gross' some years ago, but, an cwn superior method is that described more rwcntly by Gross', wherein the mt:mbratrcBs of the oml)ha- locele are not dissec,ted free, but lXtlICr are covered by skin which can be loosr~~ctl from surrounding structures and stretched over the surface of the membrancous covering of t,he abdominal viscera. We have matlc but one slight improvement on this twhnicllw. In large omphalocelcs where disprolwrtion he- tween the prot,ruding viscera and available &in is great, it is possible to comprcw the abdominal viscera by rolling the mc~mbra1~- eous covering in much the Sil.mt' W;ly tllilt 011C would roll down the top ol' a l)aI)(`r 1):1g aI'tcal* bringing the two sides togetlwr, ant1 then to approximate the skin cdgw while bol~ling the viscera, thus tightly comprwst~tl. oTll[`halo- celes extending from the siphoicl t,o the pubis, which otherwise might not. be ~~nx~~i ible by o Read before the Medical Society of Delaware. Wil- mington, October 9, 1951. o * Surgeon-in-Chief, Children's Hospital. Ill tlw tlWtmCnt~ oi' dial)hr;lgnl;llic hernias, wc have abandoned the abdominal apl)ro;lch Xld routintlly ol)Pl'ilt~e t~;!llStho~aCiCi11ly." JIM the thorn& approach it is lwssihlc to ol)en the cllwt Of a distwsscd infant in a mirttpr of a minute or two, and to eviscerate the ab- dominal orgxns from t,lie thoraric cavity, at \vbich moment the baby bccomcs a s;lt,isI';lc- tory patient from the lwint. of view ol' cardiac and respiratory reserve. The colla[~sc!il lmg Can CXpiid, the heart. is no longer compres- sed, and the metliastinum may shi t't back to its normal 1)osition. The surgeon need tlwn bC in 110 hurry, hUt Cilll at his lcisLli*c rFl)lilCC tllc abdominal viscera into the lwritoucql Cil,Y- ity through the clial)lir,a~nr;ltic de I'wt, ; the CllCSt, is tllCl1 clos(:tl iu tile USUill i';lslrio~l al'tcr sutnriiig thC dial~hra~m, and tlic iI1 I'illlt re- tlwncd to Iii:; crib wit,11 a chest wou~~d which 11e swms much better able to Ilillltll~! tJiili1 it lnrgc :hlomil~i~l wound l)clrind which arc mow ~ibtlominal contents than the lwritotical c;lVit,y C:lll C~Jll\Tlli~~Ilt~~ aC(!(Jl~llT~(Jtlattl. WC have do110 l'ourtcen di;tl)lll,;1~rn;Itic rcl);lirs t)z this twhili([uv with olic' clc~;itll, ;lil(l tllilt in it rhilii With ~~~PITx1tl~l~(` OSSifiC';ltiOll 01 t\lc' Ski111 :illtl LSlll~~llll~~~l ;llltL c~l)icllllxl ~l~`l~lilt0~ll~lS. I l:rvily thtrs tlist~~sctl 01' (`our t~i~otrl~~ms with littltk 11101'( thilll il. \V(JTcI, 1 \VOlll(l Iikcb to tIllall 0111' atti~irtioll to thcl two wmai~ritlg ~~1~01~l~w~s: ;lt lY%iil 01' tliv CSO[)hil~llS, ;Ill(i inll)c~ri'ot*atc~ illlllS, ;Illd Ollt lint :l mcthotl Of I~~~lllil,~~~lll~~l~t TOY C;lPll whkh \V\' lliJ,VC !Ollll~l Siltisl'LlCtOYJ aii(I whicall ill e;lcdll illStilll(`(~ scv'uls to l)(b sonI(`- 154 DELAWARE STATE MEDICAL JOURNAL JUNE, 1952 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 cm., 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 operat,ion. 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 cm. 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 cont,raindicates major surgery, have a colostomy performed in 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 cm. have a definitive operation car- ried out at the time of admission to the hos- pital. A combined abdomino-perineal type of a.pproach 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 t,hat one leg is outside the drapes and in the operative field. A small section 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 unt.il it is possible to reach up int,o the true pelvis, and bring down through the perineal canal thus made the blind loop of colon and exteriorize it through 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- ience we have learned t,hat 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 cared for by the three techniques outlined there should be no rectal strictures. Tight a.nuses 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. %Ve 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- tinence, 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 ~)EI,.~WARE STATE MEDICAL JOURNAL 155 ure and post-operative management of pa- these conditions warrants trial in other ped- tients with atresia of the esophagus and im- iatric installations. perforate anus. We realize that a low mor- 1740 Ba~inbridge Street 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. However, 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 5. BEFERENCES Ladd. W. E., and Gross, R. E.: Abdominal Surgery of Infancy and Childhood. Saunders Co., 1941. Philadelphia: W. B. Gross. R. E.: New Method for Surgical Treatment of Large Omphaloceles. Surgery 24:277, (Aug.) 1943. Koop, C. E., and Johnson. J.: Transthoracic Re- pair of Diaphragmatic Hernia in Infancy. Rhoads, J. E.. Pipes. In press. R. L.. and Randall, J. P.: Simultaneous Abdominal and Perineal Approach in Operations for Imperforate Anus with Atresia of Rectum and Rectosigmold, Ann. Surg.. 127:572, (March) 1949. Koop. C. E.: The Management of Imperforate Anus, Penn. Med. Jour. 53:243 (March) 1950.