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.