小儿外科畸形早期外科干预新途径—产房外科的可行性

A novel approach to treat neonatal abnormalities in their earlier stage-Feasibility of the deˉlivery room surgery system

目的探讨小儿外科畸形早期外科干预的一种新途径 ,即产房内外科纠治的可行性。方法通过文献复习及对近期开展的2例临床外科纠治病例的治疗进行可行性分析。例1 :1例巨大脐膨出儿孕妇产前34周经B超及MRI得到明确诊断 ,因预估脐膨出腹壁缺损范围达7cm ,故产房剖腹产后即行全身评估 ,同时插胃管及渐加压将脱出内脏回纳腹内 ,2h后I期手术修补成功。例2 :34周孕妇产前B超诊断胎儿腹部有巨大囊肿 ,36周胎儿囊肿缩小 ,腹水增加 ,阴囊增大、积水5cm×5cm ,提示囊肿破裂。遂决定37周行剖腹产终止妊娠 ,患儿体重3800g,经全身评估后剖腹探查发现回肠闭锁 ,近端肠管穿孔 ,弥漫性胎粪腹膜炎 ,但未形成钙化灶 ,右阴囊积液。行部分肠段切除 ,近端小肠造瘘 ,远端Bishop术式端侧肠吻合 ,囊肿壁切除 ,阴囊及腹部引流。结果2例患儿均手术成功。结论①产房内外科纠治畸形手术是可行的。②产房外科优点在于外来感染机会少 ,属零转运 ;胃肠道气体少对腹壁缺损关闭有利 ;及早干预去除病因 ,中断了病理状态进一步发展 ;越早手术切口疤痕反应小 ,及早纠治畸形消除了家长精神上痛苦。

Objective Delivery room surgery is a novel approach to treat neonates with birth defects in their earlier stage.This report discuss the feasibility of the delivery room surgery system and define its mechanism as being a surgical intervention performed in the delivery room to treat the newborn infants with a prenatal diagnosis of congenital defect immediately after the delivery.Methods The feasibility of delivery room surgery was analyzed through both of the literatures review and the delivery room surgery on two cases performed.Results Case1,a39_week_gestation newborn infant,who was antenatally diagnosed as severe omphalocele with7cm defect of the abdominal wall at28,36and38weeks of the gestational age deˉtected by ultrasonography and MRI,was successfully performed the one_stage_closure of the abdominal wall at his two_hour age after routine preoperative examination included ECG,serum electrolytes and blood gas immediately after birth.Case2,a giant abdominal cyst was found in a fetus with34weeks of gestation during prenatal routine ultrasound.By36th week of gestation,the ultrasonographic findings showed the shrunden cyst,the swelled scrotum and the increased intraperitoneal fluid,indicating the rupture of the abdominal cyst.With the associated discussion of pediatric surgeons and obstetricians,the pregnancy was determined to terminate at37th week of gestation.The neonate with a birth weight of3800g underwent the laparotomy after routine preoperative examination immediately after birth.Ileum atresia was diagnosed and meconium peritonitis due to perforation of the proximal segment of the ileum(pseudo_cyst)was found during the laˉparotomy.A bishop enterostomy was performed after the clean up of the meconium and the pseudo_cyst.Conclusions It is concluded that(1)the surgical intervention performed in the delivery room was feasible.(2)No transportation required in the obstetric surgery system,the infection rate due to environmental conˉtamination could hence be controlled to minimum.(3)The earlier the operation,the less the intra_intestinal gas existed,which was no doubt the advantage for the abdominal wall closure.(4)The early defect repair may terminate the development of pathophysiological status.(5)The earlier operation can reduce the formation of scar,and(6)The early defect repair may alleviate parents'mental suffering.