Hydeabad,01 August 2022: A prematurely born baby born : one month, and weighing only : 1.710 Kg was operated upon for many birth defects and three defects were corrected by complex operations involving the baby’s chest ( thoracotomy ) and abdomen ( laparotomy ) in one single long operation at Lotus Hospitals for Women & Children.Such complex operations on the baby’s chest and abdomen simultaneously are rarely done in the world.. There is very little literature across the world of an instance of performing two or three operations in a baby simultaneously in one sitting.
B/O.Swapna was born one and a half months early ( premature birth ) and weighed only : 1.710 Kg. She needed oxygen and respiratory support for lung immaturity. She was detected to have four abnormal birth defects : 1. Tracheoesophageal Fistula ( disconnected food pipe with abnormal connection of the windpipe to the food pipe ), 2. Duodenal obstruction due to annular pancreas ( blockage of the middle of the early small intestine due to another organ in the abdomen – pancreas encircling the intestine ), 3. Anovestibular fistula ( abnormal opening of the stool passage tube into the genital tract ), 4. Right sided Aortic Arch ( Major blood vessel the heart passing on the right side instead of the left side ). This set of abnormalities are called in medical parlance : a VACTERL association. In this baby, most of abnormalities seen in this association were diagnosed. The incidence of Tracheoesophageal fistula is : 1/3000 live births, whereas Duodenal Obstruction is : 1/2500 to 10,000 live births.
In order for a baby to feed normally milk from the mother, the food pipe, stomach, and intestines all need to be in continuity. In this child, there was a disconnection right in the food pipe ( esophagus ) that carries swallowed milk to the stomach. Additionally, there was a block in the starting part of the intestine ( duodenum ) which originates from the stomach itself. The pancreas is a digestive organ that provides digestive enzymes as well as insulin. In rare circumstances, the pancreas which is normally a leaf shaped organ behind the stomach can have a circular form ( annular pancreas ), and this form might block the duodenum. Annular pancreas is again a rare birth defect, and in this baby was blocking the flow of milk from the stomach to the intestines.
Given such a complex situation, most surgical repairs of the gastrointestinal tract are done in two or more different operations. In world literature, studies over a thirty year period at a center revealed that only five such children have been operated upon in a single sitting. At Lotus Hospitals, we have surgical expertise of over 30 years by a very senior children’s surgeon ( Dr.S.Ramaswamy ) who trained at India’s premier medical institute ( A.I.I.M.S. New Delhi ). Dr.S.Ramaswamy decided and undertook a difficult as well as risky one stage operation in this baby. Through an approach through the child’s right chest, he successfully corrected the birth defect of tracheoesophageal fistula and connected the two parts of the food pipe which were not connected to their natural state. After finishing the first operation, he then undertook the second operation in the same sitting by opening the baby’s abdomen. He found the pancreas stuck to the duodenum and completely blocking it. Since cutting through the pancreas is dangerous, he chose to disconnect the upper part and the lower part of the intestine ( duodenum ) and reconnect them in continuity in a procedure called : duodenoduodenostomy.A third operation was also performed wherein the fistula opening into the genital tract ( stool passage large intestine opening into the genital tract ) was widened so as to allow stool that is formed to be passed without any problem. The entire surgery ( three operations ) took : 100 minutes to complete ( 1 hour and 10 minutes ) ! In the world literature the studies done on such combined operations took 3 hours to 3 hours 30 minutes. During the entire surgery our Senior Children’s Anesthesiaspecialist :Dr.M.S.R.C.Murthy ensured safe maintenance of anesthesia during surgery, and meticulous maintenance of lung and heart functions apart from other vital signs. This again requires expertise to handle a small premature baby for such a long time during a lengthy operation.
In the Neonatal Intensive Care Unit after surgery, the baby was given continued artificial respiratory ( breathing ) support with a ventilator for three days, following which the baby was successfully removed from the ventilator. Feeding of milk was commenced initially through a tube passed through the baby’s nose directly into the intestine, the tip of which was placed beyond the site of surgical repair. Feeds were gradually increased in amount. On the tenth day after surgery, a special X ray ( contrast study ) was performed by pushing a dye that is opaque to X rays through the food pipe to verify continuity of the food pipe and intestines and also to check for any possible leakages. The test was successful in that the dye passed well down the natural path of the digestive system.
We then started feeding the baby ( once mature enough ) directly from her mother. She was able to successfully take milk from her mother and digest well without any problems as now her entire intestinal tract ( right from the food pipe or esophagus ) to the duodenum and beyond were restored in continuity through two surgical procedures. She is now feeding well and ready for discharge home.
It is very rare that two major surgical procedures are undertaken in one single sitting and our surgeon Dr.S.Ramaswamy was able to undertake the procedure successfully with full confidence and trust that our medical team would look after the baby’s needs after surgery. The post operative care was provided along with Dr.S.Ramaswamy, but our Senior Specialist for Newborn Diseases : Dr.V.S.V.Prasad, along with his colleagues, Dr.Shaik Jilani Basha, Specialist for Intensive Care, Senior Nursing staff : Sister Jibit, Sister.Anu,Sister.Anitha, Sister.Sandhya, along with and under the guidance and support of Sister.Vignolia, Sister. Sonia, and Sister.Rita George – Nursing Director, andmany other healthcare personnel