Neonatal Surgery in the NICU
by John H. Seashore, MD
During the past decade, a number of treatments and interventions have resulted in a marked reduction of morbidity and mortality of premature infants managed in the Neonatal Intensive Care Unit (NICU). These interventions include surgical treatment of a variety of indications including surgical closure of the patent ductus arteriosus, necrotizing enterocolitis, hydrocephalus, and others. In most neonatal centers, premature infants requiring surgical interventions are transported to operating rooms outside of the NICU. However, as I have learned in discussions with pediatric surgical colleagues, an increasing number of surgical procedures are being physically done in the NICU.
A recent report from the Netherlands, by Gavilanes and colleagues, retrospectively reviewed 45 cases of neonatal surgical procedures that were performed in the NICU.1 The operations included patent ductus ligation, insertion of ventricular catheters for hydrocephalus, repair of diaphragmatic hernias, open lung biopsy, and laparotomy including bowel resection and creation of an intestinal stoma. There was no surgery-associated infection or operative mortality. They believe that the NICU is the suitable venue for major surgery during the neonatal period, and no special area is needed to perform complication-free surgery.
This is a prospective and universal application of an approach that is used sporadically in most newborn units, especially for ligation of patent ductus arteriosus. While the number of patients is too small to draw final firm conclusions, Gavilanes et al make a convincing argument that ICU surgery can be safe and effective. There were no cases of surgically related infection, which has been the major concern with this approach. The number of deaths was actually smaller than one might expect in this population. The obvious advantage is not having to transport a critically ill infant, which usually requires four bed transfers of the baby with attendant risks of inadvertent extubation, removal of lines, hypothermia, etc.
The disadvantages of neonatal ICU surgery relate to space, equipment, and lighting. An operation on a neonate requires at least two surgeons, two nurses, and one or two anesthesiologists. Add to this an instrument table, an electrocautery unit, light sources, and other essential equipment, and 9 m2 of space becomes very congested. While this may be tolerable for short periods and if the procedures goes well, it increases the risk of problems if circumstances change. Gavilanes et al state that some of the infants were operated on while in their incubators. It is hard to believe that operating with the patient in an incubator is unacceptable except for very simple and short procedures given the poor visibility and limited space in the incubator. Attempting to perform more complex procedures would inevitably lead to contamination or a real disaster. I believe this cannot be encouraged. Most critically ill infants are placed on an open radiant warmer, which is a more suitable platform for operating, though it, too, has limitations. Because of a vertical post at the foot of the warmer, the infant is accessible from only three sides. This means that either the anesthesiologist does not have access to the airway, which is not acceptable, or the nurse has to pass instruments past an unsterile post. Many of the warming units do not have the capacity to be raised or lowered (at least not easily). Performing a complex operation on a tiny neonate requires intense concentrationthe surgeon’s energy should not be diverted to maintaining an awkward body position. For many operations, particularly those in the abdomen, it is not always possible to predict the operative findings and, therefore, what instruments and supplies might be needed. These would be readily available in the operating suite. Sending a nurse to the operating suite to obtain them could cause significant delays. The portable head lamp is an excellent supplemental light source, especially for working in small deep spaces such as PDA ligation, but the head lamp is not as effective for larger fields. The lights in the warmer unit and the portable floor lights in the NICU are usually very inadequate.
Performing surgery in the NICU certainly has a place. It would seem to be best suited to operations that are short and predictable, such as PDA ligation, lung biopsy, and perhaps a few others. Critically ill infants with diaphragmatic hernia may already be on extracorporeal membrane oxygenation (ECMO) support or soon be candidates for it; surgery in the NICU may be appropriate and even life-saving here. In many centers, small premature infants with perforated necrotizing enterocolitis are treated by simple placement of abdominal drains, which is easily done under local anesthesia in the NICU. Larger babies with NEC or other abdominal conditions are probably better cared for in the surgical suite. The distance from the NICU to the surgical suite may be a factor. In some centers, infants actually have to be transported by ambulance or wheeled through long corridors or tunnels. NICU surgery becomes more appealing in that setting.
The major disadvantage of transporting the infant is the need for multiple bed transfers. Improved technology such as methods for rapid connect/disconnection of lines and monitoring devices would be helpful. Efficient portable heating units would make it possible to transport the infant on the radiant warmer, thus eliminating two transfers. Better warming units would make surgery easier in the NICU or even in the OR, thus eliminating all transfers.
As we care for ever smaller and sicker neonates with increasing success, the need for surgical intervention also grows. We must continue to evaluate the best strategies for surgical care. (Dr. Seashore is Professor of Pediatrics and Surgery, Yale University School of Medicine.)
Reference
1. Gavilanes AWD, et al. Use of neonatal intensive care unit as a safe place for neonatal surgery. Arch Dis Child 1997;76:F51-F53.
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