Saving the Smallest Patients: Premature Baby’s Life Transformed by Advanced Neonatal Surgery

Neonatal surgery represents one of medicine’s greatest challenges—operating on the tiniest, most vulnerable patients whose bodies are still developing. When a premature baby born at just 35 weeks and 4 days developed a rare right-sided congenital diaphragmatic hernia, the multidisciplinary team at Burjeel Specialty Hospital, Sharjah, performed a complex thoracoscopic and thoracotomy repair, showcasing the advanced neonatal surgical capabilities now available in the region. 

A Complicated Beginning 

Birth Details: 

• Gestational age: 35 weeks + 4 days (premature) 

• Birth weight: 2.6 kg 

• Maternal history: G5P1, no comorbidities 

Immediate Post-Birth Complications: 

• Respiratory distress requiring surfactant therapy 

• Early-onset sepsis (blood culture positive for Group B Streptococcus) 

• Suspected meningitis (treated empirically) 

Initial Imaging: 

• Day 1: Clear chest X-ray 

• Subsequent imaging: Right-sided pneumonia with pleural effusion 

• Day 9: Echocardiography revealed mediastinal mass with leftward shift of mediastinal structures 

Clinical Progression: 

• Developed tachypnea (rapid breathing) 

• Required High-Flow Nasal Cannula (HFNC) support (FiO₂ 25%) 

• Continued respiratory compromise 

The Diagnostic Discovery 

Chest X-ray and CT Scan revealed: 

• Defect in the right hemidiaphragm 

• Herniation of right lobe of liver into thoracic cavity 

• Bowel loops displaced into chest 

• Compression of lung tissue 

Final Diagnosis: Right Congenital Diaphragmatic Hernia (CDH) 

Understanding Congenital Diaphragmatic Hernia 

CDH is a rare birth defect where: 

• The diaphragm (muscle separating chest and abdomen) doesn’t form completely 

• Abdominal organs herniate into the chest cavity 

• Lung development is compromised 

• Can cause severe respiratory problems 

• Requires surgical repair 

Incidence: Approximately 1 in 2,500 to 1 in 3,000 births 

Right-sided CDH is particularly rare: 

• Only 10-15% of CDH cases 

• Often more challenging surgically 

• Involves liver herniation (heavy organ) 

The Dual Surgical Approach 

After optimization and control of sepsis, surgery was planned on Day 16 of life. 

Initial Approach: Thoracoscopic Repair 

• Minimally invasive using 5mm neonatal-specific instruments 

• CO₂ insufflation with careful ETCO₂ monitoring 

• Identified hernia contents: right liver lobe, large intestine, small bowel 

• Gentle manipulation to reduce organs back to abdomen 

Intraoperative Finding: 

• Defect occupied nearly 50% of the diaphragm 

• Well-developed lung (positive sign) 

• Size and complexity necessitated conversion 

Conversion to Open Thoracotomy: 

• Ensured adequate exposure 

• Allowed precise repair 

• Used non-absorbable Ethibond sutures 

• Intercostal drainage tube placed 

Total operative time: Approximately one and a half hours 

Post-Operative Excellence 

PICU Care (48 hours): 

• Smooth post-operative recovery 

• Monitoring of respiratory function 

• Pain management 

• Early feeding initiation 

Hospital Course: 

• Intercostal drainage tube removed on Day 1 post-op 

• Progressive oral feeding 

• Stable respiratory status 

• Discharged in stable general condition 

Follow-Up: Well-developed lung with satisfactory function 

The Complexity of Neonatal Surgery 

Operating on a premature neonate presents unique challenges: 

1. Size Constraints 

• Limited anatomical space 

• Tiny organs and structures 

• Requires specialized miniature instruments 

• Magnification often necessary 

2. Physiological Vulnerabilities 

• Immature organ systems 

• Temperature regulation challenges 

• Fluid and electrolyte balance critical 

• Respiratory system not fully developed 

3. Anesthetic Challenges 

• Precise medication dosing 

• Single-lung ventilation in tiny patient 

• Maintaining oxygenation 

• Hemodynamic monitoring 

4. Surgical Precision 

• Delicate tissue handling 

• Minimal bleeding tolerance 

• Suturing tiny structures 

• Preventing complications 

5. Post-Operative Care 

• Specialized NICU/PICU monitoring 

• Respiratory support management 

• Infection prevention 

• Nutritional support 

Why Thoracoscopy First? 

The initial thoracoscopic approach offered several advantages: 

• Minimal incision 

• Better visualization with camera magnification 

• Less post-operative pain 

• Faster recovery if successful 

• Option to convert if needed 

Conversion to open procedure was appropriate when: 

• Defect size was larger than anticipated (50% of diaphragm) 

• Ensured complete, secure repair 

• Patient safety prioritized over minimally invasive approach 

The Multidisciplinary Excellence 

Success required seamless collaboration: 

• Pediatric Surgery: Dr. Bhushanrao Bhagawan Jadhav (surgical expertise) 

• Neonatology: Dr. Yamen Fayez Elmughanni (NICU support and optimization) 

• Anesthesia: Dr. Mohamed Eid Ali (expert neonatal anesthetic care) 

• NICU Nursing: Ms. Julie and team (specialized post-operative care) 

• OT Nursing: Mr. Rida, Ms. Bindu (ensuring specialized neonatal instruments available) 

A Milestone Achievement 

This case represents: 

• First neonatal thoracoscopic-thoracotomy surgery at Burjeel Specialty Hospital, Sharjah 

• Advancement in regional pediatric surgical capabilities 

• Establishment of complex neonatal surgery program 

• Foundation for future advanced pediatric procedures 

• Demonstration of multidisciplinary excellence 

Why This Matters for the Region 

Previously, such complex neonatal cases often required: 

• Transfer to specialized centers abroad 

• Family separation during critical time 

• Higher costs 

• Travel risks for unstable neonates 

Now available locally: 

• Expert neonatal surgical care 

• Family-centered environment 

• Immediate access to specialized services 

• Comprehensive follow-up care 

• Cost-effective quality healthcare 

Long-Term Outlook 

With successful CDH repair, children typically: 

• Develop normal respiratory function 

• Reach normal developmental milestones 

• Participate in regular activities 

• Require periodic follow-up monitoring 

• Have excellent quality of life 

Our Experts 

Advanced Neonatal & Pediatric Surgery 

Complex neonatal conditions require specialized expertise and family-centered care. Our multidisciplinary team provides comprehensive evaluation and advanced surgical solutions for the smallest patients. 

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