Fighting for Life: Five Advances in Neonatal Surgery Over 50 Years

1.

Neonatal surgery has made notable contributions to enhancing the survival rate and quality of life of newborns with critical conditions. Recent advancements in neonatal surgery focus on reducing surgical trauma, improving precision through technology, and shifting interventions earlier into the prenatal period.

2. Prenatal Diagnosis and Fetal Surgery

Prenatal diagnosis has remarkably improved our understanding of surgically correctable congenital malformations since the use of prenatal ultrasound [1]. It is a non‐invasive modality of diagnosis and has allowed us to influence the mode and site of delivery of the baby, offer prenatal surgical management and discuss the options of termination of pregnancy for seriously handicapping or lethal conditions. Prenatal ultrasound scanning with 3D and 4D images has improved since its first use 40 years ago. The lack of prenatal scanning in LMICs accounted for the large mortality and morbidity in these regions [2]. Developing and training personnel in this technique of simple screening has the potential for decreasing death in surgical newborns. Advocates for birth defects need to concentrate on preventable deaths and disabilities by introducing this simple non‐invasive technique on a global scale. Other advances in minimally invasive technique include maternal blood sampling by identifying cell free fetal DNA [cffDNA] in the maternal circulation with the aim of developing safer test for accurate diagnosis [3]. Invasive tests such as amniocentesis and chorionic villous sampling [CVS] help detect chromosomal anomalies and CVS is the most reliable method for first trimester diagnosis. Rapid karyotyping of CVS and amniotic fluid samples FISH and PCR has replaced fetal blood sampling [FBS] for many conditions [4]. Minimally invasive fetal surgery is established for some conditions and continued to advance for the better outcomes in the newborn for example, Spina bifida, sacrococcygal teratoma, large congenital lung cysts and some urological procedures.

3. Newborn Screening and Surgery

Surgery and newborn screening are linked in the early detection and management of serious conditions in newborns. Newborn screening is a comprehensive method that includes detecting visible birth defects, screening for hearing, vision and metabolic disorders shortly after birth [5]. Literature suggests that screening can positively affect up to 70% of birth defects [6]. World Birth Defects Day [March 3] aims to raise awareness about prevention programs and improving the quality of services and care received by people with congenital anomalies [7]. To mitigate this issue, the 77th World health Assembly supports a framework proposed by World Health Organization [WHO], for establishing comprehensive newborn screening program worldwide, especially in low and middle income countries [LMICs] as part of Universal Health Coverage [UHC] [5]. Newborn screening shows the pathway for early surgical procedures, significantly reducing neonatal mortalities and averting long term disabilities. The global collaborators working on birth defects recommend many evidence based practices to link newborn screening [NBS] results with neonatal surgical teams effectively. It also highlights the value of close collaboration and communication among laboratory staff, neonatal/children surgeons, and neonatologists to ensure that babies with positive screening results have timely clinical assessments and surgical management as needed [8], avoiding “four delay” frame work [Delay in seeking care, delay in reaching care, delay in receiving care and delay in completing care] [9]. It will enhance the efficiency and consistency of newborn screening follow‐up globally [10].

4. Minimally Invasive Surgery [MIS] in Neonates

Minimally invasive surgery [MIS] is one of the most transformative advances in surgical care of the past 50 years [11]. First reported in children in 1971 by Gans, improvements in technology, understanding of physiology, and surgical and anesthetic expertise have facilitated the transformation of MIS from a niche diagnostic tool to the standard of care for many pediatric/neonatal surgical conditions [12]. Though neonatal minimally invasive surgeons have demonstrated technical capacity to manage even the most intricate congenital and acquired neonatal conditions, uptake of MIS in neonates has been slower and more limited than in adults and children [12]. Initially obstructed by a lack of appropriately sized specialist equipment, the widespread adoption of MIS in neonates is now constrained by access to appropriate equipment, the steep learning curve required for safe MIS [for both the surgical and anesthetic teams], concerns about the potential harmful long‐term effects of CO₂ insufflation, and a paucity of quality data on the relative benefit of MIS over open surgery [11, 12, 13, 14]. Neonatal MIS should not be adopted as the gold standard for all surgical pathology, but rather be applied at specialist centers by individuals with high levels of expertise and in carefully selected patients [11, 14, 15]. Looking ahead, the role of MIS in neonates will be advanced through high quality research on the relative safety, advantages and disadvantages of neonatal MIS, ongoing surgical innovations such as Natural Orifice Transluminal Endoscopic Surgery [NOTES], Single Incision Laparoscopic Surgery [SILS], and robotic surgery that have the potential to further refine the minimally invasive approach, and training greater numbers of surgeons competent in neonatal MIS.

5. Advances in Perinatal Care and Anesthesia

Surgical practice has evolved with concomitant substantial advances in neonatal intensive care and support as well as anesthesia practice. This is perhaps best captured by the improvement in mortality rates for premature infants, with infants of 23 weeks gestation now with nearly 85% survival to at least the first day of life compared to near certain mortality 50 years ago [16]. These advances have been a result of the ability of neonatal teams to support multi organ dysfunction, especially premature lung disease, renal failure, and nutritional support. As a result of these advances, the incidence of surgical conditions of prematurity such as necrotizing enterocolitis has also increased. Surgeons have also innovated the care of these infants and developed non‐operative strategies such as drain placement rather than laparotomy for severe necrotizing enterocolitis and also benefited from more reliable vascular access such as peripherally inserted central catheters that can be placed by nurses at the beside [17]. “Low‐tech” neonatal ICU advancements have also shaped practice, such as kangaroo infant care, or “skin to skin contact” developed in Colombia due to a shortage of incubators, and this has become global practice [18]. Advances in pediatric/neonatal anesthesia have also resulted in improved surgical outcomes due to anesthetic management, expertise in perioperative airway, ventilator strategies and fluid management, thermoregulation, and much deeper appreciation of analgesia in infants and newborns who were thought not to feel pain or require opiates previously [19]. In addition, long‐term neurocognitive impact of neonatal and infant anesthesia is also better understood, informing protocol development, practice, and counseling of families. Improvement in these areas have extended to low and middle income countries [LMICs] that have developed low cost, innovative solutions for some previously incurable congenital conditions such as gastroschisis and esophageal atresia [20]. Expansion of the dedicated neonatal and anesthesia workforces in LMICs, as well as guidelines for surgical and anesthetic management through the health care system to ensure that neonates from the community level to the tertiary level have narrowed global disparities.

6. Multidisciplinary Team [MDT] and Parent‐Centered Care in Neonatal Surgery

Successful surgical outcomes in neonatal surgery extend beyond the surgical procedure due to the vulnerability of the patients, complexity of congenital anomalies and critical nature of the interventions; and require coordinated care involving multidisciplinary teams and a parent centered approach. Over the last 50 years, Multidisciplinary team [MDT] with involvement of neonatologists, neonatal surgeons, anesthetists, nurses, respiratory therapists, nutritionists, social workers, and other specialists such as cardiologists and geneticists has contributed immensely to the gradual and persistent decline in the mortality rates of neonatal surgical conditions [21, 22]. Collaboration improves decision making, resource utilization, identification of comorbidities, reduces complication, ensures tailored post‐operative care and improves developmental outcomes in neonates by fostering parental bonding and increasing compliance with postoperative care plans and follow‐up [22, 23]. Family‐centered rounds where the MDT and parents discuss care plans together have emerged as a best practice and boosted parental confidence, clarify care goals, and reduce misunderstandings. Families reported greater satisfaction and less psychological distress with reduced hospital stay [24]. Parent‐centered care [PCC] included respect for parents' values and preferences; clear and compassionate communication, inclusion in care decisions; support for parental roles and responsibilities; and emotional and psychological support [25]. Technologies such as telemedicine further enhanced MDT communication and parent involvement, especially in remote or resource‐limited settings. Personalized care models incorporating MDT composition and PCC strategies to individual family needs and cultural contexts are gradually developing [26, 27].

7. Conclusion

These advancements in neonatal surgery involving prenatal diagnosis and fetal surgery, newborn screening, MIS techniques, MDT approaches have greatly minimized sufferings, reduced mortality, and enhanced long‐term quality of life for newborns with congenital anomalies worldwide. In LMICs where delayed diagnosis results in high morbidity, initiative like timely newborn screening, training to the healthcare providers, and MDT models may prove transformative within existing resources. In future, high‐quality research, local and global partnerships, and well infrastructure will extend all necessary medical facilities to the doorsteps of these neonates.

Author Contributions

Tahmina Banu: conceptualization, writing – original draft, writing – review and editing, supervision, resources. Nirav Patel: writing – original draft, writing – review and editing, resources. Tanvir Kabir Chowdhury: writing – original draft, writing – review and editing, resources. Doruk Ozgediz: conceptualization, writing – original draft, writing – review and editing, supervision, resources. Kokila Lakhoo: conceptualization, writing – original draft, writing – review and editing, supervision, resources.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.