<p>The Aga Khan University Hospital's Paediatric Surgery team in Karachi has successfully performed a bedside surgery on a newborn baby for hernia repair. This surgery, a first, is an incredible achievement because unlike other surgeries, which are performed under ideal Operating Room (OR) conditions, this one was performed at the baby's bedside, in the neonatal intensive care unit (NICU).</p><p>The baby boy was born on 25 April 2023 at the Aga Khan Maternal and Child Care Centre, Hyderabad. Upon birth, the doctors realized he was having trouble breathing and diagnosed him with a defect known as congenital diaphragmatic hernia (CDH). While there is no exact data on how common this condition is in Pakistan, CDH is found in 2.3-2.4 per 10,000 live births in the US.</p><p>CDH occurs when the baby's diaphragm, which separates the abdomen from the chest, fails to close properly. A hole in the diaphragm means the abdominal organs (stomach, intestines, spleen, liver) can migrate up into the chest, where the lungs and heart are supposed to grow. In this case, the newborn boy's intestines had traveled up into his chest, restricting the growth of his lungs and heart. Depending on how severe it is, this birth defect can be fatal. </p><p>The baby was immediately rushed to the AKUH Main Campus in Karachi. As he arrived at the Emergency Room, he was intubated to help him breathe and then admitted to the NICU. The baby was so unwell, he could not be managed on a regular ventilator at first and had to be put on an advanced one. Under the care of our expert physicians and NICU team, he was eventually switched back to a regular ventilator, but his condition remained very critical. </p><p>The only solution to his CDH was surgery. But the team was in a quandary. The baby was too unstable to move to the OR and yet, he needed surgery. And though it had never been done before, it was clear: instead of bringing the baby to the Operating Room (OR), the Operating Room had to be brought to the baby!</p><p>The AKUH family rose to the occasion. The paediatric surgeons, the NICU doctors and nurses, the anesthesia team and support staff all readied themselves for the challenge, and the NICU was transformed into an operating theatre, with all the safety and sterility required for surgery. </p><p>While this might seem very new in Pakistan, bedside surgeries of babies with CDH are a global standard, backed by a growing body of research. In fact, bedside surgeries for critically ill newborns with CDH are preferred because shifting a baby on the ventilator from the NICU to the OR can be quite risky. </p><p>The lead surgeon of the case, Dr Muhammad Aqil Soomro, Section Head of Paediatric Surgery at AKUH, reflected on the risks of doing the surgery in the OR. "Sometimes, these babies are so sick that transport to the OR is dangerous for them and can affect surgery outcomes. There would be four points during transport where ventilators would need changes, putting them at risk. In this baby's case, the need to avoid transporting him, compelled us to adopt this strategy to avoid breaks in the continuity of care which can be very unsafe for a critical newborn."
</p><p>The AKUH Paediatric team took on this exceptional challenge for the sake of the critically ill baby, 5 days old at the time. Under the leadership of Dr Saleem Islam, Chair of Surgery, and Dr Muhammad Aqil Soomro, the bedside surgery in the NICU was performed on 29 April 2023. The surgery lasted two hours and was successfully completed without any major problems. </p><p>After the surgery, the baby's respiration started improving and the doctors were able to gradually wean him off ventilation and medications. The baby was discharged on 7 May 2023 and happily sent home. He will continue to be monitored over the next few weeks and months. </p><p>The team has high hopes of the baby being a survivor. However, CDH is a major anomaly and may have long-lasting repercussions. These babies can have problems with their lungs, as well as digestive disorders like gastroesophageal reflux. There is a minor chance of recurrence - the stitches used to close the diaphragm could give away. Moreover, since these babies have extended ICU stays, they may have overall developmental issues in the future as well. </p><p>But these are all known issues and doctors treat their patients keeping these in mind. These problems are also not life-crippling and can be managed and the patients can still go on to have a good quality of life.</p><p>This first bedside surgery of a critically ill newborn at AKUH has paved the way for very sick babies to be operated on in an ICU. This can help remove the potential risks that come from transporting such sick babies from the ICU to the OR. </p><p>Soon after the first baby, the second ever bedside surgery on a baby with CDH was performed on 2<sup>nd</sup> May 2023 at AKUH, just three days after the first one. Thus, AKUH has created a precedent for these babies to be operated in the most optimal way with minimal risk, following the global best practice for such cases. </p><p>The ability to perform such bedside surgeries in AKUH means not only the continuous improvement of the Paediatric Surgery Team but also that there can now be better outcomes for critically ill newborns. As Dr Muhammad Aqil Soomro said, “It means we are giving newborns who have survival rates of less than 50%, a better fighting chance for a long and healthy life."