CHAPTER 16

Principles of Pediatric Surgery

Roxanne L. Massoumi, MD, and Steven L. Lee, MD, MBA, FACS, FAAP

No matter the age of the patient, the prospect of surgery is generlly anxiety-provoking for the patient and the patient’s parents. As with any stressful patient encounter, communication is the key to educating, calming, and reassuring patients and their parents. This is particularly true in case in which patients are being referred, even initially, for surgical consultation. Pediatricians can provide significant support by giving the parents basic information about surgical care. It is also important for primary care physicians and surgeons to communicate with each other to provide the highest level of care.

Preoperative Care

Initial Consultation

When a surgical problem is suspected, the first task of the primary care physician is to initiate a referral to a pediatric or general surgeon. The purpose of the initial surgical visit is to confirm the diagnosis and discuss surgical and, if applicable, nonsurgical, treatment options. Surgical procedures are rarely performed during this consultation, and this fact should be stressed by the primary care physician prior to the surgical consult. Many children and parents mistakenly think that surgery will occur at the time of the first encounter and are therefore unduly anxious. Some parents even schedule time off from work unnecessarily with the expectation of having to provide postoperative care for their child, and they become disappointed and even angry when the surgery is not performed. Sometimes the diagnosis of the primary care pediatrician is incorrect, in which case the surgeon can reassure parents about the correct diagnosis and advise them that surgery is not necessary.

The parents and children are given a significant amount of information during the surgical consultation. A referring diagnosis is either confirmed or not, and a decision is made about whether the patient requires an operation. If surgery is indicated, it is described in detail to the parents and, if age-appropriate, to the patient as well. A thorough review of the risks and benefits of as well as any alternatives to the procedure is undertaken. An estimate of how long the procedure will take is given. A general discussion on the expected recovery is conducted, such as whether the procedure will be performed as outpatient or inpatient, where hospitalization occurs, how long the child will miss school, and whether any activity restrictions exist.

Parents and patients should be encouraged to compile a list of questions before their first clinic visit to make sure that questions are not left unanswered. Parents and patients should also write down the answers to refer to them at a later time. Typical questions include the length of time of the procedure itself, the use of anesthesia, and the length of recovery time. If parents agree to proceed with surgery, the surgeon starts the process and paperwork. Often, this is the only visit required before the date of the operation. However, some hospitals require patients to be seen by the surgeon within 30 days of the procedure; thus, a return visit may be required if the date of surgery is beyond that time frame. Additionally, some hospitals and surgery centers require patients to undergo a preoperative evaluation by the anesthesia team prior to surgery.

Preparation of Anesthesia for Infants and Children

Anesthesia is extremely safe in infants and children, and the risk of a poor outcome from general anesthesia is less than 1% at most institutions. Specialized pediatric anesthesiologists provide anesthetic care for infants and young children. If a pediatric anesthesiologist is not available, anesthetic care for infants and children is often limited to a set of experienced general anesthesiologists. Parents and patients often experience anxiety about undergoing anesthesia. Videos have been created and are available at many institutions to help explain the anesthesia process. These videos have been shown to increase medical knowledge and decrease anxiety about undergoing anesthesia.

Many types of anesthesia exist, including moderate sedation (ie, conscious sedation), regional anesthesia, and general anesthesia. Typically, the type of anesthesia is determined by the surgeon and anesthesiologist; however, the anesthesiologist makes the final decision. Although the least amount of anesthesia is desired, all patients must be treated as though they may require general anesthesia in case moderate sedation or regional anesthesia is inadequate to provide the required anesthesia for the individual operation.

To minimize the risk of aspiration when undergoing general anesthesia, the stomach must be empty of food and liquids. Although each hospital has its own specific policies, Box 16.1 lists frequently recommended guidelines for the interval between meals and surgery. In general, most infants and children must miss 1 meal before surgery. Often, it is possible to replace this meal with clear liquids.

All medications should be continued unless otherwise directed by the surgeon or anesthesia staff, and they can be taken with a small sip of water on the morning of surgery. It is also recommended that the parents or guardians bring a list of the child’s medications on the day of the operation so that the surgical staff can review the list preoperatively.

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