Pediatric Surgery

Hi there,
I have moved from the world of Cardiothoracic Surgery to Pediatric Surgery. It has been great fun and something of a challenge to operate on these tiny patients. The best thing is that they heal so quickly and the worse thing is that they do not actually tell you that they have acute abdomens. Still, I am enjoying this experience though I would never want to be a Pediatric Surgeon.
Today I corrected a very small child with pyloric stenosis. This child presented with projectile vomiting after feeding. The child’s poor mother was so emotionally wrought after suffering with this baby over the past 48 hours. She was able to get some good sleep while we corrected the defect.
I made a 1-inch curvelinear incision above the umbilicus and delivered the pylorus through this incision. I then made a 1/2 inch vertical incision through the outer muscle of the pylorus being very careful not to cut into the submucosa. I then closed the facia and skin with interrupted sutures and Steri-strips.
Mom was able to feed the baby as soon as the child come out of the recovery room. The child will take 2 oz of formula every 2 hours and gradually work up to full feeds. It might take a day or two for this child to adjust to the surgery but the child was doing fine when I left the hospital.
I placed a gastrostomy feeding tube in a profoundly disabled ex-premature baby and drained a very large abscess that another child had acquired from a fall. It was a day of little things but fun things to do in the operating room. When I am done with the surgeries, I generally go home after I have checked the patients.
Another challenge is gaining the trust of the parents. After all, would you hand over the keys to your car to a total strange? Your child is even more precious than your car so I do not take that trust lightly. That’s why surgery is the most awesome thing that anyone can do!
Natalie

Hi folks,


I had the distinct pleasure to remove a congenital bronchogenic cyst from a patient not too long ago. Bronchogenic cysts are usually solitary and lined with cuboidal or columnar ciliated epithelium with mucus glands. Most are within the lung but some are found within the mediastinum. Those within the lung communicate with a bronchus and those within the mediastinum do not. These cyts can cause pulmonary problems or may be picked up on a routine chest x-ray for sports or employment. All of these cysts must be removed surgically and many of the mediastinal cysts may be removed by minimally invasive techniques.








In this case, there was 460 ml of fluid in the cyst. We placed a scope in the mediastinum to evaluate the cyst but found that it has a bronchial attachment and thus we were not able to remove it through the scope.You can readily recognize the cyst and below it is some lung tissue. What you cannot see is the bronchial attachment to the cyst. We did a throacotomy and the patient went home four days later after doing very well. This was a very fun case.





Natalie

Hi there,
Just finished a Friday day and night of call. I had the distinct pleasure of fishing two quarters out of little folks who had swallowed them. One of my attendings had just finished explaining the most two-year-olds swallow pennies when I pulled out the quarter. We sent the quarter to pathology who will send it to the child’s parents. (Nice touch!)
The second child was six years old. She politely told me that she knew the coin was a quarter because that was “all of the money she had” and she wanted to keep it away from her brother. She said she accidently swallowed it when she forgot that it was in her mouth. The coin had wedged sideways in the esophagus just behind her breastbone. She was having difficulty swallowing saliva but no problems with breathing. I put a rigid esophagoscope down her esophagus after getting her under general anesthesia and fetched the coin. She was discharged about two hours later.
I had my usual parade of three-year-olds with nausea and abdominal pain that needed to be monitored overnight for appendicitis. This is a very difficult age to assess abdominal pain and I have seen more than one three-year-old child with an abdomen full of pus from a ruptured appendex that was running around and playing happily. A rising white blood cell count is usually my cue to put a scope in and have a look. I also do the “jump” test. I have the child get up on a stool or chair and jump off. Again, they can pass this test and still have appendicitis but it is generally reliable in children over six. (A child with peritonitis is not going to jump off the chair.)
My other realization is that children who are profoundly disabled populate pediatric hospitals. Most of the time, I never see the children who have end-stage metabolic diseases and profound mental retardation because these children are generally not out in the population. I have been operating on several children who are profoundly disabled with very limited life-spans. The cases are very sad sometimes. I have lots of respect for the foster parents who take care of these children.
My job is to put in gastric feeding tubes and perform a procedure called a Nissen fundoplication. I use a laparoscope and dissectors to free up the abdominal esophagus. I then wrap a portion of the stomach around the esophagus which helps to anchor the gastro-esophageal junction in the abdominal cavity. This prevents reflux of gastric contents into the esophagus when the lower esophageal sphinctor is not competent. The gastric tube is for feeding. Again, this is inserted through the laparoscopic.
Well, that’s my call day and night. My patients ranged in size from 900 grams to 56 kgs. Still, they were fun.
Natalie
Being a senior resident is not so bad after six months!

Yeah, working with the severly disabled children, the ones you know aren’t going to make it to 21 is heartbreaking. I work with a few little guys that have had the Nissen proceudre performed. It’s worked extremely well for their reflux.

Hi there,
Fresh from another night of pediatric surgery call. This time the weather closed in with lots of icy roads and motor vehicle collisions. I was deluged in traumas most of the night. I ended up doing three cases during the night all of the the kiddies did very well.
The most seriously injured child was pretty frightening at first. They did not have any pain but they were tachycardic after 2.5 liters of resuscitative fluid. In my book, tachycardia in a trauma victim is hypovolemia until proven otherwise which turned out to be the case.
Hypovolumia is caused by excessive blood loss, which, in this case was internal bleeding. This child was stable long enough for me to get a CT of the abdomen and pelvis that revealed a shattered spleen. Again, trauma is pretty simple if you think about what is in the abdomen that will bleed profusely. Your choices are spleen and liver. Since this patient took most of the brunt of the collision on the left side, I voted for the spleen and won.
We got into the OR, got the abdomen open and I was packing like a fool. The anesthesiologist was on the top of his game because he was ahead of me with the fluid. I mobilized what was left of the spleen and got out with room to spare. This patient needed very little blood and was doing well when I left the hospital post call. Sometimes things just work out great.
My attending physician was very comfortable allowing me to have plenty of decision-making in the management of this trauma. He hovered just enough but never disagreeded with any of my management strategies. The ER physician was a Pediatric ER fellow (base residency in pediatrics + fellowship). He was very content to allow me to take the lead. If this patient had been an adult, they probably would have been intubated but children have some much reserve. If you just look at a child, you realize that something catastrophic has to happen before you use up that reserve. I had a high level of suspicion especially after the fluid. (It’s called “gut surgery” and it’s not taught in any residency).
The rest of the night was abdominal pain in little kids and bumps and bruises from automobile accidents. These little kids are sometimes not belted by their parents and end up with injuries from very minor collisions. Moral of story: Children should always be in either a properly fitted safety seat or belted and under 12 goes in the rear seat.
Natalie

Hi there,


My public service announcement: For those of you who are frying turkeys today.





1. Make sure that your rig is on a solid flat service and outside is the best thing to do.





2. If you spill some peanut oil as you are filling, clean it up right away. Peanut oil is very flammable. Have a good grease cleaner nearby and take the time to clean up all spills promptly.





3. Keep your children and pets far away from your frying device. Hot bubbling oil and a gas flame are a recipe for a huge burn that will change your life forever.





4. Keep a grease fire extinguisher very close at hand.





5. Do not leave your meal unattended. Have someone watching the process for the entire time. Be careful placing the turkey into the oil and removing the bird. Hot oil can drip onto the heating device and cause a flash fire. Have someone help you with this process.





I have already had one admission to the burn unit with flash burns from a turkey fryer. The rig turned over and the patient slipped in the flaming oil.





Nothing can ruin your Thanksgiving faster than being admitted to the Burn Unit. Most people have their Christmass and New Year’s ruined too because it takes months to recover from a burn.





Keep safe and watch for the dangers of fires. Burns are devastating and often preventable. As the weather gets colder, people are more vulnerable.





Natalie

Hi Folks,
The article below is from the Washington Post todays issue. It describes how pediatric cardiothoracic surgeons often work. It is also very well written and illustrates some of the unique challenges of any pediatric surgery. Enjoy reading this.

Infant Heart, the Size of a Walnut, Rebuilt and Running
By David Brown
Washington Post Staff Writer
Friday, November 25, 2005; A01

Sometime in the first seven weeks of life in the womb, Zachary Davis’s heart got the wrong instructions.
The intricate folding, splitting and sprouting that produces the heart’s four chambers and a tree of major blood vessels did not follow the normal genetic plan. The heart he was born with on Oct. 20 was not the engineering marvel that can take people through nine decades.
Still, Zachary’s heart was a marvel in its own right. It shared many features of known congenital malformations. But it also had something not previously recorded in the annals of medicine. His coronary arteries, which normally deliver oxygen and nutrients directly to the heart muscle, were instead supplied by a bizarre circuit routed through his brain. It was as if an important package were being sent from one house in Washington to another down the street via . . . Baltimore.
"It usually takes lot for us to say, ‘That’s amazing,’ " Richard A. Jonas, a heart surgeon at Children’s National Medical Center, said last week. "We see a lot of unusual things. But this was out there."
This exotic misassembly was good enough to get the baby through gestation. It would not be good enough to get him through life. A week after Zachary was born, Jonas took his heart apart, added missing pieces and reconstructed it to something close to its original specifications. It took about four hours and included a 25-minute period when the infant was packed in ice, with no blood circulating.
One day soon, Zachary and his mother, Jessica Davis, will go home to La Follette, Tenn., a town of 8,000 on the Kentucky border. On this Thanksgiving holiday, however, the baby is still learning to eat enough to enable him to grow. He will need at least two more operations on his heart as he gets bigger. But doctors expect him to have a normal life.
“There are only a handful of people in the world who can take a problem like this, think it through, do a complete repair, and have the child turn out so well,” Mary T. Donofrio, Children’s director of fetal cardiology, said of Jonas. "He actually did three operations, and [Zachary] had no leftover heart defects."
Jonas, 54, a native of Australia, went to Children’s last year after 20 years in Boston, where he was a professor at the Harvard Medical School. He is an advocate of “early primary repair” – fixing heart malformations right after birth in a single operation. The team being assembled around him is turning Washington into a referral center for ultra-complicated pediatric heart surgery. Last week, he operated on an infant flown in from Abu Dhabi.
Early primary repair is difficult, even daring. How Zachary would tolerate a one-stop solution to his many heart defects, including the unique one, was hard to predict.
“What did I anticipate? It was sort of hard to have an anticipation,” the surgeon said.
A Broken Arch
Jessica Davis is a 17-year-old high school senior. Zachary is her first child. The baby’s father at this point is not in the picture, she says.
She went to school until April, when she left and began studying for her General Educational Development (GED) certificate at home. She hopes to return after Christmas and graduate with her class. She would like to be a cosmetologist.
Jessica knew something was wrong with her fetus before he was born. A fetal ultrasound detected an abnormal heart and circulatory system. She was on bed rest for the last two months of the pregnancy.
Zachary was born nearly at term on Oct. 20 at a hospital in Knoxville. He was apparently healthy and weighed 8 pounds, 1 ounce. But the heart defect made his condition unstable, and he was immediately taken to the intensive care unit. Jessica did not hold him until he was more than two weeks old.
The aorta is the body’s biggest artery. It leaves the heart’s main pumping chamber – the left ventricle – and sweeps upward in an upside-down U, giving off arteries to the heart muscle, head and arms before heading down the chest into the abdomen to serve the lower body. This first part of the aorta just outside the heart is called the "aortic arch."
In Zachary’s case, the arch did not exist as a single structure. The segment of the aorta that left the heart was abnormally narrow. The segment sent off two branches, the coronary arteries, which deliver oxygen and nutrients to the heart muscle. But then, instead of arching around and giving off many more branches, the aorta simply divided into two vessels, the carotid arteries, which send blood to the brain.
The part of the aorta that would normally have been the far end of the arch was attached to a structure called the pulmonary trunk. It gave off its usual branches. But it had no direct connection to the underdeveloped first part of the aorta.
The “interrupted aortic arch” was not the infant’s only problem. There were others.
The valve that normally lets blood out of the left ventricle into the arch was permanently closed. Consequently, blood pumped by that ventricle went instead into the neighboring right ventricle through a large hole in the wall separating the two chambers. From there, it went out of the heart and eventually into the far end of the aortic arch.
A big question in this odd circuitry was how blood was getting to Zachary’s coronary arteries. They normally receive blood just as it leaves the heart. But in his case, no blood left by that route.
It was still a mystery when one of Mary Donofrio’s former cardiology trainees called her from a hospital at the University of Tennessee in Knoxville and said they had a baby whose problems were too complicated for doctors there to handle. It was only when the infant arrived in Washington by air ambulance at two days old and Donofrio did further tests that she was able to figure it out.
What she found was that Zachary’s heart muscle was living off blood that went up the vertebral arteries to the brain, around a Beltway-like structure there called the “circle of Willis,” and then down the carotid arteries in the opposite direction of the normal flow. At the end of this journey, the blood entered the dead-end stub of the aortic arch and fed the coronary arteries that came off it.
This long detour was something Jonas had never seen. He had just published a single-author text on the repair of heart defects – a book with 300 drawings of anomalies and how to correct them – so he was pretty sure he knew what had been reported by other surgeons over the years.
He checked the electronic database of journal articles again last week. He was right; the defect was unique.
Stopping the Blood
Some of the surgery Jonas would do to fix Zachary’s heart could be performed while the baby was on a heart-lung machine that pumps and oxygenates blood. But not the most important tasks.
That’s because the machine needs to have an aorta to pump blood into, and during much of the operation Zachary’s aorta was going to be in pieces. Jonas was going to have to cut it open, graft on a piece of vessel from an organ donor, and sew the reconstructed arch to its proper attachments.
During that time the infant would have no circulation. He would be cooled in ice to below 60 degrees Fahrenheit, a state of “deep hypothermia” that slows metabolism and reduces the body’s demand for oxygen.
A newborn’s heart is about the size of a large walnut. The operation is done with the surgeon wearing jeweler’s magnifiers

attached to glasses. How long a baby can be kept safely in “circulatory arrest” varies, but it is generally not more than 45 minutes. With each minute beyond a time limit that the surgeon cannot pinpoint exactly lies brain damage, a lifetime of lost potential, unhappiness and death.
There was no part of the repair of Zachary’s heart that Jonas had not done many, many times. The outcome hinged on preparation, timing, speed, accuracy and imponderables – including the chance that Zachary’s unique feature might somehow affect his odds.
Jonas sketched out the repair, determined the order of his work and kept a running total of how long it would take. (He prefers to do this the night before, explaining that “you do literally sleep on it; you run through the steps in your sleep.”) There were 10 steps, the first seven requiring circulatory arrest.
“What is difficult about an operation like this is coordinating all those modules,” Jonas said. “You do not have an unlimited amount of time.” The right order of work is not always obvious. In this operation, for example, he sewed one end of a donated vessel as Step 6, and the other end as Step 10. The price of doing things in the wrong or inefficient order can be very high.
"You can paint yourself into a corner. You can literally get in a position where you can’t get there anymore because you did things in the wrong sequence."
Planning, though, only goes so far. “Early primary repair” requires fast, near-perfect work against deadlines that nature imposes. Some of the work can be very difficult.
For example, to create a normal two-ventricle heart in Zachary, Jonas had to cut a slit in one wall of the tiny organ. Through it he poked a piece of tissue, which he then installed as an interior ceiling for the right ventricle. In effect, he sewed a floppy object the size of a quarter to something inside a space the size of a ping-pong ball through a hole a half-inch long. It took him about 30 minutes.
“I have literally done that thousands of times,” he said by way of explaining it was not so unusual. Pushed, he added, "It wasn’t easy the first thousand times."
He gives a lot of credit to people who tell him what to expect – non-surgical specialists such as Donofrio.
"I have to know what I’m going to see when I go in. If I have to consume time figuring out the anatomy – trying to understand exactly what the child’s anomaly is – then that disrupts the whole operation."
Nothing like that happened with Zachary Davis. Zachary ended up with a normal appearing four-chambered heart in which the blood flows in the right direction.
“I was absolutely thrilled to see that the child did exceedingly well,” Jonas said.
Away From Home
Last week, Jessica Davis cradled and nuzzled Zachary with confidence as her mother, Jenny Slover, 42, looked on. He looked like a normal baby except for the wires emerging from his pajamas to an EKG monitor and the blinking blood oxygen sensor clamped on one of his fingers.
But the entire family was restless, waiting for Zachary’s feeding to reach the 2.5 ounces per session he needs to be discharged.
“I just want to take him home,” Jessica said.
Jessica will live at home, and her mother will care for Zachary during the day. That was always the plan, even before the problems.
“We’re looking forward to being able to say the journey’s over,” Slover said. "To get where we can walk through our door and say, we’re home."
© 2005 The Washington Post Company
Natalie

Hi there,
Well, the lake-effect snow is coming down full force. I was driving into the hospital in the pitch-black of 0400h when a truck skidded into me and my Toyota. Needless to say, my poor car is not drivable and I spent some quality time at Metro Hospital. It was not the start of my day that I was looking forward to.
My last day on call brought a wide variety of pediatric surgical problems from swallowed foreign bodies (coins and batteries) to diaphragmatic hernia (ECMO, oscillator and repair) to imperforate anus. I was able to take care of many of the things that came through the emergency room as my attending was exhausted from the long weekend. Together we were able to have all of the children admitted moved to the elective category. There are only a couple of pediatric surgical pathology that absolutely have to be taken to the operating room to be done in the middle of the night. Most cases can be scheduled, done electively in the light of day with a well-hydrated patient.
I have been spending some quality time on the Pediatric Oncology ward. I have a reportable case that I am working up for publication. The difficult thing about this rotation is that in addition to the operative cases, there are loads of studies that have to be nurtured and plenty of reading.
Pediatric surgeons are complete surgeons for pediatric patients. Unlike adult general surgeons, pediatric surgeons do thoracic cases, cardiac cases and vascular cases. In adults, these cases would be handled by a subspecialist. I have even done a nephectomy with my chairman. On any given call day, my cases can run the gambit. It is all very interesting. All pediatric traumas are also covered by pediatric surgery.
Well, back to my journals and research data. Even though I leave this rotation at the end of December to become chief resident on Trauma, I will continue to work with Dr. David Andrews on my research projects. He’s been an excellent teacher and has taken me to new levels.
Natalie

Hi there,
There is no better place to be than a pediatric hospital around the holidays. Even in the OR, the stockings are hung and there is a festive atmosphere around. Next week, all of the parties get underway in full swing. We have cut back on many surgeries so that the kiddies can go home for the holidays.
Today, we are having more lake-effect snow. The water temperature of Lake Erie is 43 degrees and the air temperature is 20 degrees. This makes for lots of the fine, white stuff. I am assured of a white Christmas,which really doesn’t matter too much because I am on call and waiting for the traumas.
I have done a couple of major cancer surgeries last week and those kids will be in over the holidays. Again, the place is joyful even though the diagnoses may be dismal. The children always have plenty of hope.
I am looking forward to taking care of my diaphragmatic hernia patient next week. This child has other congenital anomalies but is holding on. The hypoplastic lung problems that abound with this condition have responded to oscillation ventilation and nitrous oxide therapy. We also used gravity to get the abdominal contents out of the chest cavity. Most of these hernias occur on the left side. It is a good thinking exercise to figure out why on the left. The answer is pretty common-sense.
Anyway, back to my kiddies and their ailments. I have some work to do in the burn unit and I am hoping for no more major structure fires over the holidays or any other time. Burns are just not good.
Natalie

Hi there,
Today, I placed a child on ECMO or extracorporeal membrane oxygenation. This is the pediatric equivalent of being placed on a heart-bypass pump. I did the procedure in the Neonatal Intensive Care Unit with my attending pediatric surgeon. It was an awesome procedure.
We first make a small incision at the base of the neck in the small child after we carefully positioned the child so that we could access the proper area. We used the right side which is an easier shot as the arterial cannula goes into the carotid artery and the venous cannula goes in the internal jugular vein. We open the carotid sheath that contains both vessels along the the right vagus nerve.
We first dissected out the vessels and put Ethibond suture material around the vessels in order to have both proximal and distal control of the vessel as we did the veinotomy and arteriotomy. We then turned our attention to the internal jugular vein which was about the diameter of a coffee stirrer. After making a veinotomy about 2-mm long, we placed two 6-0 proline stay sutures on both sides. We then placed a 12-French venous ECMO catheter into the vein and advanced it about 8-cm. We wanted the base of the catheter to rest near the tricuspid valve in the heart so we threaded the catheter through the internal jugular vein which connects with the superior vena cava which attaches to the right atrium. We advanced the catheter antegrade into the heart and sutured it in place.
We then turned out attention to the common carotid artery. We made the same sized arteriotomy and place two more stay sutures on both sides of the opening. We then advanced an 8-French arterial ECMO catheter retrograde about 3 cm into the common carotid artery down to where it takes off the aortic arch. We sutured this in place and then carefully connected both cannulas to the ECMO device.
We closed the skin incision with one suture and sutured the distal ends of the catheters to the skin with 4-0 nylon sutures. We then covered the incision and catheters with a clear dressing so that they could be accessed if there was a problem.
After the procedure, the pediatric cardiologist performed an echocardiogram that confirmed placement of our catheters. We also obtained a chest-film that showed our catheters were in correct position. The echocardiogram gives real-time flow infomation in addition to the positioning. We could see the end of our venous catheter and the flow as the tricuspid valve opened and closed.
The ECMO device will be monitored 24 hours a day and seven days a week by a perfusionist. This person will monitor flows constantly, draw labs and make sure that the membrane oxygenator is working properly. The heart and lungs are bypassed in order to give the child more oxygen and better circulation. This child was born with a very severe heart and lung defect that we will repair in about a week after ECMO.
For a vascular surgeon, this procedure was totally awesome. Again, I am always pushed to the limits by my pediatric attendings. I worked in my loupes and he wore the headlamp. We obtained excellent exposure and got the job done without any problems. When we left, the flows were good and the child was doing well.
It was totally a blast!
Natalie

Great stuff! Whatis the weeks time for? To allow the kid to recover from the ECMO procedure? Recovery from prior chronic hypoxia? Something else I’d never think about?? Just curious. Thanks for the post!

Hi there,
In this particular child (with diaphragmatic hernia), pulmonary hypertension (even with nitric oxide) was preventing oxygenation. By moving to ECMO, we were able to buy some time for lungs to heal and keep oxygenation high. The downside is that the right carotid artery has been sacrificed. (Thank God for collateral circulation).
Natalie

Hi Folks,
Another night of call and operating all day and into the night. I started my regular cases at 11AM and with the added emergency cases, I finished after midnight. The good thing was that I had a nice variety of cases to do. The bad thing was that one particular resident in the emergency department wanted me to second check every child with abdomial pain. On her third call, when I was between cases, she couldn’t tell me what she had found on her initial exam. I stated that I was getting ready to do an appendectomy and that the child in the ED had to be sick enough for me to delay surgery on a child that actually had the disease. She started to cry which enraged me so I gave her the ground rules:
1. Do not call a specialist until you have done a history and physical exam. You need to be able to give me some information as to why you are consulting me. Every child with abdominal pain does not need a surgeon.
2. I do not want to know if the child has pets at home or who their parents are. I want to know what your abdominal exam findings are.
3. You can order some IV fluids and labs on a child that is dehydrated. Those things are good patient care and not the realm of surgery alone.
4. If I tell you that I am about to do a case, you NEED to tell me if you have an true emergency or something that can wait an hour for me to finish my case. If you do not know, get your senior resident to tell you and call me. Would you want me to delay emergency surgery on your child for something that was non-emergent?
The child in question turned out to have constipation and no surgical emergency. I was done with the appendectomy in 45 minutes and examined the child. The senior ED resident had actually ordered some abdominal films which were normal thus the child was admitted to general pediatrics. In the morning, the general pediatric attending asked me what I thought of the admission. He was perturbed that the child was admitted for constipaton (something that can be taken care of as an outpatient).

For the rest of the night, this pediatric intern did not call me with questions. There was no patient that I saw that she had previously examined that needed a surgeon. In every case, I went over the exam with her but it took six hours out of my day which was pretty busy.
There were two cases that actually needed me but they did not consult me until after they had found something on radiographical studies. When I read their assessments, they were thinking of sending these children home. Fortunately, the chief of radiology was reading ultrasounds and alerted me before they discharged the children. He is simply the best.
I did get to place a couple of Broviac catheters in neonates. The fun thing for me is that their external jugular veins are about the size of a thread. I popped the catheter in place in the OR, then check for placement with the fluroscope and make sure the tip of the catheter is above the right atrium as the heart beats. I tend to place these a bit lower than my percutaneous triple lumen catheters because these catheters can be in place up to several months and the kids will grow. I suture them to the side of the head just above the ear. The scalp skin is tough and nice to suture to. When the cathter is removed, the proximal incision will be covered by hair and the distaal incision will be in the neck crease. Good stuff!
I did one laparoscopic appendectory and one open appendectomy. Both children were doing very, very well when I left on Saturday morning. I did the older child (17) with the laparoscope and the younger child (4) open. The older child ended up with an umbilical incision that was one inch long and two side incisions that were 1/2 inch long. All were covered by Steristrips. The younger child ended up with one incision that was 1.5 inches long and covered with two Steri-strips. When it comes to appendectomies, laparoscopic and open are fairly equal in terms of incisions and recovery length. (This rule does not apply to gall bladders!)
I do love my late night emergency surgeries. The patients feel better rapidly and are able to go home quickly. If I had encountered a patient that was severly dehydrated with a rigid abdomen, I would probably opted to hydrate them well and give them antibiotics with the option to do them in the morning as long as they are not in shock. One of the worse things you can do is surgery on a patient that is not properly resuscitated. This can make the difference between going to the ICU and going back to the general ward.
In most pediatric patients, since they do not have chronic diseases like coronary artery disease and diabetes, they respond to correction of fluid and electrolytes promptly. Even a child with the worst peritonitis will respond to IV fluid hydration and will feel better. It is also good to give them some pain medication too.
Although the day and night was pretty long, it was pretty enjoyable after I finished my pediatric intern teaching. She is going to have a rotation on the surgical service next month. I won’t be there to ride her a bit but I have left good instructions for my colleague who will be taking my place. By the time her surgery rotation ends, she will not be calling a surgeon for constipation.
Natalie

Hi Natalie,
I very much enjoy reading your notes on the various surgeries but am unable to access the photos which I would very much like to do. Are you actually attaching photos each time or is that just left over in your subject line from a previous post that did actuallly include photos? Is it really difficult for you to attach photos? If not, please do and let me know what I have to do to access them.
Thanks,
Sheryl

Hi there,


Several weeks ago, I admitted a patient in the middle of the evening who had Pelvic Inflammatory Disease or severe inflammation of the adnexae (fallopian tubes and ovaries). This was a young woman of child-bearing age who had acquired the infection from unprotected sexual intercourse. Her fallopian tubes (salpingitis) and ovaries (oovritis) were both inflammed and filled with purulent material.





I inserted a laparoscope into a very small incision made just below the umbilicus. Under direct vision, I inserted a grasping instrument through another tiny port (5-mm) on one side and a cutting instrument through another port (5-mm) on the other side. Our camera, light source and gas pressure are all controlled by voice command. I just simply command the computer Sydne, to white balance the camera. As you can see in the photo, I commanded Sydne to take this picture just as I had entered the pelvic cavity. I have placed labels on structures. You can see the huge size of the fallopian tube that is filled with pus. The ovary is pretty obscured by the tubal edema.





[image]http://www.oldpremeds.org/ubbthreads/download.php?Number=35872[/image]








While I was in there, I removed the appendix since it was stuck to these tissues because of the inflammation. When the case was done, I closed the three tiny incisions and placed the patient on broad spectrum antibiotics. She was discharged from the hospital on post operative day 1, with minimal pain and eating well. When I saw her in office one week later, she was extremely happy to be rid of the terrible pelvic pain that had brought her into the hospital. She also said that she had learned her lesson in terms of having unprotected sex.





The long-term consequences of this problem is related to future fertility. Many women have less severe infections like this and end up with permanently scarred fallopian tubes thus preventing pregnancy or leading to ectopic pregnancies. These conditions can be very difficult to treat or life-threatening in the case of an ectopic pregnancy.





Just more photos from my three tours on Pediatric Surgery. The scope of practice of the pediatric surgeon is the greatest of any surgical specialty. From thoracic to vascular to gyn, the pediatric surgeon will handle everything including burns and trauma.





Natalie





P.S. Some of my posts will have photos and some will not. I will try to include a photo when it demonstrates something that I am trying to explain. I would hope to have more and more photos. If you right-click on the word “attachment” above, you will be able to see the photo.

Hi Natalie,
Thanks so much for that description and photo. You have a very clear way of describing the procedures, and the accompanying photos enhance the effect of “being there”. Since it will be several years before I actually CAN be there; I really do appreciate the time and effort you take to share your experiences with the rest of us. Happy Holidays to you.
Sheryl

Hi there,
Winding down towards the end of my rotation on Pediatric Surgery. I am working over both holidays (unlike my colleagues back at my home base hospital) but a pediatric hospital can be lots of fun around Christmas. Santa comes through on a regular basis.
I have had the opportunity to do some very challenging cases that only come along rarely. I got to repair a congential diaphragmatic hernia which was the first one in two years at my hospital. It was awesome. The strategy behind getting these children through this tragic congenital defect where the gastrointestinal contents are in the chest when the child is born, it treated the pulmonary hypertension. During fetal development, the defect (most commonlly on the right side), causes that lung to be hypoplastic. The child continues to have a high degree of pulmonary hypertension which can be fatal. My patient is coming along slowly after ECMO (extracorpeal membrane oxygenation), oscillation mechanical ventilation with nitric oxide and pressors. For most of my patients live, this child has been paralyzed and sedated for these high tech life support measures. At present, the diapharagmatic defect is closed and the chest tube is out. The hypoplastic lungs will take a bit longer to heal.
I treated a couple of patients with gastroschesis, where the baby is born with the gastrointestial contents outside of the abdominal cavity. In both cases, we were able to close the defect within one week of birth but the intestinal tract takes a hit from being exposed to amniotic fluid. This is my research for the next couple of years. I am studying the development of NEC (necrotizing enterocolotis) in children who have undergone gastroschesis repair. It’s exciting to have enough of a population to study this congential defect.
I have also repaired the other abdominal wall defects: omphalocele (where the GI organs are in a membranous sac outside the abdominal cavity) and cloacal extrosophy where the rectum and urinary tract are a single opening and underdeveloped outside the abdominal cavity. The last defect was the most problematic because the child was much older when the definitive repair was one. Omphaloceles and gastroschesis are repaired as early as possible.
My embryology and pharmacology were tested to the max also. When you are dealing with children, you have little room to error. Some of my patients only weighed 500 grams. My largest patient was 22 years old and weighed over 200 pounds (he had a pediatric disease).
The saddest cases were the children with the profound genetic defects that were mentally retarded. They did not understand why they needed to be going through painful procedures such as surgeries. In the end, they were better but it was heart-wrenching at times. I am a huge advocate of adequate pain relief.
My most challenging cases at times were removing foreign bodies from upper airways and esophaguses. Most of the time, the foreign body was a coin with quarters being the most popular coin swallowed. The age range of the children averaged around 16 months. I did attempt to fetch one watch battery from a five-year-old’s duodenum but I couldn’t get the object into the snare basket. In the end, the battery passed through without difficulty. It just stayed in the duodenum longer than we would have liked. A bit of milk of magnesia got it underway rapidly.
Natalie

Natalie,
I love this. I’m having more fun reading about these procedures. I’ve shadowed a general surgeon in a small town, but the procedures were either gallbladder, appendix, or hernias. It’s great to read about everything else!

Dr. Belle,
I just also want to say THANK YOU for taking the time to write up your experiences. They – and your perspectives – are fascinating, inspiring, and thought provoking.
I am always excited to see a new post by you in your rotation threads. I know we all appreciate it!
Liam