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Fundoplication is a kind of surgery which aims to prevent stomach contents from going back to the oesophagus. The operation is conducted by wrapping the upper half of the stomach, close to the lower portion of the oesophagus, thereby tightening the outlet of the oesophagus as it empties into the stomach. In maximum cases, this surgery of fundoplication gets performed by a paediatrician by using a small telescope and small instruments, which get placed through few incisions, in the size of a band-aid on the abdomen.
Why is the surgery necessary?
Fundoplication is usually recommended for children who have the following problems and symptoms, which include:
- Children who have complications or persistent symptoms related to gastroesophageal reflux (GER), which do not improve through medication.
- The symptoms of this problem include vomiting, oesophagitis gastrooesophageal stricture, recurrent pneumonia, breathing problems and insufficient growth.
- Before undergoing the surgery, a paediatrician can perform some tests on the child to confirm GER, like pH probe study or oesophogram.
How is the surgery performed?
The surgery of fundoplication is conducted in the following manner:
- As mentioned earlier, the surgery is performed with the use of a small telescope and miniaturized instruments that are placed through 3-4 band-aid size cuts on the abdomen.
- The surgery is performed within two to three hours and a child might need to stay back in the hospital for 2-3 days after the surgery.
- After the operation, when the child is in hospital, he/she would receive intravenous fluids along with pain medication.
- As and when the child feels well, he/she would be allowed to eat, drink as well as take medicines by mouth.
- For some patients, a gastrostomy tube is put inside the mouth to ensure the feedings get administered and the air gets released. The release of air is known as venting.
- It would be difficult for the child to burp for a number of weeks after a fundoplication has been done. So, the venting ensures that air leaves the stomach, which would lead to a decrease in bloating and thus keep the child comfortable.
Little bit of time would be needed for a child to fully recover from this surgery and for food to go through comfortably into his/her stomach. The first two weeks would involve only liquid diet including:
- Ice Cream
- After this in the 3rd and 4th weeks, his or her foods can include mashed potatoes, pasta, fish, cereal, cheese.
- Then after one month, they can slowly resume their usual diet.
Pain medication as per prescription is not required to be followed on a routine basis after discharge. When the child is back home, they only give either Acetaminophen or Ibuprophen.
Colostomies often get used in situations of Imperforate Anus along with other conditions where a paediatrician finds a defect in the colon or in the large intestine.
Selection of Pouch
Pouch systems are available in many styles as well as sizes. They include:
- A sticky kind of wafer which adheres to the skin and a pouch to collect the stool.
- One piece pouch has the wafer along with the pouch joined together as a single unit.
- The two piece system consists of wafer and pouch in a separate manner.
- There are also open-ended pouches and close-ended pouches
- Open end pouches are most commonly used as they help people to easily out the pouch of air and stool
Changing the Pouch - Procedure
The frequency, with which the change of pouch takes place, depends upon a number of things. A pouch must be changed after it has been there for a number of days.
The good time to get a pouch changed is before a meal or a number of hours after eating, where there is less of stoma draining.
The procedure involves:
- Carefully removing the old pouch with mineral oil. Wash and keep the reusable clip aside.
- A child could be given bath in the tub or shower with the pouch off.
- Keep an eye on the stoma for changes in size and color. There could a slight bleeding from the stoma.
- If the stoma is round, make use of the precut template to find a pattern that fits perfectly.
- A perfect fit means that no skin should be visible around the stoma.
- In case the stoma is irregular in shape, then use a firm piece of clear plastic to mark a pattern of the stoma.
- Make use of the template to find an opening on the wafer.
- Then cut the tracing with sharp scissors
- Smooth out the rough areas with finger
- Warm the wafer in the hand to help soften it.
- Apply Cavilon 3M no sting barrier film to skin around the stoma.
- If paste is used, it must be applied in a sparing manner to the wafer around the hand cut opening.
- Press the pouch on the skin by using light pressure with the hand, hence making the attachment secure.
- Apply clip to the end of pouch.
- Make the pouch empty once it gets 1/3 filled with air or stool.
- Change the whole pouch when the wafer becomes loose from the skin.
- Do not flush the pouch down the toilet.
Splenectomy is an operation conducted to remove the spleen. The spleen plays a vital role in building immunity against bacterial infections, located in the uppermost area of the left hand side of the abdomen, just below the diaphragm. There are some specific requirements with regard to the immunizations as well as blood work that might need to be completed before this surgery takes place.
Why is Splenectomy need to be performed?
There are a number of chronic illnesses like Hereditary Spherocytosis or Idiopathic Thrombocytopenic Purpura, which make it a necessity to get a child’s spleen removed. Though it is a rare case but still any kind of trauma to the spleen along with uncontrolled bleeding can create a very serious situation, wherein an emergency might arise to get the spleen removed immediately.
Immunization of child before the operation
Before the surgery of Splenectomy is conducted, immunizations are given to children as a preventive against some specific kinds of infections that are most common for patients to arise after having undergone the surgery of Splenectomy.
How is the surgery performed?
The paediatric surgeon, who performs the surgery, need not require making a large incision for going about the process of operation. In most of the instances, a splenectomy is performed in the following manner, which includes:
- A laparoscopic way through which a Paediatric Surgeon makes use of a small telescope along with some instruments of miniaturized nature, while placing them through small band-aid sized cuts on the abdomen.
- The operation gets completed within three hours
- At the time of hospitalization, a child would receive intravenous fluids, antibiotics as well medicines to get relieve from any kind of pain.
- As and when the child feels as if he or she is fit enough, he or she would be allowed to eat, drink and also take medicines by mouth.
Essentials after the Surgery
After the surgery has taken place and the child returns home after a couple of days, there are certain essentials that require to be kept in mind:
- Pain Management: Management of pain is the very first thing which should be kept in mind. The medicines prescribed by doctor for dealing with pain are not required after getting discharged from the hospital.
- Most of the children would only need Acetaminophen or Ibuprophen once they get back home.
- Care for Dressings: One may remove the gauze and clear plastic, which are placed over the small cuts, a couple of days after the surgery. The skin that surrounds the incision might have a reddish tinge and look bruised, which can last for few weeks.
- Restrictions related to Activities: There are no real restrictions with regard to the resumption o regular activities. A child can go back to school as and when he or she feels totally comfortable.
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Laparoscopic surgery is becoming the standard of care for many pediatric conditions. Laparoscopy and thoracoscopy are safe techniques with equivalent or even better results than open surgery in some situations. Laparoscopic procedures have been successfully performed in babies. An increasingly sophisticated and informed patient population often requests laparoscopy over open traditional procedures.The reason for the establishment of the subspecialty of pediatric surgery is the recognition of significant issues regarding the care of the pediatric surgical patients that warrant special attention. This is certainly applicable to minimally invasive surgery for pediatric patients. Anatomical and physiological differences in children may require a modification of the techniques used in adults. Laparoscopy and thoracoscopy cause less tissue trauma and theoretically, less postoperative pain than open surgery.
COMMON PEDIATRIC PROCEDURES
Laparoscopic Gastrointestinal surgery - Cholecystectomy, Appendectomy, Splenectomy, Gastrostomy and Nissen Fundoplication, Intussusception, Hypertrophic pyloric stenosis – Pyloromyotomy, Intestinal Obstruction
Congenital anomalies - Duodenal atresia, duodenal stenosis, intestinal malrotation, imperforate anus with recto urethral and recto vesical fistula, Hirschsprung’s disease, Choledochal cyst, congenital diaphragmatic hernia and many others.
Laparoscopic renal surgery – Pyeloplasty, nephrectomy, partial nephrectomy, nephroureterectomy has minimal estimated blood loss, less operative time, reduced hospital stay, low morbidity and rapid recovery.
Thoracoscopic pediatric procedures - Lung biopsy, drainage of empyema and decortication, mediastinal tumor biopsy, repair of diaphragmatic hernias and diaphragmatic eventration, repair of esophageal atresia and tracheoesophageal fistula, removal of pulmonary nodules and tumors, removal of blebs and pleurodesis, ligation of the thoracic duct.
The role of laparoscopy and thoracoscopy is well established in the treatment of penetrating and blunt trauma in the stable pediatric patient. Laparoscopic evaluation can guide the placement of the abdominal incision in tricky cases that need to be converted to laparotomy.
Robotic surgery is an advanced technology that enables the surgeon to perform a wide variety of minimally invasive procedures with advantage over standard laparoscopic surgery: - increased degrees of freedom, high quality of optical resolution and magnification, elimination of tremor and the ability to perform precise and expeditious intracorporeal suturing.
Children are not just small adults
Being a doctor involved with pediatric care, we have to understand the parents’ feelings and of course achieving the parents’ satisfaction in patient care. Along with these, taking care of ethical, cost effective and uncompromised quality of patient should be our priority.
Children are not just small adults. They cannot always say what is bothering them. Pediatric surgeons know how to examine and treat children in a way that makes them relaxed and cooperative. Surgical problems seen by pediatric surgeons are often quite different from those commonly seen by adult or general surgeons.
Pediatric surgeons specialize in the surgical care of children. They are surgeons who, by training, are oriented toward working with children and understanding their special needs. In addition, pediatric surgeons use equipment and facilities specifically designed for children.
Laparoscopy in children bears marked similarities to adult procedures, but experience with adult surgery does not sufficiently translate to safe surgery in pediatric patients. Pediatric procedures must be performed with a full understanding of the relevant anatomic and physiologic differences between pediatric and adult populations.