energy options

Energy options in minimally invasive pediatric surgery

 

Since the advent of laparoscopic surgery in the early 1980s by gynecologists, we have struggled to provide safe energy to divide tissues and seal vessels safely. Over the last 20 years major advances have been made and there are now major players in the marketplace that provide vessel sealing technology to both adult and pediatric patients through reasonably safe instruments. There are key aspects of a safe and usable energy device that vary widely from one instrument to another. Effectiveness of seal, speed of the seal, spread of energy (collateral damage), heat of the instrument after activation, plume of smoke or steam that obscures the operative field, and the ‘feel’ or usability of the instrument in the surgeon’s hands all contribute to the applicability and ultimate adoption of a device.

energy options

 

 

 

 

 

 

The energy options in minimally invasive pediatric surgery  include monopolar energy, bipolar energy, and ultrasonic shears. Each has its benefits and drawbacks. Monopolar (hook cautery) is by far the least expensive but also has a large plume of smoke associated with it and a large amount of spread of energy to adjacent structures. Bipolar energy comes in a variety of platforms and seems to have the least spread, heat production, and plume but is expensive and some platform’s seal times are slow. Ultrasonic energy is also expensive and may have an edge on some bipolar platform’s seal time but the jaws are quite hot and there is a large amount of steam produced from the seal. In general, monopolar sealing is much more variable and so the durability of the seal is less consistent when compared to the advanced energy devices which all have very safe and reproducible seals for physiologic pressures. One product engineer told me in confidence, and so I feel it’s safe to tell you, that the size of vessel that many manufacturers are ‘rated’ to seal is nowhere near what they can actually seal. That being said, don’t be stupid, ok?

 

In the US the market share is dominated by the Ligasure (Medtronic – bipolar energy) and the Harmonic Scalpel (Johnson and Johnson – ultrasonic shears). There are other devices that are vying for adoption: Sonicision (Medtronic – cordless ultrasonic shears), Enseal (Johnson and Johnson – bipolar) Thunderbeat (Olympus – bipolar and ultrasonic combination), and the JustRight Sealer (Bolder Surgical – bipolar with decreased seal times and energy (read: spread, heat, etc) and a 3 mm instrument). I know that is a lot to take in. There are plusses and minuses to each and each should be applied by the surgeon’s experience and comfortability as well as tailored to each case.

 

Specific Applications

 

Only the JustRight Sealer was developed for pediatric patients and so the others have been adopted in pediatric practice. Because of this, there are specific cases where the strengths or weaknesses come into play. The JustRight sealer is the only 3 mm sealer on the market and is peerless when it comes to neonatal laparoscopy and thoracoscopy. The obvious downside of the sealer is that it does not have a cutting option, it seals and the tissue is ‘distracted’ (read: torn) and it is pricier than other sealers. There is a learning curve but the instrument is really impressive once you are used to it. The upsides are striking and they use much lower energy than adult bipolar instruments which means less plume, less heat, less spread, and ridiculously fast seal times – somehow. It is my go-to instrument for any case that uses shorter instrument lengths (comes in 20 cm shaft length).

 

The hook cautery shines for cases where spread of heat doesn’t matter – think laparoscopic cholecystectomy – the liver is very forgiving. Its cost consciousness balances out many of its shortcomings however, when encountering a big vessel or in a small space and spread, plume, or a cool instrument is important, look elsewhere.

 

In my mind, the Ligasure is the workhorse of the 5 mm instruments. The other currently available 5 mm options (Thunderbeat, Enseal, etc) come down to preference and what you’re used to. I haven’t heard a convincing argument from them on why I should switch.

 

Ultrasonic shears are very good when you need an active jaw to enter tissue – think partial nephrectomy. One of my colleagues also uses it (cool side down) for Heller myotomies though I have not been impressed with that application. I don’t know anyone who has a strong preference between Ethicon’s and Covidien’s shears – the cordless option is nice in theory but a bit heavy in my experience.

All in all, there are many options on the table for pediatric surgeons to choose among. For our smaller patients nothing beats the JustRight Sealer and I’m eager to see their future developments – more to come on this soon! Until then, my choice is the Ligasure for any 5 mm case given how versatile and relatively safe it is.

burns first aid

Burns First Aid

Burns first aid is the principal difference between a burn that heals well with dressings and one that may result in a permanent scar.

You leave the coffee to percolate near the edge of the bench. There’s a smash, followed by a scream, and it brings you running back to the kitchen to find your toddler covered in hot coffee. What do you do now??

 

In Virchester, we hear this story every week. It’s among the most common histories of the new burns we seen annually. Hot liquid scalds are the single most common mechanism. Hot beverage scalds occur when the child pulls the liquid down on themselves, or when a (usually) parent with a cuppa trips over a child. What the parents did next often makes the difference between a burn that heals just with dressings, versus one that may leave a permanent physical scar. There is no substitute for effective burns first aid.

The most effective first aid is to remove clothing, and run the affected area under cool running water for 20 minutes. 1

burns first aid

Some is better than none, and late is better than never. 2 Anything else you read online is inaccurate, inadequate, or inconsistent. 3 Anything else you might do is less effective as first aid. 4 Ice is bad, don’t use it. 1 Some traditional first aid substitutes (aloe vera, honey, toothpaste) coat the burn and reduce pain by occluding exposed nerve endings from air currents. They do little to decrease the metabolic burden the burnt tissue is under. Running water appears to be more effective than still water, perhaps because it washes away pro-inflammatory cytokines from the area. Research to explain this is ongoing. For smaller children be conscious to guard against heat loss. Queensland is pretty hot most of the year, and our tap water is between 2 and 15 degrees year-round. This temperature range is equally effective, so the water doesn’t have to be really cold. Tepid water, rather than cold, will mitigate hypothermia in children. Wrapping the child in a warm towel after 20 minutes cold running water will also help prevent heat loss.

Cover the wound with plastic film (cling film, Saran wrap, Glad wrap). It’s essentially sterile out of the box, so you don’t have to worry about infection. 5 Burns clinicians can see through it to assess the burn without having to undress the wound and cause further distress and pain to your child.

Provide your child with pain relief, and work to decrease their (and your) anxiety. Proper analgesia is not just kind, it’s also associated with faster wound healing. 6 Anxiety can mimic pain and appears to have many of the same outcomes with respect to delays in healing.

Seek expert medical attention, ideally directed by a Burns Centre.

The majority of children’s burns are scald injuries, and are superficial partial thickness. With effective burns first aid and modern dressings, the majority will heal without scarring. Modern dressings are more expensive than traditional dressings and so may not be stocked by your local family practitioner. Many of these burns are likely to heal even with old-fashioned dressings, but do you REALLY want to take that chance with your child. It makes no sense to me to go to all that trouble of providing effective first aid, only to then put a second- or third-tier dressing on the burn. We use silver-containing, antimicrobial dressings on all children’s burns in our Burns Centre. There are no exceptions to this rule.

References

1 Cuttle L, Kempf M, Kravchuk O, et al. The optimal temperature of first aid treatment for partial thickness burn injuries. Wound Repair Regen 2008; 16: 626–34.

2 Cuttle L, Kempf M, Liu P-Y, Kravchuk O, Kimble RM. The optimal duration and delay of first aid treatment for deep partial thickness burn injuries. Burns 2010; 36: 673–9.

3 Burgess JD, Cameron CM, Cuttle L, Tyack Z, Kimble RM. Inaccurate, inadequate and inconsistent: A content analysis of burn first aid information online. Burns 2016; 42: 1671–7.

4 Cuttle L, Pearn J, McMillan JR, Kimble RM. A review of first aid treatments for burn injuries. Burns 2009; 35: 768–75.

5 Liao AY, Andresen D, Martin HCO, Harvey JG, Holland AJA. The infection risk of plastic wrap as an acute burns dressing. Burns 2014; 40: 443–5.

6 Miller K, Rodger S, Kipping B, Kimble RM. A novel technology approach to pain management in children with burns: A prospective randomized controlled trial. Burns 2011; 37: 395–405.

Declaration

Craig McBride is a paediatric burns surgeon. He works in the Burns Centre responsible for many of the cited publications above. He’s not an author on any of them. He has no commercial ties to any company selling water packaged as a first aid treatment for burns.

antenatal counselling

Antenatal Counselling

Antenatal counselling for paediatric surgeons is principally to provide the parents-to-be with evidence-based information on the surgical management of the presumed diagnosis, to answer their questions and to help support them make informed decisions. We are not obstetricians or neonatologists and it is not appropriate for us to try and answer their specialized questions on anything other than the paediatric surgical management of the condition; albeit some of the more general questions we can cover and we may have a preference on the need, or not, for caesarean section. Ideally, therefore, antenatal counselling should be carried out in a multidisciplinary clinic alongside specialized feto-maternal obstetricians and neonatologists. When this is not possible, patients should be provided with the opportunity to meet the other disciplines separately.

antenatal counsellingEveryone will have their own approach to the consultation and this post is not claiming to be the only technique but aims to provide a reproducible structure which you can adapt as you see fit; in my view, it’s a pretty good start. As per any patient interaction start by checking what they already know. The antenatal counselling should then cover the following 5 questions; four ‘what’s’ and one ‘where’:

 

What is the anomaly?

Basic description of the abnormality and how it is different compared to normal anatomy. This is also the chance to explain what we have seen on imaging that raises the suspicion of the specific diagnosis, any potential differential diagnoses and any common associations. For example, polyhydramnios and an absent stomach bubble being suggestive of oesophageal atresia, but that there are some rarer things it may be any we will, therefore, confirm the diagnosis after birth. If the child has got oesophageal atresia there are also some other associations we would also look for and the baby would, therefore, have a renal and heart scan etc after birth. You have to gage each consultation to work out the right level of detail for that parent/parents.

What is going to happen in the rest of the pregnancy?

Most of this should be left to the obstetrician to answer, but if counselling on your own, a general description of follow up scans and what is being looked for / what we might be worried about – e.g. hydrops in lung lesions or intra-abdominal bowel dilatation in gastroschisis.

What will happen after delivery?

Brief description of what they should expect, for example, that a congenital diaphragmatic hernia will be electively intubated or a congenital lung lesion will be observed

Are there other investigations that need to occur, for example, is there a potential for an associated cardiac anomaly that may not have been antenatally detected.

What are the likely long term implications?

Is there associated mortality or potential long term issues such as continence with myelomeningocele?The details vary depending on the anomaly but we have a duty to be honest and clear. Parents will also vary and different people will want different levels of information. Offering a chance for a second antenatal counselling session may help reduce anxiety, and providing written information allows parents to relook at the information in their own time frame.

Where will they deliver?

Do they need to deliver at your centre or can they deliver nearer to home? This will vary based on the likely diagnosis and geography. In the UK, with a child unlikely to need intervention, delivering nearer to home may be the most appropriate. In Australia where there’s the potential, the child may need transfer and the paediatric surgery centre is thousands of miles/kilometres away then delivering in the paediatric surgery centre to prevent mum and baby being separated postnatally may be more sensible. Also worth reassuring them that if there’s an emergency, they go to the nearest centre and they will be appropriately managed which may include transfer, but allows them and the foetus to be checked.

Additional tips to consider:

Ask if they know the sex – it makes the consultation more personable and allows you to avoid the awkward ‘it’ reference. Some carers may even use a name.

One of my colleagues always starts by stating it is NOT the fault of the parents – he backs this up with an explanation of why; I think this is really good for the parents to hear, but be careful with gastroschisis in recreational drug abusers for example (Risks of gastroschisis ).

Be as positive as possible but don’t give false hope – neither they nor you can change the diagnosis and pregnancy is stressful enough without making the next few weeks harder. They need to know that they are safe, we will deal with whatever we face as it happens and that they and their child will get excellent care. BUT, do not give false hope. Unfortunately, not all congenital diaphragmatic hernias will have a good outcome. Be realistic, be fair.

Do not get bogged down in minutiae – tell them the most likely outcome, not every little detail; most babies with gastroschisis are discharged fully fed at 6 weeks. Some babies take a bit longer, some get home earlier. There are some babies with gastroschisis that also have an associated blockage in the bowel (atresia) which needs further surgery, but we will deal with that if it occurs. They do not need to know at this stage about the rare risks of NEC, or late adhesional obstruction, or distress with the umbilical appearance in gastroschisis.

Finally, termination of pregnancy – it is not our role to advocate for or against termination of pregnancy. The structure outlined above allows us to provide parents with the information available, an idea of how confident we are in the diagnosis and the overall likely long term implications. With clear and honest information provided to them the parents can then decide how they wish to progress with the pregnancy.

References:

Antenatal diagnosis of surgically correctable anomalies: effects of repeated consultations on parental anxiety. Aite L, Trucchi A, Nahom A, Zaccara A, La Sala E, Bagolan P. J Perinatol. 2003 Dec;23(8):652-4. doi: 10.1038/sj.jp.7210992.

epigastric hernias don't need surgery

Epigastric hernias don’t need surgery. They are asymptomatic protrusions of pre-peritoneal fat through a tiny mid-line defect in the linea alba. They are irreducible. The reported prevalence is over 10% and epigastric hernia repair represents approximately 4% of hernia surgery. This is in the face of no evidence whatsoever of complications related to the problem itself. Epigastric hernias in paediatric surgical practice are an excellent area to consider the influence of evidence and experience. Epigastric hernias don’t require surgery.

Operative experience (sic) reveals a defect between interweaving fibres of the linea alba with variable protrusion of pre-peritoneal fat. The defect is never greater than a millimetre but the rest of the herniated fat may spread out to a diameter of 20mm. This is the “bulge” noted by parents, palpated by practitioners, perceived (truly) as irreducible and the causation of referral, even as an emergency conflating the words hernia and irreducible. The description of the lesion by the family is almost pathognomonic, “you need to see it in the right light Doctor, with leaning just off to one side…” The symptomatology of the lesion, however, is harder to clarify despite various attributions of localised pain, tenderness, difficulty with extension and change in bowel habit. The fat has no sensation, is never seen as infarcted or even inflamed. Bowel is never present in a paediatric epigastric hernia and attribution of symptoms, therefore, becomes challenging.

The literature reflects many of the issues discussed above. The pathogenesis is unclear but probably relates to the weave of crisscrossing fibres. The symptomatology is confused. One of the very few review articles published in 2000 suggested that “little is known about their presentation and natural history in this age group” dismissing a paper from 1960 that proposed a conservative approach to the matter. The “symptoms” described, however, the “mass” as being reducible, enlarging or tender. This is entirely contrary to my personal experience. I cannot think why this centre and many others that charge money for such surgery might have such a divergent view of the value of the intervention.

It is clear that the surgery involved in repairing such a tiny defect will be more significant than the defect itself. Fantastical minimally invasive approaches are also described to fix this issue that has no symptoms or complications. The astute surgeon should carefully assess the patient, the history described and the risks and complications of the surgery proposed and offer the appropriate choice to the family. Epigastric hernias don’t need surgery. Caveat emptor.

 

 

Caveat emptor (Latin) let the buyer beware.

 

References

Ponten, J., E. Somers, and H. Nienhuijs. “Pathogenesis of the Epigastric Hernia.” Hernia 16.6 (2012): 627-33

Coats, Richard D, Mary A Helikson, and Randall S Burd. “Presentation and Management of Epigastric Hernias in Children.” Journal of Pediatric Surgery 35.12 (2000): 1754-756

FOAM

 

FOAMed is Free Open Access Medical education. Medical teaching has been around since Thgg showed Gthh how to treat an infected sabre tooth cat wound, back in the Stone Age. However, Mrrr wasn’t around as he was away hunting and so he never learned. Mrrr died a few weeks later of an infected sabre tooth cat wound. Teaching cannot always take place at appointed times and that affects patient care. Ask Mrr.

The essential knowledge in paediatric surgery should not be locked in a facility or charged for but should be globally accessible, crowd-sourced, an educational adjunct providing inline (contextual) and offline (asynchronous) content to augment traditional educational principles. This is the concept of FOAM. This is the stimulus to develop this resource and share links and input from around the world.

 

FOAMed initially started in Emergency Medicine and Intensive Care in 2012. Around the world a community of like-minded groups were created, each constantly evolving, working collaboratively and interacting such that education resources in Melbourne might be used in Manchester, shared in New York, refined in Cape Town and finally distributed on the web to make the world a better place and improve the care of our patients, everywhere. FOAM is independent of platform or media — it includes blogs, podcasts, tweets, online videos, text documents, photographs, Facebook groups, and according to the scientific literature, a whole lot more. This is FOAM and these are some of our friends.

St Emlyn’s is an Emergency Medicine site. We share the same virtual campus with them at Virchester.  One of our staff is also on faculty there. St Emlyn’s produce internationally acclaimed content regarding all aspects of Emergency Medicine but also has a strong suit in the concepts of education and learning theory. They recognise clinicians are not machines and so have multiple resources crafted to support us in our psychological and physical welfare.

St Emlyn's

In the paediatric sphere  Don’t Forget the Bubblesis an essential site and we have worked with them giving presentations at their amazing conferences. They are internationally renowned for developing knowledge related to emergency and general paediatric care and even for some of their “research.”

Don't Forget the Bubbles

One of the principles of FOAM is the generation of evidence, rather than eminence-based medicine. The idea scientific literature should guide care more than old professors shouting loudly. The SGEM is a leader in this, continually striving to shorten the knowledge gap of new practice evolving through research and then become part of established practice. Visit this site and start to understand the true implications of the literature we read.

The Skeptics Guide to emergency Medicine

If you start searching you will find the volume and availability of education available are truly overwhelming. Over at RebelEM our friend Salim Rezaie explains how we might consider using this amazing and initially overwhelming resource.

RebelEM

Lastly, the field of pediatric surgery (and pediatric surgery too) is pretty barren when it comes to FOAMed. It is interesting to consider why this might be but the leader currently in our field is our friend and colleague Todd Ponsky. His global cast podcasts can even be accessed through their own app “Stay Current,” available wherever you get your apps.

Global Cast MD

There is so much opportunity and so much information available in FOAMed, none of us can know it all. It is said that in the past we used to expect clinicians to carry all the knowledge with them as a library. To be honest that never worked. What we can do now is to be the librarian and know where to find that information. If you have thoughts or links that you use, please let us know in the comments section and we can spread the FOAMed further.