Surgical checklist application and its impact on patient safety in pediatric surgery.

BACKGROUND: Surgical care is an essential component of health care of children worldwide. Incidences of congenital anomalies, trauma, cancers and acquired diseases continue to rise and along with that the impact of surgical intervention on public health system also increases. It then becomes essential that the surgical teams make the procedures safe and error proof. The World Health Organization (WHO) has instituted the surgical checklist as a global initiative to improve surgical safety. AIMS: To assess the acceptance, application and adherence to the WHO Safe Surgery Checklist in Pediatric Surgery Practice at a university teaching hospital. MATERIALS AND METHODS: In a prospective study, spanning 2 years, the checklist was implemented for all patients who underwent operative procedures under general anesthesia. The checklist identified three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anesthesia ("sign in"), before the skin incision ("time out") and before the patient leaves the operating room ("sign out"). In each phase, an anesthesiologist,-"checklist coordinator," confirmed that the anesthesia, surgery and nursing teams have completed the listed tasks before proceeding with the operation and exit. The checklist was used for 3000 consecutive patients. RESULTS: No major perioperative errors were noted. In 54 (1.8%) patients, children had the same names and identical surgical procedure posted on the same operation list. The patient identification tag was missing in four (0.1%) patients. Mention of the side of procedures was missing in 108 (3.6%) cases. In 0.1% (3) of patients there was mix up of the mention of side of operation in the case papers and consent forms. In 78 (2.6%) patients, the consent form was not signed by parents/guardians or the side of the procedure was not quoted. Antibiotic orders were missing in five (0.2%) patients. In 12 (0.4%) cases, immobilization of the patients was suboptimal, which led to displacement of diathermy grounding pad. In 54 (1.8%) patients, the checklist was not used at all. In 76 (2.5%) patients the checklist was found to be incompletely filled. CONCLUSIONS: Our study supports the use of the checklist as an essential safety tool and reinforcement of the same. The checklist may act as a valuable prompt to focus the team, to ensure that even the simple things have been cared for.

Needle in a haystack: Intraoperative breakage of pediatric minimal access surgery instruments.

The search for tiny bits of broken pediatric minimal access surgery (MAS) instruments in an operative field is akin to the search for a needle in a haystack. With the extension of MAS to the pediatric age group, instruments are becoming smaller and equitably more prone to breakage. When breakages occur, retrieval, especially in the pediatric abdominal cavity, can be challenging. Inability to do so would affect patient safety and also lead to a web of medico legal and ethical issues. We present two cases of intraoperative breakage: An eyeless 3-0 polyamide suture needle and a 2-mm grasper blade both of which were successfully retrieved and fortuitously escaped becoming retained surgical items.

Review of video-assisted thoracoscopy in children.

Open thoracotomy is the standard procedure for various thoracic diseases against which other procedures are compared. Currently Video Assisted Thoracoscopic Surgery (VATS) has gained widespread acceptance in the management of a variety of thoracic disorders. It decreases the morbidity and duration of hospital stay. A total of 133 children with various thoracic diseases who presented at a University Teaching Hospital in the Department of Pediatric Surgery, from June 2000 to December 2007, were included. Of the 133 patients,116 patients had empyema, all of whom were subjected to VATS, and an attempt at debridement/decortication and drainage was made. Other thoracic disorders treated included lung abscesses, lung biopsies, hydatid cysts, and so on. Patients with empyema were treated according to their stage of disease. Of the 116 patients who underwent thoracoscopy, 16 had to be converted to open surgery due to various reasons. The mean duration for removal of drain was three days and the average total duration of hospital stay was six days. Similarly the application of VATS was advantageous in other thoracic diseases.

Minimal access surgery in children: an initial experience of 28 months.

BACKGROUND: This study reports our 28 months experience with minimal access surgery (MAS) in children. MATERIALS AND METHODS: This was a review of all children who underwent MAS between December 2004 and March 2007 at the Departments of Paediatric Surgery, Seth Gordhandas Sunderdas Medical College (GSMC) and King Edward the VII Memorial (KEM) Hospital, India. Results and observations were tabulated and analysed, comparing with observations by various other authors regarding variety of indications such as, operative time, hospital stay, conversion rate, complications, safety, and feasibility of MAS in neonates, in the appropriate operative groups. RESULTS: A total of 199 procedures were performed in 193 children aged between 10 days and 12 years (average age: 5.7 years). One case of each, adrenal mass, retroperitoneoscopic nephrectomy, laparoscopic congenital diaphragmatic hernia (CDH) repair, and abdominoperineal pull-through for anorectal malformation, were converted to open surgeries due to technical difficulty. The overall conversion rate was 3%. Morbidity and mortality were very minimal and the procedures were well tolerated in majority of cases. CONCLUSION: We concluded that MAS procedures appear to be safe for a wide range of indications in neonates and children. Further development and expansion of its indications in neonatal and paediatric surgery requires further multi-institutional studies and larger cohort of patients, to compare with standards of open surgery.

Endoscopic management of spontaneous perforation of a cystic duct in a 10-year-old child.

A 10-year-old boy presented to us with acute abdominal pain and vomiting. The patient was stable on clinical examination. On ultrasound and computed tomography scan of the abdomen he had persistent peritoneal collection with edematous pancreas. Abdominal paracentesis revealed bile and 99m Tc HIDA (hepatobiliary iminodiacetic acid) scan showed a biliary leak. A percutaneous drain was inserted for collection, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. A spontaneous cystic duct perforation was confirmed on ERCP and a biliary stent was inserted. The patient's general condition improved, his percutaneous drain was removed on day 6 post ERCP and the biliary stent removed after 3 months. The patient is asymptomatic and doing well at 6 months' follow up. Spontaneous perforation of a cystic duct is an extremely rare condition with very few reported cases in the literature. Radionuclide scanning and ERCP are reliable modes for diagnosis and localization of the site of the leak. ERCP and biliary stenting are successful in the management of these patients.

Intestinal obstruction in children due to Ascariasis: a tertiary health centre experience.

BACKGROUND: Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. The aim of this research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management. MATERIALS AND METHODS: This is a single centre, two consultant based 5 year retrospective study of childhood intestinal obstruction due to worms. Diagnosis in the suspected patients was based on history of passage of worms per mouth or rectum and on x-ray and ultrasonography findings. Only the patients of intestinal obstruction with documented evidence of roundworm infestation were included in the study and were followed for one year. RESULTS: One hundred and three children with intestinal obstruction due to Ascaris lumbricoides were treated in the past five years at our centre. Abdominal pain was the most common presentation seen in 96 children followed by vomiting in 77 children. 20 children had history of vomiting worms and another 43 had history of passing worms in stool. Abdominal tenderness was present in 50 children, 48 had abdominal distension of varying degree, 50 had abdominal mass due to worm bolus, and 16 had or developed abdominal guarding or rigidity. All the children were managed as for acute intestinal obstruction along with hypertonic saline enema. The aim of management was "to starve the worm and hydrate the patient". 87 patients (84.47%) responded favourably and were relieved of the obstruction by the conservative management, 16 children (15.53%) had abdominal guarding or rigidity and underwent emergency exploration. CONCLUSION: Roundworm obstruction should be considered in the differential diagnoses of all cases of intestinal obstruction in children. Clinical history and examination along with X-ray and ultrasonography are very helpful for diagnosis of this surgical emergency. Most cases of intestinal obstruction due to Ascaris can be managed conservatively; however emergency surgery is needed in patients with abdominal guarding and rigidity.

A study of blood glucose in paediatric laparoscopy.

BACKGROUND: There are few studies on stress responses to laparoscopic surgery in children. This study was conducted to assess the blood glucose levels in children undergoing laparoscopy. We also studied the effect of two different intravenous (i.v.) solutions on blood glucose in open and laparoscopic procedures. METHODS: One hundred and twenty healthy children, aged 2-12 years, undergoing either open or laparoscopic surgery, were randomized to receive either dextrose normal saline (DS) or Ringer's lactate peri-operatively (RL). All patients had blood glucose measurements performed immediately after induction but prior to the i.v. infusion of any fluid. Blood glucose was again measured 1 h after induction in the open cases and 1 h after insufflation in the laparoscopy cases. RESULTS: In the groups, baseline blood glucose values were comparable. In all groups, blood glucose concentrations increased from the immediate post-induction (baseline) values. When RL was infused, the 1-h blood glucose was higher in the laparoscopy group as compared with the open group. However, when DS was infused the difference between the 1-h blood glucose in the open and laparoscopic procedures was not statistically significant. In the laparoscopy group, the 1-h blood glucose value was significantly higher in the patients receiving dextrose solution. CONCLUSION: Laparoscopic procedures in children are associated with a rise in blood glucose levels similar to open surgery. The hyperglycaemic response was more pronounced when dextrose-containing solutions were infused peri-operatively.

Congenital diaphragmatic hernia with gastric volvulus.

Gastric volvulus is a surgical emergency presenting in various forms. Association with diaphragmatic defect is well known. Here we describe three cases of gastric volvulus associated with diaphragmatic defect having varied presentations and their management. A rare case of gastric volvulus with complete gangrene of the stomach is also reported. Three types of gastric volvulus have been described depending on the rotation axis: organoaxial, mesentericoaxial and combination of both types. Operative treatment includes reduction, correction of underlying cause and gastropexy.

Thoracoscopic excision of mediastinal cysts in children.

AIM: Thoracoscopy offers great advantages when compared with open surgery in terms of postoperative pain and pulmonary complications. Considering the benign nature of most of the mediastinal cysts, thoracoscopy is safe and feasible with minimal morbidity. The purpose of this article is to review our experience with four cases of mediastinal cysts resected successfully within a period of one year by thoracoscopy. MATERIALS AND METHODS: The cases of mediastinal cysts operated by thoracoscopic excision in K.E.M. Hospital, Mumbai from November 2005 to December 2006 were reviewed. The age varied from six months to 10 years. The patients presented with respiratory distress or recurrent lower respiratory tract infection. All patients underwent Chest X-ray and CT scan thorax to delineate the location of the cyst and its relationship with adjacent vital structures. Two patients had anterior and two had posterior mediastinal cyst. The ports were placed depending on the location of the cyst on the CT scan, following the principles of triangularization. The cysts were excised mainly by blunt dissection. RESULTS: All the patients were successfully managed by thoracoscopic surgery. None of them had intraoperative complications. Dissection in patient with history of recurrent respiratory tract infection was difficult because of adhesions. Intercostal drain was removed within 48hrs and the patients were discharged on the fourth postoperative day. CONCLUSIONS: Thoracoscopy in mediastinal cysts is a safe and effective procedure with low morbidity and a shorter hospital stay.

Primary pulmonary hydatid cysts in children-a report of three cases.

Three children with a total of six primary pulmonary hydatid cysts, all of whom underwent surgical management, are presented. Of these six hydatid cysts, two were treated with thoracotomy with cyst enucleation and capittonage, three with thoracoscopy-assisted minithoracotomy with enucleation and capittonage, and one with limited resection.

Minimal access surgery in children - 5 years institutional experience.

CONTEXT: Minimal access surgery (MAS) in children are common place and performed worldwide with gratifying results as the learning curve of the surgeon attains plateau. We share our experience of this technically evolving modality of surgery, performed at our setup over a period of 5 years. We also review and individually compare the data for commonly performed procedures with other available series. Author also briefly discuss potential advantages of MAS in certain debatable conditions performed quickly and with cosmesis as open procedure. MATERIALS AND METHODS: We performed 677 MAS in children aged between 7 days and 12 years. Five hundred and sixty-eight of these were Laparoscopic procedures and 109 were Video assisted thoracoscopic surgeries (VATS). In all laparoscopic procedures, the primary port placement was by the Hasson's open technique. We have used 5, 3 and 2 mm instruments. Our study include 259 inguinal hernia, 161 Appendectomies, 95 VATS for empyema, 51 orchiopexies, 49 diagnostic laparoscopy, 29 cholecystectomies, 22 adhesionlysis and other uncommonly performed procedures. RESULTS: The ultimate outcome of all the performed procedures showed gratifying trend, the data of which are discussed in detail in the article. CONCLUSION: As we gained experience the operating time showed a decreasing trend, the complication rates and conversion rate also reduced. The advantages we came across were better postoperative appearances, less pain and early return to unrestricted activities.

An antenatally-diagnosed solitary, non-parasitic hepatic cyst with duodenal obstruction.

Congenital solitary, non-parasitic liver cysts are uncommon lesions that are rarely diagnosed antenatally. The cystic nature of the antenatally-diagnosed abdominal cyst in our case was confirmed postnatally by ultrasound. Partial excision with marsupialisation and release of extrinsic bands on the second part of the duodenum was done.