Preparing your child for surgery

Surgery is scary for kids and parents, alike, but not talking about an upcoming surgical procedure can create more fear and anxiety in children. In episode number 29, Child Life Specialist Brianne Ortiz offers tips for preparing children, from toddlers to teens, for surgery.

The amount of information, in addition to how and when it’s presented, depends on the emotional and cognitive age of the child. Brianne recommends parents speak to children, ages 3 to 5, approximately three to five days before the scheduled surgery. These younger-aged children often think they’ve done something wrong, so it’s important to reassure them that’s not the case and to present information in concrete terms they understand. She reminds parents that toddlers don’t have a concept of time. Instead of saying a procedure will last an hour, for example, explain that it will be over in about the same time as their favorite TV show.

Adolescents most often worry about waking up during surgery and about pain. Brianne educates teens on the role of the anesthesiologist and the hospital’s pain scale. She encourages teens to engage with their care team and not be afraid to speak up.

Listen to the episode for more helpful tips, including resources offered by CHOC.

CHOC Radio theme music by Pat Jacobs.

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Will Your Newborn Need Surgery? Plan Now

The news comes as a shock, usually during the first prenatal ultrasound between the 16th and 20th week of pregnancy. Treatment planning, however, cannot begin too soon when a developing baby is diagnosed with a complex birth defect.

 

Some babies are born with complex conditions requiring surgery during the first few hours following birth. From the moment prenatal testing reveals an abnormality, CHOC Children’s is ready to help with the prenatal care and birth planning necessary to ensure the best-possible outcome.

CHOC has a trained and experienced team that includes perinatologists, neonatologists, pediatric surgeons and NICU nurses to guide families through the months before delivery. And families are essential to the planning process.

“The well-being of the child is surprisingly dependent on the well-being of the family, both psychologically and emotionally,” said Dr. David Gibbs, division chief, pediatric surgery, CHOC Children’s Specialists. “Preparation helps the family cope better, and the family that is coping better is able to provide better care for their child.”

According to Dr. Gibbs, recent advances in the care and outlook for babies born with abnormalities have come from closer prenatal coordination with perinatologists and families, combined with highly specialized neonatal intensive care. The CHOC NICU is rated by the American Academy of Pediatrics as a Level 4 NICU, the highest designation available and given only to facilities that also provide onsite surgical repair of serious congenital or acquired malformations.

That immediate access to the full NICU medical team, resources and support is critical for babies born with gastroschisis, a condition that requires surgery within the first hour following birth, and omphalocele, which must be corrected within the first few days. For the smallest and sickest, CHOC’s Small Baby Unit offers additional support to help babies grow and recover more quickly with fewer infections and setbacks.

For babies born with congenital diaphragmatic hernia, the CHOC Surgical NICU provides the optimal environment in which to stabilize and gain strength before surgery. One special room inside the CHOC NICU converts into a state-of-the-art operating room, allowing pediatric surgeons to perform delicate procedures within the unit.

And babies born with congenital cystic adenomatoid malformation (CCAM) may actually get to go home for continued evaluation months before surgery.

Deciding Where You’ll Deliver

Dr. Gibbs added that an important element of prenatal planning is deciding in advance where your baby will be born. Moms who know their baby will need surgery may choose to deliver at a hospital that is near a pediatric facility like CHOC. When the baby is born, the CHOC Transport Team is ready 24 hours a day to transport the baby to CHOC from hospitals throughout the region. Specially trained and equipped, this team uses ground and air transportation to travel to and from hospitals throughout Orange, Los Angeles, Riverside, San Bernardino and San Diego counties — and even beyond.

“We expect most children will do well and have normal lives,” Dr. Gibbs said. “But the first step is meeting with the perinatologist, pediatric surgeon and NICU team. Starting that relationship as soon as possible will make the process of coping with what may seem to be an overwhelming process a lot easier.”

CHOC’s surgeons provide cardiothoracic surgery, gastrointestinal (GI) surgery, general surgery, neurosurgery, urological surgery, otolaryngological (ENT) surgery, plastic surgery, ophthalmologic surgery and orthopaedic surgery.

Learn more about surgical services at CHOC.

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Ear Troubles in Children with Cleft Palates

In this CHOC Radio segment, Dr. Jason Toranto, pediatric plastic and craniofacial surgeon, and Dr. Nguyen Pham, pediatric otolaryngologist, discuss some of the ear troubles experienced by children who have cleft palates. Both physicians are part of CHOC’s Cleft & Craniofacial Program.

Children with cleft palates often suffer from abnormalities in any part of the ear, but the vast majority of the problems are due to the Eustachian tubes not functioning properly.   In cleft palates, the muscles that open the tube have abnormal connections making the tube opening difficult or impossible.  This makes these patients more prone to ear infections.  Ear tube surgery is one consideration, based on the number of ear infections experienced by the child, fluid behind the Eustachian tubes, and hearing loss.  Dr. Pham carefully evaluates his patients to determine the best treatment plan.

Listen to episode number 28 to learn more about the connection between cleft palates and ear troubles.

 

CHOC Radio theme music by Pat Jacobs.

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Matthew’s Story: Healing in the Surgical NICU

Grace Wu beams as she watches her son Matthew smiling and happy after enjoying his bottle.

“It’s good to sbabies surgeryee him so happy and active,” she says. “That he could do that makes me very, very happy.”

It’s a marked change from the days following Matthew’s birth almost four months ago.

As a newborn, he was diagnosed with volvulus, a condition wherein the intestine is twisted and can ultimately cut off blood circulation. Symptoms of volvulus include a distended stomach and intolerance to feeding, which Matthew exhibited.

The baby was quickly transferred to CHOC Children’s for emergency surgery at just three days old. CHOC surgeon Dr. Saeed-Ur-Rehman Awan repaired the malformation by performing an ileostomy, wherein the intestine is brought outside the body.

Next, Matthew needed time to heal his organs. He spent the next three months recovering in CHOC’s Surgical Neonatal Intensive Care Unit, a special part of the hospital’s main NICU dedicated to the care of babies who need surgery.

There, Matthew was under the care of a multidisciplinary team that included Dr. Irfan Ahmad, a CHOC neonatologist and co-director of the surgical NICU, and many other clinicians.

In the unit, the team cares for patients jointly, discussing the cases of children like Matthew as a group and forming a treatment plan that often calls for the expertise of other specialties at CHOC.

Another key component of the surgical NICU care team is parents and families. In Matthew’s case, his parents and grandfather, Jerry, partnered with clinicians on every stage of the baby’s care.

“Jerry was there every single day holding Matthew – even when he was crying,” Dr. Ahmad says. “He was a great member of the team, and he provided a lot of support.”

As Matthew began eating orally in small volumes as well as through intravenous methods, he geared up for a second surgery that would reattach his intestines. That procedure was performed just three months after the first.

After several more weeks of recovery, Matthew was able to eat fully from a bottle and was on his way home, much to the relief of his family.

“I was very worried because for the first time, I thought I might lose him,” Grace says. “I am very thankful for the care he’s received.”

More articles about CHOC’s Surgical NICU:

Former CHOC Patient is Cancer Free Thanks to Da Vinci Robotic Surgical System

Julia Shenkman is a healthy and accomplished 17-year-old. She has a second-degree black belt in Taekwondo, is a member of her high school’s science team, and is fourth in her senior class in academics. Julia has another distinction: She’s a former CHOC Children’s patient who underwent a surgical procedure that involved the use of the then-landmark Da Vinci robotic surgical system.

In late 2003, CHOC became the first pediatric hospital in California to begin offering robotic surgery for children. The Da Vinci robot was an improvement over minimally invasive laparoscopic surgery because it gave surgeons a better view inside the surgery site and allowed them to more precisely manipulate instruments, which translated to less pain, fewer complications and shorter recovery time for patients.

In January 2006, Julia, then 8, was whisked to the emergency department at St. Joseph Hospital for severe abdominal pain and frequent vomiting. Blood work and X-rays for appendicitis turned up negative. It wasn’t until Julia’s doctor at CHOC, Mustafa Kabeer, pediatric surgeon, ordered an ultrasound that the cause of her distress was found: a large mass in her right ovary. Using the Da Vinci system, Dr. Kabeer operated on Julia and successfully removed the tumor, which was malignant. After three months of chemotherapy, Julia recovered and remains cancer free.

Julia with Dr. Mustafa Kabeer, CHOC Children's pediatric surgeon.
Julia with Dr. Mustafa Kabeer, CHOC Children’s pediatric surgeon.

Pediatric surgeons at CHOC have performed about 100 robot-assisted surgeries, says Dr. Kabeer, who before coming to CHOC helped implement the world’s first pediatric surgery robotics program at Children’s Hospital of Michigan in 2001. Recently, Dr. Kabeer started using the Da Vinci system to perform complex operations through one incision in the belly button, such as for removal of the gallbladder. The Da Vinci system at CHOC was made possible by a $1.5 million sponsorship from Costco Wholesale Corp.

“This type of technology helps us perform a wide variety of surgeries — some of them very complex,” Dr. Kabeer says. “It takes time, commitment and vision to start and maintain such a program, but this is one of the unique things about CHOC: We want to do this, and we are committed to doing it.

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Hernia Repair: Quick and Common

When hernias in children don’t close by themselves, surgeons can repair the protrusion caused by an organ or tissue pushing through an opening or a weak spot in the abdominal wall, a CHOC Children’s pediatric general surgeon says. NEWok20130425_1072

A common procedure, hernia repair is typically an outpatient surgery, meaning the child can go home the same day as the surgery after a few hours of recovery, Dr. Troy Reyna says.

An infant younger than 3 months, however, would be hospitalized overnight as a precaution, he says.

“During surgery to fix a hernia, we’re closing that little hole that causes the bulge,” Dr. Reyna says. “We can often do laparoscopic surgery, which means there is a tiny incision using a camera to direct the sutures and needles to the abdominal wall. With baby boys, we usually will make an incision, but it’s small.”

The operation is relatively short, usually taking 30 to 40 minutes, he says.

Parents are most often worried about their child undergoing general anesthesia for the surgery, but Dr. Reyna assures parents that the anesthesiologist treating their child at CHOC specializes in working with babies and children.

“This is what they do,” he says. “They know that children are not little adults and have a totally different anatomy.”

If they haven’t closed already, umbilical hernias can be fixed when the child is 2 or older, Dr. Reyna says. A child with an inguinal hernia should have surgery within one to three weeks of diagnosis to prevent possible complications to other organs, he adds.

Parents who suspect their child has a hernia should seek a medical evaluation from their pediatrician, Dr. Reyna recommends.

“I tell parents we don’t expect them to be medical experts but whenever their child has a lump or bump in an unusual place, feel free to ask about it,” he says. “The only silly question is the one that doesn’t get asked.”

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It’s All About Comfort in CHOC’s Fully Integrated Operating Rooms

A child life specialist and young boy interact in the main lobby of the Tidwell Procedure Center, on the third floor of the Bill Holmes Tower.
A child life specialist and young boy interact in the main lobby of the Tidwell Procedure Center at CHOC Children’s Hospital.

Comfort comes in many forms at CHOC Children’s, and not all of them involve a prescription pad. And that’s important because pain management is highly complex and must be individualized for each patient’s physical, developmental and emotional needs.

Did you know the same distraction techniques used to re-direct children’s behavior are often used to enhance our patients’ comfort? That’s why an engrossing game of Mario Kart or a visit from a friendly pet therapy dog may be just what the doctor ordered.

“Our goal is to keep our patients as comfortable as possible,” said Dr. Paul Yost, a pediatric anesthesiologist at CHOC. “And sometimes we can use distraction in a way that is much more beneficial to our patients than pain medication. Distraction and other non-medication techniques may allow patients to leave the hospital sooner, with less discomfort and fewer complications.”

At CHOC you will find state-of-the-art inpatient and outpatient surgical care provided within a compassionate, family centered, all-pediatric environment. Our pediatric anesthesiologists are experts in the many techniques that provide comfort, while promoting faster healing and recovery.

Additionally, CHOC offers pain management consultation for all patients around the clock. Our pain management team includes Dr. Hai Nguyen, a fellowship-trained pediatric pain management specialist, and Cheryl Deters, a nationally certified pediatric nurse practitioner.

One of seven operating rooms in the Tidwell Procedure Center.
One of seven operating rooms in the Tidwell Procedure Center.

“For a child, fear and anxiety equal pain,” Dr. Yost said. “The mind plays a very important part in how the body responds to comfort, so we work very hard to minimize fear.”

Using a multi-disciplinary approach, the pain management team works closely with CHOC Psychology, Child Life and other medical specialties. In addition to distraction, non-medication pain management techniques may include guided imagery, traditional Chinese medicine, acupuncture, acupressure, massage, and art and music therapy.

“We have the skills and tools to help our patients cope, including many options that only a children’s hospital can provide,” Dr. Yost said. “Choosing to bring a child here is the most important decision a parent can make. We have the expertise to get our patients through situations as safely and comfortably as possible.”

To learn more about surgery services at CHOC, please click here.

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Hernias in Children: What Parents Should Know

CHOC_HerniasSpotting a lump or bump on a child’s body would be scary for any parent, but mom and dad can rest assured: Hernias are common and their repair is among the most common procedures performed on kids, a CHOC Children’s pediatric general surgeon says.

Just in time for national Hernia Awareness Month, Dr. Mustafa Kabeer offers detailed information on this common ailment.

Hernias occur when part of an organ or tissue pushes through an opening or a weak spot in the abdominal wall and creates a protrusion which is visually present. Children with hernias are often born with them, and when a hernia is first noticed depends on when enough pressure is generated to allow other tissues to protrude through the weakened area, Dr. Kabeer says.

“Families or kids might see big or little bumps, and, in most cases, near the belly button or groin,” he says. “Sometimes in premature babies, we see hernias right when they’re born, and sometimes we don’t see them until the child is older.”

Though there are many varieties of hernias, Dr. Kabeer recommends that parents of young children make themselves aware of three types.

Epigastric hernias

First, epigastric hernias occur when a tiny portion of fat protrudes through the abdominal wall in the midline between the belly button and chest, creating a tiny bump a few millimeters wide.

“They can cause some discomfort and they don’t go away on their own,” Dr. Kabeer says. “When we find them, we fix them.”

Inguinal hernias

Secondly,inguinal hernias occur when part of a child’s intestine protrudes between the abdominal muscles and is seen as a bulge in the groin. Girls born with this type of hernia are more likely to have a protrusion on both sides.

This type of hernia is very common, especially in premature babies. This type of hernia should be repaired in a timely manner because, if left unfixed, they can cause discomfort and, on rare occasions, lead to the intestine being stuck in the hernia. This could cause obstruction and require a more urgent operation, says Dr. Kabeer.

“We want to fix these soon,” he says.

CHOC_Hernias2Umbilical hernias

Finally,umbilical hernias appear in babies born with a weakness in the belly button. This type of hernia is very common, and not something that should concern parents, Dr. Kabeer says.
Present when a baby cries, strains or coughs, these hernias cause no discomfort and rarely prompt larger problems, he says.

Dr. Kabeer estimates that 85 percent of umbilical hernias go away with time. That said, if a child still has a protrusion by age 3 or 4, CHOC surgeons will repair the hernia, Dr. Kabeer adds.

Physician can advise treatment

Parents who notice a hernia on their child’s body – particularly those near the groin or between the belly button and chest – should make an appointment with their pediatrician to help determine the type and course of treatment.

Though often harmless, some hernias prompt concern because the protruding organ or tissue can get stuck in the opening, which can compromise blood flow, Dr. Kabeer says. This can damage the protruding part, such as the intestines or even an ovary in girls.

Aside from the obvious bulge, symptoms of hernias can include pain and swelling. Babies who have an obstruction often exhibit abdominal distention, vomiting, redness and pain. If this occurs, parents should seek emergency treatment immediately, Dr. Kabeer cautions.

Short surgery, recovery

Should surgery be required to repair a hernia, the short procedure is performed under general anesthesia and requires no hospital stay, he says.

Recovery is also relatively fast following hernia repair surgery, Dr. Kabeer says. School-aged children are back to normal after about a week, and younger children recover even faster.

Learn more about surgery at CHOC Children’s.

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Kids and Surgery

boy before surgeryWHAT TO TELL YOUR CHILD BEFORE SURGERY
Parents should understand and work through their concerns, because if the parents are scared, the child will be scared; if the parents are calm, the child will be calm too, says Dr. David Gibbs, a CHOC Children’s Pediatric
Surgeon. “I try and listen to what the family has to say. I need to know what the family is afraid of and what is bothering them,” Dr. Gibbs says. “I try to make the parents realize they are doing the right thing and we will help you through this.” CHOC allows parents to stay with their child in their hospital room during the entire surgery hospitalization period but are not allowed in the operating room.

TIPS FOR SURGERY DAY
Dr. Gibbs recommends that parents have their hospital bag packed the night before surgery so they will arrive at the hospital on time. Also, parents should not eat in front of their child because the child won’t be allowed to eat. “I recommend promising the child some kind of special treat or gift after the surgery. I think it’s fine to say, ‘After we go through this, we’re going to get you some toy or thing you wanted and celebrate you having gone through this.’ Have the child bring a favorite blanket, special outfit, stuffed animal or toy, something that reminds him of home. It makes the child feel a little more comfortable.”

GETTING YOUR CHILD ON BOARD
Preparing your child in advance and planning ahead for surgery will help make your child feel more comfortable about the surgery and recover better and faster, says Dr. Gibbs. “Don’t plan a trip to Disneyland a week after the surgery. Do whatever it takes to make your child calm, relaxed and pain-free. This will help him heal better and faster and he will be more compliant. This is not just about making him feel better. It’s about making him recover faster. If the child feels that he or she is a part of the experience with some degree of control, then they will get better faster.”

FAST FACTS

  • The number of children under the age of 18 admitted for surgery as inpatients in the U.S. annually: 450,000
  • Number of inpatient surgeries performed at CHOC in 2013 (Orange and Mission Campuses): 3,591
  • Number of outpatient surgeries performed at CHOC in 2013 (Orange and Mission Campuses): 4,990

View the full feature on Kids and Surgery

Dr. David L. Gibbs
Dr. David L. Gibbs
CHOC Children’s
Pediatric Surgeon

PHYSICIAN FOCUS: Dr. David L. Gibbs

Dr. Gibbs is a pediatric surgeon,
president of the medical staff at CHOC Children’s and the CHOC Children’s Specialists Division Chief of Pediatric Surgery.

Dr. Gibbs completed his internship and residency at Massachusetts General Hospital in Boston, followed by fellowships in pediatric surgery at the UCSF Fetal Treatment Center in San Francisco, the Long Island Jewish Medical Center, Schneider Children’s Hospital/Pediatric Surgery in New Hyde Park, New York, and the Hospital for Sick Children in Toronto, Canada. His clinical interests include pediatric laparoscopic surgery and neonatal surgery.

Dr. Gibbs’ philosophy of care: “When a child needs surgery, it can be just as scary for the parents as it is for the child. We treat the entire family with the greatest compassion and understanding.”

EDUCATION:
Ohio State University

BOARD CERTIFICATIONS:
Adult and Pediatric General Surgery

More about Dr. Gibbs | CHOC Children’s Pediatric Surgery

This article was featured in the Orange County Register on May 12, 2014, and was written by Amy Bentley.

12 Questions to Ask Before a Child’s Surgery

questions_before_kids_surgeryWhen a child faces surgery, the procedure can be just as scary – or even scarier – for a parent.

The good news is that CHOC Children’s practices patient- and family-centered care, and works to ensure parents and patients are informed.

Parents with a child facing surgery should ask plenty of questions to learn as much as possible about their child’s surgery and post-operative care – and CHOC’s surgical services team is ready with answers.

“You have to do whatever you need to do so you feel like you are being a good parent,” says Dr. David Gibbs, a pediatric surgeon and president of CHOC’s medical staff.

Dr. Gibbs recommends that parents ask the following questions before a child’s surgery:

  1. How will this operation help my child?
  2. Is the surgery an inpatient or outpatient procedure?
  3. How long will my child need to be in the hospital?
  4. What type of incision will be used?
  5. What medications will he need?
  6. What are the risks of the surgery and the anesthesia?
  7. What type of post-surgery care will the child need afterward?
  8. How will my child’s pain be managed?
  9. When will my child be fully recovered?
  10. What limitations will my child have after surgery, and for how long?
  11. When can my child eat and drink after surgery?
  12. Is there anything else you think we need to know about this surgery?

Learn more about the Tidwell Procedure Center and surgery at CHOC.

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