Paediatric surgery in a general hospital

The view of the general surgeon

Elective operations

• 1981 2007

• Hernias Hernias

• OrchidopexyOrchidopexy

• Circumcisions Circumcision

• Cutaneous lesions Cutaneous

• Insertion of V-P shunts

Emergency operations

• 1981 2007

• Spina bifida• Appendix Appendix• Hernia Hernia• Intussussception• Scrotal operations Scrotal operations• Pyloric stenosis Pyloric stenosis

Consultant staff

• Raigmore Belford Caithness

• Anaes 14 3 3

• Surgeon 8 4 3

Hernia/Groin operations

• Year Raigmore Belford Caithness• 1991 46 3• 1993 55 3• 1995 46 3• 2003/5 56(28) 5(3) 4(2)

• Number <=5 44(22)/1(1)/4(2)

Circumcision

• Year Raigmore Belford Caithness

• 1991 31 5

• 1993 40 8

• 1995 25 4

• 2003/5 40(20) 0 5

Number <=5 13/0/3

Orchidopexy

• Year Raigmore Belford Caithness

• 199138 10

• 199340 1

• 199526 4

• 2003/5 86(43) 4(2) 5(3)

Number <=5 49

Appendicitis

Raigmore Belford Caithness

• 2003/5 109(55) 8(4) 16(8)

• Number <=5 1 at Raigmore

Pyloric Stenosis

• Year Raigmore Belford• 1991 8 0• 1993 5 0• 1995 6 0• 2003 2 0• 2004 1 0• 2005 0 0• 2006 1 0

Two recent cases

• 4 week old (gestational age 43 weeks)

• Weight 3.0Kgs

• Pyloric stenosis

• 9 week old (gestational age 43 weeks)

• Weight 3.6 kgs

• Incarcarated inguinal hernia

Total number of operations 2003/5

All ages <=5 • Raigmore 414(207) 219(105)

• Belford 63(32) 10(5)

• Caithness 50(25) 12(6)

• Excludes ENT/Opth/ortho/dentists

Classical problem(1)

• Low number of admissions

• Low number of operations

• Increasing numbers of surgeons and anaesthetists

• Increasing public expectations re outcome

Classical problems(2)

• Will travel for elective procedures

• Expect emergency care locally

• Guidelines re “children friendly areas” increasing

• Political pressure

Requirements for paediatric surgical care (1)

• Designated ward (beds)

• Designated lists

• Paediatrician active involvement

• Theatre reception child friendly

• OP clinic child friendly

• A&E child friendly area

Requirements for paediatric surgical care (2)

• Paediatric trained nurses

• Paediatric trained surgeons

• Paediatric trained anaesthetists

Types of Hospital

• Teaching hospitals

• DGH

• Remote & Rural hospitals

Teaching hospitals

• Aberdeen, Edinburgh and Glasgow

• They have all the above

• Can therefore provide a comprehensive paediatric surgical service

Requirements for paediatric surgical care (1)

• Designated ward (beds)

• Designated lists

• Paediatrician active involvement

• Theatre reception child friendly

• OP clinic child friendly

• A&E child friendly area

Requirements for paediatric surgical care (2)

• Paediatric trained nurses

• Paediatric trained surgeons

• Paediatric trained anaesthetists

Dundee

• Visiting service from Edinburgh 2 days per week. Clinics and op lists

• Joint appointment

• 2 local surgeons do 1 in 4 o/c for 3 &<3

• Edinburgh cover the other nights.

• GS look after 4 and >4

• Active involvement of paediatricians.

District General Hospital

• Can and should provide all of the above requirements.

• No neonates• Elective service by nominated

GS/Anaesthetists• Emergency service - ?all GS/Anaesthetists

? separate rota• Visiting service ?clinics ?op lists

Requirements for paediatric surgical care (1)

• Designated ward (beds)

• Designated lists

• Paediatrician active involvement

• Theatre reception child friendly

• OP clinic child friendly

• A&E child friendly area

Requirements for paediatric surgical care (2)

• Paediatric trained nurses

• Paediatric trained surgeons

• Paediatric trained anaesthetists

Raigmore hospital

• 8 GS

• 2 do elective work

• 8 do emergency work

• 1 fully trained paediatric surgeon

• Elective theatre/clinic work in Inverness

• 1 week O/C in Aberdeen

Remote and rural hospitals

• They have very few of the above

• Could provide a visiting service for elective cases

• What about the emergencies?

• Should they transfer all emergency paediatric cases?

• Island versus mainline hospitals

Requirements for paediatric surgical care (1)

• Designated ward (beds)

• Designated lists

• Paediatrician active involvement

• Theatre reception child friendly

• OP clinic child friendly

• A&E child friendly area

Requirements for paediatric surgical care (2)

• Paediatric trained nurses

• Paediatric trained surgeons

• Paediatric trained anaesthetists

The future

• More visiting services to DGH and R&R• Elective work by those who undergo training as

trainees• Emergency work by these surgeons when O/C.• When not O/C ?transfer ?”babysit”?phone

around. GS o/c treat 5 and >5• ? Dual appointments by 2 hospitals close to

each other.• Active paediatrician involvement.

Surgical training

• N&N/E scheme do 6/12 in first year or two

• This will continue with MMC

• ? Where else will training be available

• Needed to provide future DGH surgeons

• Proleptic appointment or top up training