Day care laparoscopic Surgery in Pediatrics

Views:
 
Category: Entertainment
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Day care laparoscopic surgery (DCLS) in Pediatrics:

Day care laparoscopic surgery (DCLS) in Pediatrics Dr Prakash Agarwal Dr R.K.Bagdi Dr Raghavendran Apollo Children’s Hospital, Chennai .

CRITERIA OF DAY CARE SURGERY:

CRITERIA OF DAY CARE SURGERY Day-care surgery, is the performance of elective operative procedures under general anesthesia in patients who are admitted to and discharged from hospital the same day. The patient receives the same hospital treatment with regard to care, safety and medical records as would an inpatient.

Introduction::

Introduction: Paediatric Day surgery – Nicholl (1909) In recent years - increasing amount of surgery on children on a day stay (ambulatory or outpatient) basis. Children make excellent candidates for day case surgery-healthy, free of systemic disease and typically require straight-forward, minor or intermediate surgical procedures. Introduction of Laparoscopic day-case in Pediatrics since 2003.

AIM:

AIM Clinical outcomes of Paediatric laparoscopic surgery in day care Cost-effectiveness Increased efficiency is not obtained at the expense of the overall quality of the treatment

Benefits of DCLS in Paediatrics:

Benefits of DCLS in Paediatrics It lowers the cost of hospital care Increases the availability of hospital bed. It has been shown to be safe, with as few complications and as short recovery periods as traditional inpatient surgery. Early ambulation Decreased probability of acquiring an in-hospital cross-infection Decreased separation anxiety, less emotional stress for the child and reduced disruption of the family unit.

DCLS in Pediatrics:

DCLS in Pediatrics INCLUSION CRITERIA ASA Gr I & II Staying close to Hosp Willing to return to hosp in case of problem Parents able to understand the instructions well EXCLUSION CRITERIA Co-morbid conditions Raised LFT Staying far from the hospital Insurance company not agreeing for Day care surgery If a second surgery is planned The role of DCLS in pediatric practice is yet to be established. There has been only two reports on DCLC in children

Clinical care pathway:

Clinical care pathway Referral of children with presenting illness to outpatients clinic History and examination & Informed consent for laparoscopic procedure Outpatient CBC, U&Es, LFTs and abdominal ultrasound scan Inclusion criteria for DCLS met-DCLS scheduled Inclusion criteria for DCLS not met- DCLS not appropriate Admission on morning of procedure and cases posted in the list Anaesthetic/Analgesia protocol PONV prophylaxis and management Nursing Protocol

OUR EXPERIENCE (2010-2014) Lap procedures performed as Day care:

OUR EXPERIENCE (2010-2014) Lap procedures performed as Day care CONDITIONS NUMBER OF CASES REMARK LAPAROSCOPIC CHOLECYSTECTOMY 15 13 – TAP BLOCK 02 – PORT SITE LOCAL INFILTRATION LAPAROSCOPIC ORCHIDOPEXY SINGLE STAGE – 24 TWO STAGE – 4 + 4 32 PORT SITE LOCAL INFILTRATION LAPAROSCOPIC HERNIA MALES - 22 FEMALES -12 34 PORT SITE LOCAL INFILTRATION LAPAROSCOPIC VARICOCELE LIGATION 4 PORT SITE LOCAL INFILTRATION Total 85

Patients and methods:

Patients and methods Data relating to the cases were collected prospectively and clinical outcomes were audited All patients were seen in the outpatient clinic before DCLS and explained regarding the procedure. Informed consent was obtained. Blood tests and an abdominal ultrasound scan were requested & anesthesist review. Patients were admitted electively on the morning of the procedure and Underwent a Lap procedure on the list.

Operative considerations:

Operative considerations ANESTHESIA Induction of anesthesia was with propofol. All patients were ventilated via an endotracheal tube with air, oxygen, and sevoflurane. Prophylactic antiemesis – ondansetron Analegsia – Tap Block SURGERY A standard three / four-port technique was used 5mm /10mm at the umbilicus, 2 X 5mm at the iliac fossa CO 2 insufflation below 12mmHg and rate from 1-3 L/min. At the end of, an attempt was made to evacuate all CO 2

Transversus Abdominis plane (TAP) Block:

Transversus Abdominis plane (TAP) Block

Non palpable undescended testis (n=32) Staged – 4+4:

Non palpable undescended testis (n=32) Staged – 4+4

Laparoscopic hernia repair (N= 34):

Laparoscopic hernia repair (N= 34)

CHOLELITHIASIS (n=15):

CHOLELITHIASIS (n=15)

Post Operative considerations:

Post Operative considerations Early mobilization was encouraged Postoperative feeding regime from liquids to light diet for 72 hours Pain was assessed by the Nurse and scored using the Wong and Baker FACES pain rating scale. Patients were reviewed in the afternoon by the anesthetic team and jointly by the surgical and the nursing team and a decision was made regarding discharge Final decision regarding discharge made jointly by the patients’ families and the nursing team.

Criteria for discharge:

Criteria for discharge Normal temperature, pulse and blood pressure, Tolerance of fluid and light diet, Adequate pain control, comfortable mobilization, and patient/ carer satisfaction with discharge.

RESULTS::

RESULTS: Jan 2010- March 2014 = 85 patients M:F = 68:17 Age = 2-16 years (11.8 years) Ultrasound: Done preoperatively to diagnose cholelithiasis in all patients who underwent lap chole & normal internal organs for patients with hernia and UDT.

RESULTS:

RESULTS Duration of Surgery- 35-70 min (Avg 57 min) Intra operative problems - Nil Post operative problems - Nil Conversion to open - Nil Pain score at Discharge – 3/10 PONV - Tolerable Pain score on follow up – 2/10 (R shoulder tip pain in 4pt of Chole) Patients with TAP block were more comfortable.

Observations::

Observations: Admission on the day before the procedure was unnecessary Explanation of the procedure and discharge policy to the families in the outpatient setting was extremely important in acceptance of having a major procedure performed in an ambulatory setting. Day care surgery is less expensive than inpatient surgery. The use of Transversus abdominis plane (TAP) offers excellent pain relief in day care setting.

Role of the nursing team:

Role of the nursing team Should not be underestimated. Requires a major shift away from a traditional conservative approach with regard to introduction of enteral feeds, mobilization, and pain management. Introduce an element of balance to the decision regarding patient discharge

Successful outcome:

Successful outcome Rigorous patient selection is a prerequisite for the success of DCLS. A cornerstone of successful DCLS practice is adequate pain management. The use of transversus abdominis plane block demonstrated huge benefits. No PONV due to routine combination intraoperative antiemetics , minimization of the use of long acting intravenous opioids , and a strict dietary regime

Take home message:

Take home message DCLS in children is feasible in the majority of patients requiring a sole procedure Performed with excellent results without compromising patient safety. DCLS is cost effective A multidisciplinary team approach Adoption of a clinical care pathway Adequate pain management and avoidance of PONV are a prerequisite for success.

LITERATURE:

LITERATURE

THANK YOU  :

THANK YOU 

authorStream Live Help