21 Paediatric surgery 21

21 Paediatric surgery

21.1 Various positions – 280

21.1.1 Supine position – 280

21.1.2 Prone position – 282

21.1.3 Lateral position – 284

21.1.4 Lithotomy position – 286

21

While there are no essential differences in the positio- ning of older children and adults for surgical procedures, there are certain special aspects to be taken into con- sideration for infants, newborn babies and premature babies. The temperature in the operating theatre should be more than 25°C and the small patient should be kept warm with a warming mat and a warming lamp before and after the operation. A temperature sensor on the surface of the patient’s body is mandatory to protect from burning. There is no need to spread out the arms of

small children, the arms are positioned close to the body and fixed with a compress. Small foam pads are placed under the knees and feet to pad the lower extremities.

Infants legs are fixed with a plastic strip instead of the belt.

Basically there are differences in the following posi- tionings: supine, prone, lateral, lithotomy and special positions, e.g. for minimally invasive proce dures where the surgeon stands at the foot end or between the patient’s legs.

21.1 Various positions

21.1.1 Supine position

. Figs. 21.1–21.6.

Indications

All open and minimally invasive procedures to the intra-abdominal and thoracic organs for congenital deformities (e.g. gastroschisis, omphalocele, diaphragmatic hernia), emergency operations (e.g. volvulus, necrotising en- terocolitis, trauma), forms of cancer (e.g. Wilms’ tumour, hepatoblastoma, neuroblastoma), urological procedures, hernia operations, funnel chest, placing a port catheter and procedures to the neck (neck cyst).

Preparations

4

Padding for knees, feet and under the buttocks (for hernia/undescended testicle)

4

Padding under the abdomen important during open laparotomies, not for laparoscopic procedures

4

Warming mat, warming lamp

4

Arm positioning device only for older children Positioning

4

Children’s operating table in the neutral position

X-ray apron depending on the procedure

4

Connect the warming mat and lamp, affix the temperature sensor

Prepare and induce the anaesthetic in the supine position

Spread out and pad the arms for older children

4

Abduct the arms laterally (90°) for funnel chest operations

4

Padding at the feet, knees and pelvis/abdomen depending on the operation

Apply the neutral electrode, connect to the HF surgery device

4

Fix the legs with body belt for older children or plastic strips in younger children

4

Use compresses to protect the electrode during disinfection

Position the operating lamps

4

Spread the legs, Trendelenburg position of the head depending on the operation

Risks

4

Plexus injuries on overstretching the arms when spread out

Positioning injuries from lacking or inadequate padding

Burns from lacking moisture protection for the neutral electrode

. Fig. 21.4. Padding under the legs and feet . Fig. 21.3. Laparoscopic procedure on an infant without padding

under the thorax

. Fig. 21.1. Infant with imperforate bile duct . Fig. 21.2. Padding under the back for optimum exposure

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21.1.2 Prone position

. Figs. 21.7–21.10.

Indications

All procedures to the skin and lower soft tissues on the back, buttocks and backside of the legs (haemangioma, tumours, sacrococcygeal teratoma). For anal atresia, the legs are sterile but mobile, a sterile towel roll is placed under the pelvis. In the high form, the patient has to be transferred from the supine to the prone position during the operation.

Preparations

4

Padding for the face, genitals, knees and feet, and under the pelvis (for anal atresia)

4

Warming mat, warming lamp

4

Arm positioning device only for older children Positioning

4

Children’s operating table in the neutral position

4

Connect the warming mat and lamp, affix the temperature sensor

Prepare and induce the anaesthetic in the supine position

4 Transfer to the prone position in the operating theatre, for older children

using a second operating table (see adults), it necessary

4

Spread out and pad the arms for older children

4

Padding for the face (gel ring), genitals, knees and feet, and under the pelvis/abdomen, depending on the procedure

4

Apply the neutral electrode, connect to the HF surgery device

4

Fix the legs with body belt for older children or plastic strips for younger children

4

Use compresses to protect the electrode during disinfection

Position the operating lamps

Risks

4

Positioning injuries from lacking or inadequate padding (particularly for the face and genitals)

4

Burns from lacking moisture protection for the neutral electrode

. Fig. 21.7. Prone position with arms position- ed under the body

. Fig. 21.10. Prone position, fixed with a belt . Fig. 21.9. Padding for the face to prevent positioning injuries

. Fig. 21.8. Padding for the legs and thorax

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21.1.3 Lateral position

. Figs. 21.11–21.16.

Indications

Congenital deformities to the oesophagus (e.g. oesophagus atresia, oesopha- gus duplications), open and minimally invasive procedures to the lungs (e.g.

sequestra, bronchiectasis, tumours).

Lateral position on the healthy side, position on the left-hand side for oesophagus atresia

Preparations

4

Gel cushions/sandbags, possibly wedge cushion

Gel cushions for the legs

4

Leg holders (only for larger children)

Padding for the legs and feet

Warming mat, warming lamp Positioning

4

Children’s operating table in the neutral position

4

Connect the warming mat and lamp, affix the temperature sensor

Prepare and induce the anaesthetic in the supine position

Transfer to the lateral position in the operating theatre

4

The upper arm is positioned in the cranial direction, padded and fixed in a cloth sling to the anaesthetic screen, for infants the arm is fixed in a lying position at the head with plaster strips

4

In larger children, pull the lower arm so that the body weight does not lie directly on the shoulder and extend in this position

4

Stabilise the body with sandbags or gel cushions, possibly wedge cushions

Fix the lower leg with body belts for older children and plaster strips for

younger children

4

Pad the parts of the body at risk from pressure

4

Apply the neutral electrode, connect to the HF surgery device

Use compresses to protect the electrode during disinfection

Position the operating lamps

Risks

4

Positioning injuries from lacking or inadequate padding (particularly for the face and genitals)

4

Burns from lacking moisture protection for the neutral electrode

. Fig. 21.16. Lateral position for lower lobe resection . Fig. 21.15. Arm positioning

. Fig. 21.14. Padding under the legs . Fig. 21.13. Padding under the back

. Fig. 21.11. Modified lateral position for thoracoscopy . Fig. 21.12. Arm spread out, fixed to the anaesthesia screen

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21.1.4 Lithotomy position

. Figs. 21.17–21.21.

Indications

Rectoscopy, cystoscopy and procedures to the anus and rectum (e.g. abscesses, perianal vein thrombosis).

Preparations

4

Two leg holders, pads for the legs

Warming mat, warming lamp

4

Arm position device only for older children Positioning

4

Children’s operating table in the neutral position

4

Connect the warming mat and lamp, affix the temperature sensor

Prepare and induce the anaesthetic in the supine position

Spread out and pad the arms of older children

4

Fit the leg holders to the corresponding clamps

Position the legs and remove the leg plates

4

For infants, the legs can be hung in slings or from the anaesthesia screen

Position the pelvic just above the edge of the buttocks plate

4

Lower the still raised legs until the thighs are almost horizontal

Pad the parts of the body at risk from pressure

4

Position the operating lamps Risks

4

Positioning injuries from lacking or inadequate padding (particularly for the face and genitals)

4

Burns from lacking moisture protection for the neutral electrode

. Fig. 21.17. Cystoscopy, padded leg holders

. Fig. 21.21. Padding of the legs

. Fig. 21.20. Lateral view of the positioning . Fig. 21.19. Lateral view of the positioning

. Fig. 21.18. Spreading the legs out at right angles