for Pediatric General Surgery

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© Springer Nature Switzerland AG 2020
Craig Sims, Dana Weber and Chris Johnson (eds.) A Guide to Pediatric Anesthesiahttps://doi.org/10.1007/978-3-030-19246-4_15



15. Anesthesia for Pediatric General Surgery



Claudia Rebmann1  


(1)
Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia

 



 

Claudia Rebmann



Keywords

Dorsal nerve block of penisCaudal analgesiaPyloric stenosis, anesthesiaInfant hernia, anesthesiaPediatric laparoscopyAnesthesia for intussusception


Children having general surgery present an enormous diversity of ages, conditions and procedures. The majority of procedures involve simple, superficial surgery and are performed on healthy children managed as day cases who require little or no pre-operative investigations. Local anesthetic techniques are useful for these surgeries, and some suitable techniques are summarized in Table 15.1. Children also undergo major surgery that may require special considerations, and these are discussed later.


Table 15.1

Summary of local anesthetic techniques common to several general surgical procedures





























Procedure


Local anesthetic technique


Herniotomy


Caudal or ilioinguinal/iliohypogastric


Orchidopexy


Caudal or ilioinguinal/iliohypogastric


Umbilical hernia repair


Rectus sheath block or local infiltration


Circumcision


Caudal or dorsal nerve block or ring block


Exploration scrotal contents


Local infiltration


Laparoscopic appendicectomy


Infiltration of port sites


15.1 Herniotomy


Inguinal hernias are common in children. They occur in three percent of term infants and are more common in preterm infants, who are also more likely to have bilateral hernias. In adults, hernias are due to a defect in the abdominal wall, but in children they are due to a patent processus vaginalis. This leaves a peritoneal diverticulum that intestine can herniate into, or for fluid to accumulate and cause a scrotal hydrocele. An inguinal hernia usually presents as a groin lump that can be reduced. An irreducible or obstructed hernia is more common in infants and causes bowel obstruction and compression of the testicular or ovarian vessels. Infants and children with an obstructed hernia undergoing emergency surgery are at risk of regurgitation and aspiration and are intubated after a modified rapid sequence induction. Preterm neonates are more prone to obstructed hernias and their hernias are electively repaired at an early age, often before they are discharged home from the neonatal nursery.



Note


Hernia repair in children—herniotomy, during which the patent processus vaginalis is tied off. Hernia repair in adults—herniorrhaphy during which the abdominal wall defect is repaired. Different cause and different procedure.


15.1.1 Anesthesia for Herniotomy in Children


Beyond infancy, general anesthesia is given using a laryngeal mask airway (LMA), and either an ilioinguinal/iliohypogastric block or local infiltration is used to supplement postoperative analgesia. Surgery takes 30–60 min.


15.1.2 Anesthesia for Herniotomy in Neonates and Infants


There are four issues related to anesthesia in this age group: general or regional anesthesia, management of the airway, analgesia and the risk of apnea after anesthesia. Although neurotoxicity from general anesthesia has been raised as a concern in these infants, the surgery cannot be delayed until an older age because of the risk of the hernia causing obstruction, and there is no evidence of a neurotoxic effect in humans from a single brief anesthetic.


15.1.2.1 General or Regional Anesthesia


General anesthesia is most commonly used for herniotomy. Awake spinal anesthesia can be used for neonates if surgery is shorter than 30–40 min. It doesn’t reliably give adequate surgical conditions in older infants. Regional anesthesia avoids the risk of airway management in the neonate, avoids respiratory problems in some very small preterm neonates with chronic lung disease, and avoids the possibility of neurotoxicity from anesthesia. It also reduces early apnea after anesthesia (see below). The disadvantages are the high technical failure rate performing the spinal block (more than 10%), and its short duration (see Chap. 10, Sect. 10.​5.​4). Awake caudal anesthesia can be used, but the block is slower in onset and not as dense, and leg movement during surgery can be a problem. If a spinal block is used for surgery, wound infiltration or an iliohypogastric block is done for analgesia after surgery.


15.1.2.2 Airway Management


Most neonates and young infants are intubated for herniotomy. There are advantages and disadvantages of intubation compared to the LMA in this age group (Table 15.2). Intubation is common because access to the airway is limited due to its proximity to the surgical site, and hypoxia develops rapidly if the airway is lost. Beyond about 3 months of age, the LMA may be associated with less adverse respiratory events than intubation.


Table 15.2

Options for managing the airway of neonates and infants during general anesthesia







































Technique


Comments


LMA


Pros


May reduce respiratory events associated with extubation


Laryngospasm and obstruction possible during surgery


Cons


Necessitates deeper plane of anesthesia


Low leak pressure may prevent IPPV


Size 1 classic LMA unreliable


Intubation


Pros


Secures airway


Avoids airway obstruction during anesthesia


Facilitates IPPV and PEEP


Facilitates light plane of anesthesia without risk of laryngospasm


Cons


Awake extubation may be associated with coughing and desaturation


15.1.2.3 Analgesia


There are three options for analgesia.


  1. 1.

    Caudal analgesia is safe and reliable, and is a good choice for neonates and infants, particularly for bilateral repair. Caudal analgesia has the advantage of providing good quality analgesia during surgery, allowing a light plane of anesthesia to potentially reduce the risk of postoperative apnea in former preterm neonates. A block to T10 is required, achieved by a dose of 1 mL/kg of ropivacaine 2 mg/mL.


     

  2. 2.

    The second option is an ilioinguinal-iliohypogastric nerve block (see Chap. 10, Sect. 10.​7.​1). This is a good choice in older children who may be upset by leg weakness and numbness resulting from caudal epidural analgesia. A suitable volume is about 0.2 mL/kg of ropivacaine 2 mg/mL per side as required.


     

  3. 3.

    The final option is wound infiltration with local anesthesia by the surgeon. This option does not provide intraoperative analgesia, and supplementation with opioids is needed.


     

Preschool-aged children may still benefit from a small dose of fentanyl during surgery, even if a regional block has been given. Emergence delirium is common in this group, and fentanyl reduces its incidence (see Chap. 1, Sect. 1.​8.​1). After discharge, pain is not severe and is managed with paracetamol, and ibuprofen if the patient is older than 3 months.


15.1.2.4 Postoperative Apnea


Neonates, and especially former preterm neonates, are at risk of apnea after anesthesia. This occurs in 6–10% of former preterm infants age 44 weeks postmenstrual age (PMA) or younger. Awake spinal anesthesia does not reduce the overall incidence but reduces the number of early apneas in PACU and the level of intervention needed to treat apnea. Intravenous caffeine base 10 mg/kg (equivalent to 20 mg/kg caffeine citrate) reduces the incidence of post-operative apnea after general anesthesia and is given to former preterm infants with a postmenstrual age of less than 44 weeks at the time of surgery. Former preterm infants who are younger than 52 weeks PMA (60 weeks in some centers) and term neonates younger than 44 weeks PMA must be admitted overnight for apnea monitoring (see Chap. 14, Sect. 14.​4.​4).



Keypoints


Children with obstructed hernia are at risk of aspiration.


Former preterm infants are at risk of apnea after anesthesia.


15.2 Undescended Testis and Orchidopexy


About 3% of term boys are born with an undescended testis. Most undescended testes can be palpated in the inguinal canal and the majority will descend into the scrotum during the first year. They are associated with infertility, testicular tumors and psychological problems. They are also more susceptible to testicular torsion and infarction and are often associated with inguinal hernias. If the testis has not descended by 6–9 months of age it is unlikely to ever descend and is surgically brought into the scrotum (orchidopexy).


Orchidopexy surgery uses the same groin incision as herniotomy, as well as a scrotal incision. An ilioinguinal/iliohypogastric nerve block provides good analgesia but does not cover the scrotum. Subcutaneous infiltration over the symphysis pubis blocks the genitofemoral nerve, or the surgeon can infiltrate the scrotal incision during surgery. Opioid analgesia is usually required. A caudal block with of 1 mL/kg of local anesthetic to block to about T10 is a good choice for young children. Antiemetics are routinely given to children older than 2–3 years. Orchidopexy pain tends to be more severe and longer lasting than the pain after herniotomy and many other day stay procedures in children. Despite this, analgesia on discharge is usually successfully managed with paracetamol and ibuprofen. Older boys (pre-teens) may need oral opioids for the first 24 h after surgery.


If the testis is not even palpable in the inguinal canal, the 2-stage Fowler Stevens procedure is performed. Firstly, laparoscopy is performed and if the testis is present, the testicular vessels are clipped. In the second stage several months later, laparoscopy is performed again, and the testis is pushed into the scrotum and fixed there through a scrotal incision.


15.3 Torsion of the Testis and Surgery to Explore Scrotal Contents


Acute scrotal pain may be due to torsion of the testis or the appendix of the testis (Hydatid of Morgagni). The majority of cases occur around puberty and are due to torsion of the appendix of the testis. Surgery to explore the scrotal contents is performed urgently because of concern of testicular ischemia. Pain is not usually severe enough to delay gastric emptying, and face mask or LMA anesthesia is reasonable unless the child is not fasted or is vomiting beforehand. The procedure is not particularly painful afterwards. These children are usually too old for caudal analgesia, and instead wound infiltration is used with opioid analgesia and antiemetics.


15.4 Circumcision


Male circumcision is commonly performed for recurrent balanitis or balanitis xerotica obliterans (BXO) that results in phimosis (inability to retract the foreskin). Some children undergo circumcision during infancy for social or religious reasons. On the one hand, during infancy the risk of anesthesia is higher and there is the possibility of neurotoxicity from anesthesia. On the other hand, the risk of anesthesia is reduced if the anesthetist cares for large numbers of children each year, and a single, short anesthetic does not affect neurodevelopment in humans.


15.4.1 Analgesia for Circumcision


The procedure is very stimulating, and laryngospasm is a concern early in surgery when anesthetic depth might not have been optimized. Caudal analgesia, dorsal nerve block and ring block are suitable alternatives for analgesia after circumcision (Table 15.3). A caudal block to the level of only S2–4 is needed for circumcision. This requires a dose of 0.5 mL/kg ropivacaine 2 mg/mL or L-bupivacaine 0.25%, maximum of 10–15 mL. An alternative caudal technique is to aim for a saddle block using a small volume of more concentrated solution (L-bupivacaine 0.5% 0.2–0.3 mL/kg), but in practice motor block is difficult to avoid. Caudal block is probably best used for children younger than 6–8 years. It often causes paresthesia of the legs in older children, which is annoying to them. A ring block of the penile shaft is simple to perform, but local swelling or hematoma from the local anesthetic may affect surgery, and its duration is shorter than other techniques. A Cochrane review of the three alternatives for analgesia found no difference in the need for rescue or other analgesia between the three. In day-case surgery, penile block may be preferable to caudal block in children old enough to walk due to the possibility of temporary leg weakness after caudal block. After discharge, analgesia is provided with a local anesthetic cream and simple oral analgesics.


Table 15.3

Comparison of local analgesia techniques for circumcision in children





























Block


Duration


Comments


Caudal


2–4 h


More reliable block in younger children


Major central block


May delay walking


Penile


4–6 h


May be technically difficult (ultrasound may improve success rate)


Rare penile ischemia


May not cover ventral surface of penis


Ring block


2–4 h


May cause local swelling and interfere with surgery


May cause local hematoma


Less reliable in younger children


Antiseptic/local anesthetic creams


Can be reapplied


Variably effective, good supplement after discharge


No intraoperative analgesic effect


15.5 Hypospadias Repair


Hypospadias is a condition in which the urethral opening is not at the tip of the penis, located instead at some point further down the ventral side of the glans penis or shaft of the penis. More proximal urethral defects are more likely to have an associated ventral shortening and curvature, called a chordee. Several surgical repairs are used (Magpi , Wackmans), but all involve laying open the upper urethra and then closing it over a catheter to create a new, distal urinary opening. The initial repairs are usually carried out in infancy, although some mild cases are not detected until later in childhood when the boy begins to stand to urinate. Caudal analgesia is ideal for this procedure as it reliably blocks the sacral segments. Major hypospadias repairs require strong analgesia for 24–48 h. Either a caudal catheter and local anesthetic infusion can be used, or if a single-shot caudal was used, an intravenous morphine infusion is started in recovery in preparation for the caudal wearing off. Ring blocks of the penis cause local swelling and may interfere with surgery, and penile blocks may be used, but they do not cover the ventral surface well. Retrospective studies comparing penile block and caudal block for hypospadias surgery have found an association between caudal block and the occurrence of urethral fistula after surgery. However, the overall incidence of this complication is low and it is unclear if caudal analgesia causes the complication, or if it occurs because a caudal block is more likely to be performed in more difficult, proximal hypospadias cases.


15.6 Division of Tongue Tie


Although a short and simple surgical procedure, anesthesia for division of tongue tie is challenging. The frenulum tethers the tongue (tongue tie) and affects feeding in infants and speech in children. A scalpel or diathermy is used to divide the frenulum, usually with minimal bleeding. A shoulder roll helps to open the infant’s mouth and improves access for the surgeon. Anesthesia is challenging for several reasons. The procedure is commonly performed in infants and their small airway is shared with the surgeon. The procedure is brief, but very stimulating and may trigger laryngospasm. An LMA is commonly used to manage the airway. The risk is loss of the airway, either due to displacement of the LMA or laryngospasm. A key point is to ensure adequate depth of anesthesia before incision—a bolus of propofol 1–3 mg/kg is wise if there is any doubt. Fentanyl is given so the baby is not in pain after awakening, and paracetamol is adequate for analgesia after surgery.


15.7 Umbilical Hernia Repair


Umbilical hernia repair is performed under general anesthesia, most often with an LMA. There are three points of note about this procedure. Firstly, the peritoneal cavity is entered, and omentum or bowel can protrude into the wound during surgery. Although this could be prevented with muscle relaxation, acceptable operating conditions are provided by maintaining a deep plane of anesthesia with apnea and positive pressure ventilation—if the child breathes spontaneously, the tone in the abdominal wall may push the omentum into the wound. Secondly, the procedure is more painful than inguinal hernias, and a multimodal approach is needed, including a rectus sheath block or wound infiltration. Simple oral analgesics are adequate after discharge. Finally, it is associated with a high incidence of nausea and vomiting, and dual antiemetic therapy is indicated.


15.8 Laparoscopic Surgery


Laparoscopic surgery is performed for a widening range of procedures in children of all ages, including neonates. It is considered to improve outcome by minimizing tissue trauma and pain, speeding recovery and shortening hospital stay.


15.8.1 Physiological Effects of Laparoscopy


Young children absorb proportionally more carbon dioxide through the peritoneum than older children and adults. This is due to a proportionally large peritoneal surface area and a lack of intraperitoneal fat that reduces the distance between capillaries and peritoneum and would otherwise buffer carbon dioxide. Children appear to handle this increased carbon dioxide load without significant acidosis.


As in adults, carbon dioxide insufflation in children increases intra-abdominal pressure, decreases total lung compliance and functional residual capacity (FRC), and causes atelectasis and ventilation-perfusion mismatch. Infants and neonates are particularly at risk of respiratory compromise—their closing lung capacity is already close to FRC and their oxygen consumption is high. The severity of these pulmonary effects depends on the abdominal pressure, and for these reasons a lower pressure is used in neonates and infants than in children and adults. Fortunately, the infant abdominal wall is very pliable and the abdominal contents can be visualized at lower pressures.


The cardiovascular effects of the pneumoperitoneum depend on the intra-abdominal pressure and age. They are the result of four factors—mechanical compression of splanchnic vessels, postural changes, increased sympathetic tone and the release of vasoconstrictors including renin and vasopressin. At low abdominal pressures, venous return and cardiac output increase, and the systemic and pulmonary vascular resistance increases. Blood pressure and heart rate commonly increase. Cardiac output falls at pressures above 15–20 mmHg. Neonates and infants are more sensitive to the cardiovascular effects from pneumoperitoneum. Bradycardia may occur with peritoneal stretching from rapid carbon dioxide insufflation, although tachycardia more commonly occurs. Children with cyanotic heart disease are at risk of paradoxical gas embolism and may not be suitable for laparoscopic surgery.



Note


Typical pneumoperitoneum pressure to reduce respiratory and cardiovascular effects during laparoscopy


Neonates and infants younger than 4 months: 5–6 mmHg


Small children: 8–10 mmHg


Older children and adults: 10–15 mmHg

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Nov 27, 2021 | Posted by in ANESTHESIA | Comments Off on for Pediatric General Surgery

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