Handbook of Surgical Consent
Annotate
Cite
Introduction to paediatric surgery 462
Groin hernias 464
Midline hernias 466
Orchidopexy 467
Circumcision 469
Hypospadias 471
Branchial remnants 472
External angular dermoid 474
Thyroglossal cyst 476
Tongue tie 477
Appendicectomy 478
Excision of Meckel's diverticulum 479
Pyloric stenosis 481
Reduction of intussusception 482
Oesophageal dilation and foreign body/bolus removal 484
Central venous access 485
Tissue and lymph node biopsy 486
Lymphatic malformation in head and neck (cystic hygroma) 488
Introduction to paediatric surgery
This section is written with the assumption that disclosure is being provided to, and consent obtained from, the parents. It goes without saying that the competent child should also be involved in the disclosure, so in this situation, the conversation should be couched in terms that enable the child to participate. Some competent children will want to provide their own consent, and are entitled to do so. However, many competent children exercise their autonomy by choosing to allow their parents to sign the consent form on their behalf.
The frequency with which a complication may occur has no bearing on whether it should be disclosed. Historically, courts have toyed with the notion that a numerical threshold for disclosure could be considered, where risks whose incidence lay below an arbitrary threshold, e.g. 1%, did not require automatic disclosure (see Box 15.1). This has been abandoned by the courts, and should equally be abandoned by surgeons. Risks should be disclosed if it is reasonably foreseeable that they could occur, and if the reasonable patient would consider them to be significant. Deaths during neuroblastoma surgery or bladder paralysis following the excision of a sacrococcygeal teratoma are rare, but they do occur. A reasonable parent would consider these complications significant. Surgeons sometimes forget, however, that the possibility of such outcomes may never occur to parents. Whether the knowledge will alter their decision to consent is quite a different matter, but it is proper that they are given the appropriate information, irrespective of the likelihood of the complication occurring. It is appropriate to put a rare risk into the context of its infrequency, but not to exclude its disclosure on this basis.
We generally, avoid allotting specific numerical values to complication rates. In reality, the complication rates derived from any of the procedures listed in the text should not be expected to exceed 5–10%. For reasons already given, the actuarial risk of a complication should not influence its disclosure. However, if parents request an estimation of the risk of a particular complication, the local rate of occurrence of the complication should already have been identified by audit, and this is the figure that should be disclosed. It is the pertinent risk estimate for this patient's operation.
In this chapter, disclosure for quintessentially general paediatric surgical procedures is reviewed. Thus, pyloric stenosis and branchial remnants are, hopefully, fully addressed. There is also a group of diagnoses falling into both paediatric and adult practice. In examples where we have an equal interest, e.g. appendicectomy, the disclosure is provided. But in topics where the expertise is largely in adult practice, such as cholecystectomy, where the paediatric aspects of the clinical picture have no bearing on disclosure, we defer to our adult surgical colleagues, and the relevant section will thus be covered elsewhere.
The reader will note, perhaps with initial surprise, that the disclosure for children's surgery is not necessarily proportional to the complexity, difficulty, or rarity of the procedure. Experience reveals that it is the rather more prosaic operations, often day cases, which generate the most damning criticism from parents, who consider that they were inadequately informed before providing consent. Circumcision and umbilical surgery forms the lion's share of litigation over consent in routine elective children's surgery, while litigation over imperfect consent in complex (non-cardiac) neonatal surgery is almost unheard of.
Surgery is ever changing, and it is common to find that several commonly and acceptable operations are available for the same condition. Obvious examples include the option of laparoscopic or open surgery; of percutaneous or open venous access; or of the several approaches to distal hypospadias. Where these options exist, their existence should be disclosed to the parents; and furthermore, the reasons why you have selected your proposed option should also be disclosed.
For the purposes of these descriptions, it is assumed that disclosure will reflect that all operations may result in pain, swelling, scarring, infection, and bleeding. In the clinical circumstances when one of these consequences is particularly pertinent, it will be addressed.
Groin hernias
Description
Groin hernias are commoner in males and are predominately caused by the failure of closure of the processus vaginalis. Thus, inguinal herniae arise due to persistence of the processus vaginalis, with an open deep ring large enough to allow viscera to slip down into the inguinal canal. If narrower, the ring may only allow fluid to enter (patent processus vaginalis—PPV), leading to hydrocele formation (Fig. 15.1). Femoral hernias are uncommon in children.
PPV and hydrocele.
Alternative procedures/conservative measures
Since many PPVs will resolve spontaneously in the first few years of life, this natural history should be disclosed if the surgery is being offered before the age of 3 years
Benefits
Therapeutic: Repair hernia
Inguinal hernia repair
Hernia repair can fail, and the most commonly performed repair in children (inguinal herniotomy) has its highest recurrence rate in preterm babies
Surgery in the inguinal region carries the risk of damage to the spermatic cord; thus division of the vessels, vas, or nerve are all foreseeable
The consequences of damage to cord structures include testicular loss, increased chances of infertility and paraesthesias
Bleeding—sometimes causing a scrotal haematoma
PPV ligation
Children undergoing PPV ligation face similar risks
Femoral hernia repair
Femoral hernia repair may additionally result in damage to the femoral vein
Incarceration/ischaemia
Since the contents of the inguinal or femoral sac may include bowel, damage to this is foreseeable, but rare
However, the parents need to acknowledge that ischaemic damage to entrapped viscera, or due to pressure on the spermatic cord, may itself lead to visceral and or testicular damage, or loss, quite separate from the risk attributable to surgery
This risk is proportionate to the period of ischaemic obstruction, and occurs irrespective of damage that may be caused during surgery
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Routine outpatient review
References
Midline hernias
Description
Umbilical hernias are common and are usually caused by a delay in the formation of an umbilical cicatrix. This becomes evident at or soon after birth. Most will gradually reduce over time and close spontaneously by 3–5 years.1
Alternative procedures/conservative measures
The main risk of repairing umbilical hernias is that it could prove to be an unnecessary procedure, since they are rarely symptomatic
Many will resolve spontaneously by 3–5 years. This natural history should be disclosed to the parents. Litigation, on the basis that imperfect disclosure has led to a procedure to which the parents would not have otherwise consented, is not uncommon
Benefits
Therapeutic: Repair hernia
Significant/frequently occurring risks
Recurrence postoperatively is uncommon
If the sac is large and associated with an elephant's ‘trunk’ of redundant skin, a period of many months may elapse before the bulge flattens into a normal contour. Some surgeons excise the redundant skin, but risk an inferior result than that obtained by natural healing
For those using an incision outside the curtilage of the umbilicus, the parents need to be advised of an additional skin-crease scar
Supraumbilical hernias may be more prone to complication, and less frequently resolve
Epigastric hernias are notoriously easy to miss at operation, since although the swelling that they cause is easily perceived; the defect through which this emerges is often only 1 or 2mm in diameter. The sac is diaphanous, contains extraperitoneal fat, and emerges into the subcutaneous fat layer. The sac and its contents are thus difficult to identify, and unless the preoperative marking is meticulous, finding the defect can be impossible. The possibility of missing the defect must thus be disclosed
If there is extensive subcutaneous dissection, this increases the risk of seroma formation, which should be disclosed. This difficulty is sometimes reflected in a surprisingly extensive scar, which should be anticipated during consent
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Routine outpatient review
Reference
Orchidopexy
Description
Undescended testes (UDT) can be congenital or acquired. Congenital UDT has been described as being due to failure of embryological testicular descent and is present from birth. Acquired UDT, on the other hand, is described as being due to failure of spermatic cord elongation as the child grows, where the testis is initially intrascrotal and later re-ascends.1 It has an incidence of 2–4% in term males at birth, which falls to about 1% at one year.2 Timing of orchidopexy is controversial but current opinion ranges from 6 to 18 months.
Benefits
UDT is associated with infertility and is a risk factor for testicular cancer. Orchidopexy positions the testicle in the optimal place for spermatozoa production and research suggests that timely orchidopexy decreases the risk of testicular cancer.3
Additional procedures that may become necessary
Disclosure should include the possibility that an orchidectomy may be required intraoperatively, if the quality of the testicular remnant precludes its fixation. If a ‘good quality’ testis lies on a spermatic cord that is of inadequate length, a staged operation may be required
Disclosure may become complicated when at the outpatient examination, a testis cannot be found on one side
The likely surgical plan will be an examination under anaesthesia, and routine orchidopexy if the testis can be palpated at this stage
If not, during the same anaesthesia, a laparoscopy may then reveal an abdominal testis; which may be suitable for an orchidopexy in one or two stages
Alternatively, laparoscopy may reveal the testicular vessels and vas entering the deep ring, after which an open groin exploration is required, to identify and in all likelihood excise a blighted (and thus impalpable) testis
Some surgeons believe that exploration of the closed deep ring is unwarranted as no viable testicular tissue will be found
A blighted testis may be identified lying intra-abdominally, and excised
However, the performance of this sequence differs widely between paediatric surgical units. Given the potential for confusion during disclosure, it is prudent to be utterly sure what the operative plan will be before trying to explain it to the parents
Significant/frequently occurring risks
The main risk of orchidopexy is testicular loss, following inadvertent damage to the testicular vessels
Division of the vas deferens is also a well-recognized complication
Parents need to realize that moving the undescended testis into the scrotum will not necessarily make it function normally, and the principal reason for performing the operation is to bring the testis into a subcutaneous site where it can be periodically examined by the mature patient. Self-examination is part of prudent healthy living, akin to self-examination of the breast, and can facilitate the early diagnosis of malignancy
The increased risk of malignancy in the originally undescended testis is also an important element of disclosure, although the numerical risk, while greater than that of the normal population, is still low
If the spermatic cord is not adequately freed, residual tension may drag the testis back out of the scrotum postoperatively, causing recurrence. Equally, this may occur after a competent operation
The risks of spermatic cord damage during surgery for recurrence are higher than in the primary procedure
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Routine outpatient review
References
Circumcision
Description
Circumcision is the removal of some or all of the foreskin from the penis (Fig. 15.2). Dual parental consent is required for cultural circumcision, originating in English common law and now reiterated by the General Medical Council.
Circumcision.
Additional procedures that may become necessary
Meatal dilatation in cases of severe BXO
Benefits
Remove scarred foreskin in BXO and obtain a histological diagnosis
Relief from recurrent balanitis
If circumcision is performed on a healthy foreskin for cultural reasons or parental wishes, notwithstanding the lack of medical benefit to the child
Significant/frequently occurring risks
Whatever the indication for circumcision, postoperative bleeding is a ubiquitous risk
Meatal stenosis is more common when the circumcision is performed for BXO
Transient urinary retention is variously reported
The possibility of a postoperative result that does not accord with parental expectations should be addressed, particularly in those children having a cultural circumcision. In this group, a parental wish to have the glans completely and permanently exposed may not adequately be expressed preoperatively, and should be anticipated by relevant disclosure
If too much skin is removed, a tight or bent erection may result, which again should be disclosed in consent
The initial postoperative appearance can be alarming, with a combination of swelling and bruising. This may cause both the parents and child some distress
Glanular hyperaesthesia should be disclosed, which may be experienced postoperatively
A description of what the circumcised penis will look like will ensure that the parents know what to expect, and give them an opportunity to influence the final result
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Routine outpatient review only required in cases of recurrent balanitis or suspected BXO
Hypospadias
Description
The name hypospadias is derived from the Greek hypo, ‘under’ and spadon, ‘a tear’. It is a congenital abnormality of the penis in which the urethral meatus opens at varying positions in the line of the urethra on the ventral surface of the penis. It may be associated with a hooded foreskin and a penile chordee. It occurs in about 1 in 300 males.1
Benefits
Cosmetic appearance
Gives the child a normal axial urinary stream
Straightens an otherwise bent erection
Significant/frequently occurring risks2
Complications inherent in hypospadias surgery include:
Fistula formation
Meatal stenosis
Urethral stenosis
Flap failure and consequent asymmetry of the resulting skin cylinder
Deformity
Residual curvature of the erect penis
Urethral diverticulae secondary to meatal stenosis may also be described
To put this into some context, you may choose to quote the local unit's reoperation rate for children with a similar severity of hypospadias that corresponds with the index patient
However, the near-inevitable postoperative swelling and bruising should be disclosed, which may alarm unsuspecting parents; and the potential difficulties associated with postoperative urinary drainage and dressings
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Depends on unit protocol
Catheter out usually around 1 week postoperatively
Outpatient review at 2–3 months followed by a review when patient is around 4 years old and is potty trained
References
Branchial remnants
Description
There are four paired branchial arches in humans and these are analogous to the gills of our evolutionary ancestors. Branchial anomalies occur as a result of abnormal development of the branchial arches during embryogenesis. They may present as cysts, sinuses or less commonly fistulas.1,2 The most common are the second branchial arch sinuses, which present as an external opening along the anterior border of the lower third of sternocleidomastoid. The internal part of these sinuses opens into the tonsillar fossa. First branchial arch anomalies are the next most common. These can present externally anywhere in the region between the external auditory meatus and the submandibular area.
Benefits
Generally parental preference for cosmetic reasons
Excision prevents later infection
Alternative procedures/conservative measures
Conservative: With preauricular remnants, consent for excision should focus on the justification for the procedure. Preauricular pits and swellings are often asymptomatic in childhood, and it should be made clear that the reason for the removal in infancy and early childhood is almost invariably based upon parental preference rather than clinical necessity
Significant/frequently occurring risks3
When excising branchial remnants or fistulas, persistent residual infection is the most obvious risk
Scarring is also a frequently occurring risk and must be discussed during disclosure. This latter is pertinent because of the occasional necessity to make a second incision, so that the upper part of the fistulous tract, as it ascends to the pharynx, can be removed
Potential damage to contiguous structures should be disclosed
Risks of postoperative scarring and infection should be disclosed, together with risks to the facial nerve in appropriate cases
Postoperative infection is relatively common; the risk of deep-seated infection in the cartilaginous structures of the external ear may be rare, but is difficult to eradicate, so should be disclosed
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Depends on unit protocol
Outpatient review at 2 months to check for scarring or recurrence
References
External angular dermoid
Description
Dermoid cysts are painless, mobile, subcutaneous cysts that are common in children. They may become symptomatic if the cyst becomes infected. The cysts are found along the lines of embryological fusion, in this case at the lateral border of the eyebrow. Many surgeons attempt to place the skin crease incision within the region of the putative eyebrow, thus anticipating its camouflage by the growth of hair.1 The cyst wall may be closely associated with or fused to the skull periosteum, through which a feeding vessel may emerge; and the cyst may have induced a bony depression in the outer table of the skull.
Alternative measures
Conservative management would include a non-operative ‘watch and wait’ policy but these cysts gradually enlarge and treatment is by excision
Benefits
Cosmetic
Avoids the complication of the cyst becoming infected
Significant/frequently occurring risks1
The main risks to be disclosed relate to:
Scarring
Recurrence
A lateral or high dermoid may make scar placement within the eyebrow impractical, and a swelling is thus exchanged for a visible scar, which the parents need to be warned of
If the cyst is closely associated with or fused to the periosteum, combined with a delicate cyst wall, it can make complete excision of the intact cyst difficult
Bursting the cyst during excision will result in spillage of its contents, and this may lead to local inflammation of the surrounding tissues for a few days postoperatively, but has no long-term sequelae. Fragmentation of the wall, with retention of a fragment within the wound, may result in recurrence, the risk of which should be disclosed
Dermoid cysts, less commonly, can be found in the midline on the face, or related to the medial canthus. The same risks of scarring and recurrence apply. However, the surgeon should be immediately wary, since the diagnosis may be wrong, and in reality, the lesion may originate either from the frontal or ethmoid sinuses, or deeper intracranial structures, via meningeal herniation through a skull defect
This differential diagnosis, and the need for further investigations preoperatively, should be openly discussed with the parents, who may otherwise be perplexed that the lesion is not simply removed as a matter of routine
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Depends on unit protocol
Outpatient review at 2 months to check for scarring
Reference
Thyroglossal cyst
Description
Thyroglossal cysts arise as a midline swelling, usually just inferior to the hyoid bone, and may elevate with protrusion of the tongue. They develop from epithelial remnants left as the thyroid gland descends from the foramen caecum during embryological development. Thyroglossal cysts may be hard clinically to differentiate from a midline dermoid cyst in the neck, and disclosure is thus, to an extent, conditional on confirming the diagnosis at operation. Sistrunk's operation involves removing the cyst together with the underlying track and the central part of the hyoid bone, to reduce the incidence of recurrence.1
Alternative measures
Parents, initially unwilling to proceed with surgery, may elect for a trial of conservative management
This is not unreasonable, but their decision should be tempered by disclosing that if they wait too long, the cyst may become infected, and the operation may become more difficult
Benefits
Improved cosmetic appearance
Prevent further infection
Significant/frequently occurring risks
The risk of inadvertently removing all thyroid tissue by excising the thyroglossal cyst can be avoided by ensuring that in addition to the cyst, a normal thyroid gland is visible on ultrasound preoperatively
The cyst will almost certainly recur if the body of the hyoid bone is not removed, together with any obvious superior track. Recurrence may also be more likely if there has been pre-existing infection
The cysts are often associated with a history of infection; the possibility of postoperative infection should be disclosed
The dissection and excision of the body of the hyoid sometimes causes a sore throat for a few days; although the surgery is usually done as a day case procedure, the possibility of an overnight stay for pain relief should be anticipated during disclosure
Although the need for a scar is self-evident to most parents, the length of the scar may take them by surprise, since they base their own estimate on the diameter of the cyst, rather than the need to dissect the track, thus this requires discussion before consent
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Depends on unit protocol
Outpatient review at 2 months to check for scarring or recurrence
Reference
Tongue tie
Description
Disclosure needs to include the observation that the indications for surgery are still a matter of some controversy, although the current trend may favour intervention in infancy. Current NICE guidelines1 suggest dividing tongue-ties in babies to improve breastfeeding, when symptomatic.2,3 However, in older children, there is no evidence to suggest that division improves either speech or feeding.
Alternative procedures/conservative measures
Tongue tied babies who are having difficulties breastfeeding will usually be able to bottle feed without difficulty
Breastfeeding advice and counselling
Benefits
May improve breastfeeding
May improve nipple pain in breastfeeding mothers
Significant/frequently occurring risks
Bleeding
Incomplete division
Collateral damage from diathermy (monopolar diathermy should be avoided)
Type of anaesthesia/sedation
In some centres it is performed in the swaddled awake baby; in others, under general anaesthesia; so whatever technique is locally adopted, the alternative approach should be acknowledged
In older children, it is performed under general anaesthesia, often using bipolar scissors
References
www.nice.org.uk.Appendicectomy
Description
Appendicitis is a disease that many parents have heard of and may have experienced themselves. Such familiarity may breed a temptation to assume that disclosure may be minimized, particularly in the hastened circumstances, when the anaesthetist has called for the patient, and you are in danger of losing the emergency slot on the list.
Alternative procedures/conservative measures
Conservative management with antibiotics and subsequent delayed appendicectomy if an appendix mass is present
Benefits
To remove inflamed appendix and treat infection
Significant/frequently occurring risks
The parents need to know that successful appendicectomy may still be followed by sepsis, so postoperative antibiotics over several days may be required
It may not be possible to find a faecalith in an inflamed pelvis, making postoperative abscess formation more likely
It also needs to be made clear that if a pelvic mass is encountered following a preliminary examination under anaesthesia, the procedure may be abandoned, and the mass treated conservatively1
Damage to contiguous structures is unusual during open appendicectomy, but should be acknowledged; as should stump perforation
Since open and laparoscopic approaches are both commonly performed, disclosure should include the rationale for why the proposed approach has been chosen
Whether it is a ‘risk’ is debatable but the likelihood of finding and removing a normal appendix should be disclosed
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Outpatient review at around 2 months to check for resolution of pain and appendix histology
Reference
Excision of Meckel's diverticulum
Background
Meckel's diverticulum results from the failure of complete obliteration of the embryonic vitelline or omphalomesenteric duct. In many children presenting with rectal bleeding, Meckel's diverticulum can be included within the differential diagnosis.1 If a positive radionuclide scan is obtained, disclosure to the parents can reasonably assert that the diverticulum is the source of the bleeding. Excision involves resection of a wedge or sleeve of ileum (Fig. 15.3) to ensure that the base of Meckel's diverticulum is resected.
Meckel's diverticulectomy: a = wedge excision; b = with sleeve of ileum.
Benefits
Removal of the source of bleeding
Significant/frequently occurring risks
The general risks of open or laparoscopic access to the abdomen, evisceration of the ileal segment bearing the diverticulum, its resection and primary anastomosis can then be disclosed, with the general risks of anastomotic leakage, infection and bleeding
However, in many cases, the child will go to theatre without a firm diagnosis, since radionuclide scans have a high false negative rate, and both upper and lower gastrointestinal bleeding still lies within the differential
Disclosure thus needs to be tailored to local practice. Upper and lower gastrointestinal endoscopy, which if negative can be followed by laparoscopy and/or laparotomy all have a role in the management, but it is important to be utterly sure of the operative sequence before disclosing it to the parents
Furthermore, the possibility of finding no bleeding lesion within the gut, despite all these efforts, must be disclosed, since this is not an uncommon result
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Outpatient review at 6–8 weeks
Reference
Pyloric stenosis
Description
Pyloric stenosis is due to hypertrophy of the pyloric muscle, leading to gastric outflow obstruction. It typically occurs between the 3rd and 6th weeks of life and presents with non-bilious, projectile vomiting. The baby is often unsettled and may be dehydrated. On examination, visible peristalsis may be present, together with an olive-sized tumour in the epigastrium or right hypochondrium. A test feed may help display these signs.
If the history suggests pyloric stenosis, yet examination is equivocal, an ultrasound may help confirm the diagnosis (sensitivity 795%). Initial treatment is rehydration and correction of electrolyte imbalance due to vomiting (hypokalaemic, hyponatraemic, metabolic alkalosis), followed by surgery in the form of pyloromyotomy (either open or laparoscopic).1
Benefits
Resolution of vomiting and return to normal feeding
Significant/frequently occurring risks1
The risk of a false-positive diagnosis should be acknowledged
The risk of an inadequate pyloromyotomy, and persistence of symptoms must be acknowledged
Equally, the risk of mucosal perforation, and the steps that will be taken if this occurs, should be discussed
Wound infection is still common; if both right upper quadrant and peri-umbilical incisions are used in the local unit, it would be prudent to inform the parents if the wound infection rates from these alternative approaches differ markedly
Parents also need to realize that postoperative vomiting is common for the first few days, and that an instant cessation of this sign may not occur
For children undergoing a laparoscopic pyloromyotomy, the generic risks associated with this approach, including damage to contiguous structures, should be disclosed
In all patients, the risk of incisional hernias could be addressed when the rationale for choosing the planned route of access, i.e. laparoscopic, peri-umbilical is presented. During the period when these commonly used alternatives are still widely employed, the reason for preferring one above the others needs to be disclosed
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Outpatient review at 6–8 weeks to assess feeding and review scar
Reference
Reduction of intussusception
Description
Intussusception is caused when one section of bowel invaginates into another section of bowel; most commonly occurring between the terminal ileum and ascending colon (Fig. 15.4). The majority of intussusceptions are reduced by air enema; the radiologist performing this will doubtless warn the parents of the risk of gut perforation, and failure to reduce. However, before the child goes to the radiology department, surgical consent will also be required, anticipating the possibility of failure of the radiological reduction.
Intussusception of terminal ileum.
Additional procedures that may become necessary1
Surgical reduction (either open or laparoscopic) if radiological reduction by air enema fails, or if perforation occurs
Bowel resection and anastomosis may be required and must be disclosed
If it is local policy to perform an appendicectomy in addition to the surgical reduction, the reasoning behind this, and the related risks, should be disclosed
The possibility of finding a lead point, and how this will be dealt with, should also be discussed
Serious/frequently occurring risks1
Perforation during attempted air enema reduction
The potential for gut resection and anastomotic leak must be disclosed
The risk of recurrence, which is applicable to both open and closed reductions, should also be discussed
The potential for adhesions to form and possible subsequent small bowel obstruction
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Outpatient review at 6–8 weeks to assess bowel habit
Reference
Oesophageal dilation and foreign body/bolus removal
Description
Patients who have had a previous oesophageal anastomosis, typically those born with oesophageal atresia or those with severe reflux, have a risk of developing an oesophageal narrowing or stricture.1 These patients may present subacutely with a reducing ability to swallow any feeds that are not liquid. Alternatively, as emergencies, with a history of food sticking in the throat, followed by coughing and choking. In some cases, the children are dribbling, as they are unable to swallow their own saliva.
Previously well children are also at risk of foreign body obstruction. The child's innate desire to explore the world by putting everything into their mouths often leads to the paediatric surgeon being asked to remove coins, batteries and other non-foodstuffs from the inquisitive child's oesophagus.
Benefits
Remove foreign body/food bolus
Resumption of normal swallowing
With any oesophageal manipulation, oesophageal perforation and its consequences represents the most serious complication, and should be disclosed, together with the steps that will be taken to treat it if it is seen to occur, or to check that it has not, once the operation is over
Details of the consent disclosure for dilation will depend on whether it is performed with bougies or balloons, and flexible or rigid oesophagoscopy
Equally, patients with foreign bodies or bolus obstruction may suffer perforation, although in this case, there is the additional possibility that the foreign body may pass into the stomach during the induction of anaesthesia. The parents therefore need to appreciate that the offending item may not be retrieved immediately, or even during the hospital stay
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Timing of outpatient review depending on the severity of the stricture, on average three dilations are required
For oesophageal foreign body removal in a patient with no previous oesophageal problems, no follow-up is required
References
Central venous access
Description
This routine procedure may require surprising variations of consent, because of the widely different potential approaches. Catheters may be short or long term; single or multi-lumen; external or connected to a subcutaneous port. The insertion may be via a percutaneous approach to the jugular, subclavian, or more distal veins, with or without ultrasound guidance.1,2 Alternatively, insertion may be achieved by an open operation, usually to the jugular venous system or its tributaries. As a result, disclosure may vary, although there are common elements running through all procedures.
Benefits
Delivery of chemotherapy, most commonly, other medications (e.g. antibiotics in children with cystic fibrosis), or parenteral nutrition.
Haemorrhage is a prominent risk, together with damage to contiguous structures, including artery, nerves, and pleura during the percutaneous subclavian approach and the contents of the carotid sheath in open or percutaneous jugular insertions. This damage itself may lead to the need to control leaks of blood and air
In the longer term, open venotomy may preclude reuse of the vein on a later occasion, while a long-term subclavian line may induce subclavian stenosis and render the vein equally unusable
Equally, the presence of the catheter itself, although safely inserted, may cause complications, notably thrombosis, perforation, and infection
Furthermore, catheters may fracture and become dislodged
Disclosing complications of such complexities may be too burdensome for parents of children who have other acute concerns, such as the very recent diagnosis of malignancy. For this reason, disclosure for central venous catheterization is a topic well suited to an information sheet, allowing parents to digest the information at a more palatable rate than can usually be achieved during oral disclosure.
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
These patients are not routinely followed up in an outpatient setting as they are usually looked after by an oncology or paediatric team. Any line problems will be promptly brought to your attention
Often long-term lines will need replacing as a result of complications such as infection and displacement
Long-term catheters will need removing when the treatment period is over and this will require a brief general anaesthesia
References
Tissue and lymph node biopsy
Description
The mode of biopsy needs to be discussed, together with the reasoning behind selecting the proposed method. It is also important to emphasize that the histology results may take some time to be ready, and that depending on the rarity of disease or difficulty of histological diagnosis, this may be a matter of weeks.
Benefits
Serious/frequently occurring risks
Most parents initially fail to realize that an excisional biopsy may fail to excise a tumour. Furthermore, in some diagnoses such as soft tissue sarcoma, an incisional biopsy is often strongly preferred, and an initial excisional procedure avoided. Neither an excisional nor an incisional biopsy can guarantee a firm diagnosis. This must be carefully explained preoperatively
The risk of bleeding and damage to contiguous anatomical structures must be acknowledged, together with the perioperative actions that may be needed to rectify the situation
Most usually performed in the head and neck, axilla, and groin, node biopsy is notably associated with damage to contiguous structures, such as inferior branches of the facial nerve in submandibular biopsy or the accessory nerve as it courses across the posterior triangle of the neck
Parents need to be warned that the biopsy may yield false-negative results, and that the results may take many days, sometimes weeks, to emerge from the laboratory
They also need to realize that pathological nodal masses are often bosselated, reminiscent of a bunch of grapes. In these circumstances, only one or two nodes will be excised from the mass, which thus will not be much reduced in size. Without this warning, they may immediately be dissatisfied that the ‘excision biopsy’ is apparently incomplete
It is sometimes necessary to biopsy a node which proves to be enlarged due to atypical mycobacterial infection. The biopsy may thus result in a discharging sinus, which may be persistent. In circumstances where this is foreseeable, the parents should be warned of this potential result, and the almost inevitable phase of an ugly and puckered scar
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Follow-up should be expedient and with the histology results, and may require oncology involvement
It will include a discussion of ‘where we go from here’, which will depend on the histology
References
Lymphatic malformation in head and neck (cystic hygroma)
Description
Cystic hygromas are congenital lymphatic malformations. They may be diagnosed antenatally and if large, some may cause airway obstruction at birth. Alternatively, they may present in early childhood as multilocular cystic swellings, most commonly in the neck or axilla, although they can occur anywhere.
Indications for surgery include disfigurement, infection, or if the malformation was causing symptoms (depending on site and size).
Disclosure should ensure that the parents appreciate that in cases where the lesion is not impinging on the airway, or impeding swallowing or vision, there may be a strong case to adopt a conservative approach, since many of these lesions resolve spontaneously
Equally, if eradication is desired, the injection of sclerosants may present a realistic alternative (in some cases) to excisional surgery, while posing less threat of structural damage
Benefits
May improve cosmetic appearance
May improve function of any structures impinged upon
Serious/frequently occurring risks
If parents wish to embark on excisional surgery, disclosure should include:
The risk of incomplete excision and recurrence of the lesion
Even if the hygroma is successfully removed, the majority of patients will acquire a postoperative transient lymphocoele, due to leakage of lymph from the transected lymphatic channels (which originally supplied the lesion), during the first month postoperatively
The preoperative cross-sectional imaging will give an idea of the anatomical ramification of the lesion, and can usefully be shown to the parents during disclosure, to help them appreciate the risk of damage to contiguous structures within the operative field
A large scar is likely
Type of anaesthesia/sedation
General anaesthesia
Follow-up/need for further procedure
Follow-up may be long term and include evaluation often with clinical photography
References
