General Surgery of ChildhoodProblems and Solutions?

FD MunroConsultant Paediatric Surgeon

RHSC, Edinburgh

General Surgery of Childhood

• Surgery of chidren “traditionally” provided by general surgeons in DGH

• Specialist paediatric surgeons for “local” catchment of children’s hospitals

• Elective - predominantly D/C– UDT, inguinal hernia, circumcision, hydrocele,

umbilical hernia etc

• Emergency– Abdo pain, appendicectomy, acute scrotal pathology,

I&D simple abscesses, suture of lacerations, early management of trauma

The Problem• Annual fall in DGH activity of 15% across UK• Declining rapidly in some areas• In others, perceived threat due to imminent

retirements of “grandfather surgeons”• Failure to train replacements• Impact of change in “paediatric” age range to

include up to 16 years• Risk of inadequate capacity in both current

and planned children’s hospitals• Well recognised and subject of several recent

reports but no action!

Fife

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

circ

ing hernia

orch

ppv

appx

Operations 0-12 years

Operations 0-12 years

Forth Valley

0

20

40

60

80

100

120

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

circ

ing hernia

orch

ppv

appx

Ninewells

0

20

40

60

80

100

120

140

160

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

circ

ing hernia

orch

ppv

appx

Operations 0-12 years

Edinburgh RHSC

0

50

100

150

200

250

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

circ

ing hernia

orch

ppv

appx

Operations 0-12 years

Scotland

0

200

400

600

800

1000

1200

1400

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

circ

ing hernia

orch

ppv

appx

Operations 0-12 years

Annual admissions appendicitis (Average 2000-2005)

0

20

40

60

80

100

120

140

Borders

Fife

West LothianRIE/WGH

F/V

TaysideD&G

RHSC Ed

0-12

13-16

total

Annual admissions NSAP (Average 2000-2005)

0

50

100

150

200

250

300

Borders

Fife

West LothianRIE/WGH

F/V

TaysideD&G

RHSC Ed

0-12

13-16

total

Annual admissions HI (Average 2000-2005)

0

100

200

300

400

500

600

Borders

Fife

West LothianRIE/WGH

F/V

TaysideD&G

RHSC Ed

0-12

13-16

total

Who is to blame?

• Anaesthetists?• Surgeons?• Managers?• Royal Colleges?• SEHD?

What’s wrong with centralisation?

• Erosion of caseload for paediatric anaesthesia (especially emergencies)

• Inability to manage even non-operative cases• Increased travel and disruption for families• Risk that other surgical services follow and

ultimately even medical paeds• Overload capacity of Children’s Hospitals

What might we gain by maintaining local services?

• Greater convenience for families and children• Maintain “critical mass” of paediatric surgical

and anaesthetic activity• Maintain expertise in paediatric emergency

anaesthesia and resuscitation in local hospitals

• Improved links between local hospitals and regional children’s hospitals

Specialist Children’s Services Review

• General Surgerywww.specialchildrensservices.scot.nhs,uk/pages/workstreams

Solutions 1• No lack of anaesthetic expertise or willingness to deal

with children• Safe care requires surgical, anaesthetic and medical

paediatric input and co-operation• Local anaesthetists, paediatricians, theatre and ward

staff all involved• Surgery and in-patient paediatrics must be co-located

for emergency care• Separation of elective and emergency services on

different sites unlikely to be viable• “Elective first”

Solutions 2

• Emergency service requires the commitment of all general surgeons and anaesthetists

• Elective service could be provided by a local general surgeon with a declared interest and appropriate training, a visiting specialist surgeon or both

• Local clinical lead essential• Hospitals require a multidisciplinary forum to discuss,

plan and review children’s surgery.

Elective v Emergency

• For Forth Valley and Tayside

• 892 ops in 2005

• Elective 70%

• Emergency 30%

Ages 0-5 6-12 13-16

Elective 48% 35% 18%

Emergency 12% 25% 63%

C/O/I/U/H 59% 32% 9%

Appendix 2% 38% 60%

Elective v Emergency

• Common elective operations are different in children to those for the analogous conditions in adults– Inguinal herniotomy v herniorraphy– Ligation PPV v Lord’s or Jaboulet

• Common emergency operations are the same as in adults– Appendicectomy– Testicular torsion

Models of service

• General Surgeon with an interest in children’s surgery

• Specialist Paediatric Surgeon– Regional appointment– Inreach– Outreach

• “General Paediatric Surgeon”

Tayside Model • Specialist paediatric surgeon appointed with

sessions both in Tayside and Lothian• Local general surgeons with an

interest in children’s surgery• Enabled the continuation of all children’s general surgery in

Tayside• Selected specialist surgical cases• OP clinics for both general and specialist cases• Local specialist consultation for in-patients• Link with the specialist department in RHSC both for

general surgeons and paediatricians• Greater use of telemedicine links

Tayside Model 2

• Maximises use of diagnostic facilities locally• Allows earlier repatriation of complex cases• Education

– General surgeons– Paediatric surgeons– Paediatricians/Neonatologists– Obstetricians– Anaesthetists

Next steps

• Solutions need to be in place very soon• Uncertainty as to availability of appropriately trained

general surgeons in near future• Predicted “glut” of trained paediatric surgeons in next

1-2 years• Regional solution involving specialist paediatric

surgeons favoured as a short term fix• Improved training for all general surgeons in children’s

surgery and encouragement of some to subspecialise• Service delivery by a combination of “visiting”specialist

and local general surgeon with interest

Questions?