Page 43 - 59peadiatric-surgery-speciality8-14_opt

CHAPTER 14

Psychological Issues in

Paediatric Surgery

Akanidomo J. Ibanga
Hannah B. Ibanga

Introduction Required Surgery
The last few decades have been marked by tremendous improvement Any procedure that is required in order to improve the quality of life for
in the successful performance of most paediatric surgical procedures. the child is termed required surgery. Required surgery does not need to
This improvement is in terms of both increased knowledge and skills be done immediately, as is the case for emergency surgery. In this situ-
of attending physicians and updated surgical equipment now available ation, more time is available to plan and prepare the child and parents
for a variety of procedures. This has resulted in a higher survival rate involved for the surgery
as well as a reduction in the associated risk. Despite these improve- Minor Surgery
ments, however, many children and parents still experience high levels Minor surgery is a term reserved for invasive procedures that have a
of distress when children are awaiting an invasive surgical procedure. short recovery time. These operations can actually be carried out in
1–4
This chapter looks at issues in paediatric surgical practice that make it an outpatient basis, or the child can go home the same day in most
stressful not only for the child awaiting surgery but also for the child’s cases. The recovery time for the child to return to normal functioning
parents. We first look briefly at the classifications of surgical proce- is usually very short. Although listed as a minor procedure, it is not
dures and the sources of stress for the child and parents. We then look considered so by parents whose children are awaiting these procedures.
at the commonly reported stress-related emotional experience, first for
the child and then for the parents, and how this relates to prognosis. Stress and Anxiety
This discussion is followed by elaborating more on the conditions in Irrespective of the class of invasive procedure a child is to undergo,
sub-Saharan African countries that contribute to possible heightened many children and their parents find it stressful. LeRoy and his col-
5
levels of stress, and we draw this chapter to its conclusion by looking leagues looked at different sources of stress for children who were
at some evidence-based efforts to reduce surgery-related stress and how awaiting an operation as well as their parents, and came up with a
effective or feasible the application of these may be in the sub-Saharan slightly different list for each of them. The sources of stress for chil-
health care environment. dren include: (1) physical harm or injury, resulting in discomfort,
pain, mutilation, or death; (2) separation from parents and dealing
Overview of Surgical Procedures with strangers in the absence of a familiar, trusted adult; (3) fear of
Many parents who may be present during ward rounds or may have the unknown; (4) uncertainty about limits and acceptable behaviour;
overheard discussions or may have had consultations with their child’s and (5) loss of control, autonomy, and competence. In contrast, the
physician come across terms that refer more to the type of surgery for sources of stress for parents and guardians include: (1) concern about
the child. They may thus hear the surgery being referred to as either the possibility of physical harm or injury resulting in discomfort, pain,
major, minor, emergency, elective, or required. It is outside the scope of mutilation, or death to the child; (2) alterations in the parenting role;
this chapter to discuss these in detail, but it suffices to briefly describe (3) lack of information; (4) the intensive care unit (ICU) environment;
these terms here. and (5) postoperative changes in the child’s behaviour, appearance, or
Major Surgery emotional responses.
Surgery is regarded as major when it involves the head, neck, chest, or Anxiety is the most commonly reported stress-related emotion
abdomen. Examples of these would be surgical operations involving experienced by children awaiting surgery and their parents. Brophy
6
organ transplants or repair of congenital malformations, heart disease, and Erickson, in their survey of those awaiting elective surgery, found
or correction of foetal developmental problems. In comparison to other that 60% of the children reported being anxious. Note that this was for
forms of surgery, this class usually involves a higher risk and longer elective surgical procedures, which are simple and preplanned; for these
hospital stay, both pre- and postoperatively. children to still experience anxieties or fears of compromised physical
Emergency (Urgent) Surgery integrity as well as death, it would be logical to assume that the reported
Emergency surgery is carried out with a focus on correcting a life- percentage would greatly increase were we to survey those awaiting
threatening condition. Examples of these would be a result of an acci- more complex surgical procedures. In the following subsections, we
dent (motor vehicle or many forms of domestic accidents) or where briefly look at the child’s and parents’ anxieties and how these affect
there is an intestinal obstruction or any other life-threatening condition. surgical outcomes. We highlight our need to have a greater understanding
and to develop a response to help alleviate these anxieties.
Elective Surgery Children’s Anxiety
Unlike the previous surgeries, elective surgery does not correct a life- 7–9
threatening condition and is not an absolute necessity for the health Numerous researchers have found an association between preopera-
of the child. It is, however, a surgery that is carried out with the hope tive anxiety and negative postsurgical outcomes. When a child is about
of improving the child’s quality of life. Surgery to remove a hernia or to undergo surgery, for instance, and is to be anaesthetised, the child
tonsils, as well as circumcision, would fall under this class. who is anxious at this stage is very uncooperative, often making the
process more pronounced and prolonged. The greatest risk of nonco-