Pediatric Surgery:

 

Subspecialties Meet the
Unique Needs of Children

When Dr. C. Everett Koop, surgeon-in-chief,
arrivec at Children’s Hospital in 1946 as the
Hospital's first full-time pediatric surgeon, the
surgical roster included three patients. “One
was @ true surgical case, and the other two
were iong-term patients suffering from ortho-
pec:c oropiems,”’ Dr. Koop explained.

re nes Deen at ihe neim of @ service that in
é veers nas gtown tc encompass nine Givi-
ong with “enough depth in each service that
inere ig nothing, surgically speaking, that is
inevalaple nese at Children’s Hospital.”’

institution was 5291, cne-half of all admis-
ions. The number is expanding.

The growth of ihe surgical service at
Hospital paraliels—and in many
onsible ‘or-— ithe advances mace
Lairic surgery worldwide. The
ining ground for

4
‘

  
  
   

c
a

m
4

kinec Dediaince Surgecns
d-ect ceserimeris in hosp:
me wed end whose work
of omcren

Dr. Koop's involvement with pediatric sur-
gery came almost by accident, but once his
interest was aroused, his commitment was
total. ‘I realized that children didn't get a fair
shake in surgery, and | saw this as one of the
great ineauities in medicine. Children had as
much wrong then as they do now. And yet we
were So ill-equipped to take care of them,” Dr.
Koop said. Pediatric surgery was so new at
the time of Dr. Koop’s arrival at Children’s that
he was but the sixth surgeon in the country to
change his surgical practice from adults
exclusively to children, and he was one of the
first to champion pediatric surgery as a
specialty based on physiologic principles
rather than seeing children as small adults.

Once at the Hospital, Dr. Koop turned his
energies to building a staff of general sur-
geons as well as surgical subspecizlists. The
first specialist 1o be brought in was a neuro-
surgeon, in 1947, beceuse the large numbers

of bapies being bern wiih spina bifida, of open
- spine, and hydrocephaius. increesed spinai

fiuid in the neac, presented a major challerce
in pediatric care. Ke wes tne natz 7's first full
time pediainc neurcsurcecn. Ure: 2s Came
next, in 184E. so that the many children with
fiom ca: celects of ine urinary tract couid
be treatec.

“Because many chilcren's services had
crown up eraund the specialty of orthopedics,
end because it was common practice in those
cays for every children’s hospita! to nave an
ea’, nose anc throat man on siaff, we already
had those specialties functioning. However,
they were nct yet associated with an aca-
cemic program in the university,”’ Dr. Koop
explained. Plastic surgery had a more rapid
ceveicoment at Children’s Hospital in the late
1940s than i might have otherwise because of
the presence of Dr. Robert Ivy, a pioneer in
tne field, who was at the Hospital of the
University of Pennsylvania, Dr. Koop said.

in the next few years the oiner subspecial-
ties —cardiovascular surgery, dentistry and
conthaimology. were brought into the fold as
well. “Cardiac surgery at Children’s differed in
its scope, tnough, from what is normally
thought of for adults. At Children's the cardio-
vascular surceons concentrate their efforts on
the heart ano the vascular system, while the
general surgeons are responsible for the other
surgical probiems of the chest. Most heart
surgeons who treat adults do both heart and
chest procedures,”’ Dr. Koop explained.

“Along with the emergence of our depart-
ment of highly skilied surgeons came the
development of a superb anesthesia cepart-
ment,”’ said Dr. Koop. “When | first came to
Children’s | realized that if you can't put the
baby io sleep and weke him up, the surgical
procecure won'l work. | consider it a great
privilege to have grown up with this specialty.”

Chicren’s Hospitai is providing the setting
for dramatic advances in newborn, or
neonaeial, surgery as well. The turnabout in
the surviva! ct tiny infants suffering from
mejor, life-threatening surgical defects came
in 1962 with the establishment of the nation's
first neonatal intensive care unit at Children’s
Hospital.

The unit was the creation of Dr. Koop, who
was frustrated by the high mortality rates of
infants undergoing surgery. It was funded
through a five-year pilot grant from the United
States Children’s Bureau. ‘| hoped to show
that with intensive nursing care of these
bedies in a carefully controlled environment,
and with closer backup by the anesthesiolo-
OS's. respireiory ineradisis end ledoratory
Siaif, we COu.d Overcome many of ihe prob-
lems which caused so many infants to die.”

Dr. Koop’s nunch proved valid. Today the
Survival rate in these infants has been turned
around. “If we iest 90 percent of the babies
wil @ pericuiar cefect 25 years ago, today
we save 90 percent,’ Dr. Koop explained. He

for iilustrating the success of the neonatal
iInlensive care unit. ‘This problem, where the
baby’s esopre

ced esosneses! atresia as the ‘index case”’
t

gus ends blindly, insiead of
ec ic ine stomach presents as
ange &@§ you can Und in the

nieer much inati

oa
m

  

Ai Children’s Hospital those statistics are
impressive. ‘In the 1950s. when we did our
first assessment of survival for esophageal
atresia, we were saving 50 percent, which
wes considered phenomenal in those days.
Today we never expect 10 lose a full-term
baby with esophagee! atresia, and we haven't
fost one for tne past nine years. We've done
about 475 of these procedures, and even with
premature infants who have additional life-
threatening problems the survival rate is 87
percent,” Dr. Koop said.

Another innovation has been creation of a
day surgical center, where youngsters may
undergo certain procedures in the operating
room without being admitted overnight 10 the
Hospital.

The children come in the morning, undergo
surgery and usually are home by dinner. Tne
service has been in such demand that the
Hospital is currently seeking approval from the
Health Systems Agency to construct a larger
Center on the fourth floor of the building, with
funds contributed by the Widener Estate.

Dr. Koop explained, ‘With the huge expan-
sion of our orthopedics and otorhinolaryn-
gology services and the demand for more
patient bed days by our plastic surgeons, it
seemed we'd never be abie to satisfy our sur-
gical needs because of a freeze on beds by
the Health Systems Agency.

“By expanding our outpatient surgery we
can open up beds in the Hospital automati-
cally anc provide more operating time for
those services that require development.

“It isn't sufficient just to have an outpatient
surgical service, though. One must have a
self-contained unit to do best by the patient
and to prevent infections that these children
can catch from others if they are not in a
separate area."

Despite its pioneering role in neonatal
surgery and some of the other subspecialties,
Dr. Koop feels proud that '‘we never have rid-
Gen one hobby horse, so to speak. This is not
a hospital where patients come just for one
kind of problem. Its attractiveness as a train-
ing program is that there is a constant variety
of all types of surgical problems, ranging from
the common to the esoteric.

“And although a lot of surgery in children is
routine, we pay just 28 much attention tc that
child as to tne one undergoing a compiex pro
cedure. We heave to remember that chiicren
have remarkable bounce, but limited reserve,
anc that they c'ler the same chaliences in
intraoperative and posioperative care no mat-
ter how straight-forward or how intricate the
surgery, Dr. Koop said.

“| think one of the ciher unusue! aspects of
our surgical Cepartment is the operating room
staff, especially the dedication and longevity of
many of the OR nurses, They help make our
cepariment a ‘team effort’ that creates a
pieasant environment for all who are
inve:ved.,

“When i came te Criidren’s Hoscital. my

:¢Cal wes 10 Cevelop the most com -c-ehensive
surgical team for chicren tnat cou-o pe found