11.2 Surgical Management

Pediatric oncology surgery is CPHON Domain III.A.6 and III.B.8: biopsy versus resection versus staging, the operations that enable treatment (ports, gastrostomy tubes), the operations that are the treatment (nephrectomy, limb salvage, laminectomy), and the peri-operative traps that kill children—airway collapse under anesthesia with a mediastinal mass, and sending a profoundly thrombocytopenic child to the operating room without a transfusion plan.

Biopsy, resection, staging, and the procedures that make treatment possible

Diagnostic biopsy obtains histology, genetics, and risk assignment. The tract should sit inside a future resection field whenever sarcoma or other solid tumors make that relevant—orthopedic oncology owns bone-sarcoma biopsy for that reason. Resection aims for oncologic local control: complete, microscopic residual, or planned delayed resection after chemotherapy shrinks the mass. Staging surgery samples nodes, inspects peritoneal surfaces, or confirms residual disease after therapy (second-look).

Supportive operations are not optional extras:

• An implanted port or other central venous access for chemotherapy, blood products, and nutrition.
• A gastrostomy tube (G-tube) when mucositis, radiation, or neurologic injury will make oral calories unsafe or inadequate.
• Nephrectomy for typical U.S. Children's Oncology Group–style Wilms tumor when the mass is resectable up front (SIOP-style neoadjuvant chemotherapy before nephrectomy is a different cooperative-group philosophy—see the Wilms section).
• Laminectomy or laminotomy for spinal cord compression (neuroblastoma dumbbell tumor, epidural sarcoma, or vertebral metastasis) when the team chooses surgical decompression rather than, or in addition to, emergency chemotherapy, steroids, and radiation.
• Delayed primary resection after neoadjuvant chemotherapy is the bone-sarcoma and many neuroblastoma and rhabdomyosarcoma script: chemo first, then surgery on a smaller, better-defined mass.
• Limb salvage (wide resection plus endoprosthesis, allograft, or rotationplasty) is preferred for extremity osteosarcoma and many Ewing tumors when an oncologically adequate, usable limb can be preserved; amputation remains correct when neurovascular structures cannot be spared.

A 14-year-old with distal femoral osteosarcoma should hear limb salvage versus amputation as a function-and-margin conversation, not as a consolation prize. A 15-month-old who suddenly cannot walk from a paraspinal neuroblastoma needs emergency imaging and a cord plan that may include laminectomy the same night.

Counts, anesthesia, and the mediastinal-mass disaster

Absolute neutrophil count and platelet thresholds for the operating room are protocol- and surgeon-specific. Do not memorize a single national ANC or platelet number as ONCC fact. The nursing rule that is testable: do not send a profoundly thrombocytopenic child to the operating room without a plan—product in the room, a working line, a type-and-screen, and an agreed platelet goal for that procedure. A 6-year-old with platelets of "too low to count" and a scheduled central-line repair at 07:00 needs platelets timed to incision, not a hope that the count will rise in the elevator.

Anterior mediastinal masses (T-lymphoblastic lymphoma or leukemia, Hodgkin lymphoma, germ-cell tumors) are an airway disaster under induction anesthesia. When muscle tone is lost, the mass compresses trachea and great vessels; the child who sat talking in the waiting room cannot be ventilated supine. Nursing stance:

• Obtain upright imaging (chest radiograph and upright CT when the child can tolerate it).
• Do not sedate for "a quick biopsy" until anesthesia, oncology, and, when needed, otolaryngology or extracorporeal-support teams have an airway plan.
• Prefer the least anesthesia possible: peripheral blood, pleural fluid, or a carefully planned sitting biopsy rather than casual deep sedation.

A 12-year-old with T-ALL, orthopnea, and a huge anterior mediastinal mass who is "just going to CT asleep" is a preventable arrest. Sit the child up. Call anesthesia. Delay the pretty scan if the airway is not planned.

Second-look, ostomy and nephrectomy teaching, pain and infection

Second-look surgery inspects residual disease after chemotherapy—classic in selected neuroblastoma and some ovarian or germ-cell pathways. Families should hear that "second look" is information and possible further resection, not proof that the first operation failed.

Nephrectomy teaching: flank or abdominal incision care, remaining-kidney protection (no contact sports that risk the solitary kidney per team advice, blood-pressure follow-up, avoid unnecessary nephrotoxins), and that one healthy kidney can sustain a child. Ostomy teaching after pelvic rhabdomyosarcoma, extensive bowel surgery, or typhlitis-related diversion: pouch changes, peristomal skin, hydration, and when output or discoloration is an emergency. A 4-year-old with a new colostomy after pelvic surgery needs a parent who can empty the bag before discharge, not a laminated diagram left in the chart.

Pain after laparotomy or thoracotomy is multimodal: age-appropriate opioids, acetaminophen, regional techniques when infection and counts allow, and attention to ileus. Neutropenic, opioid-exposed, vincristine-treated children get constipated and then obstructed. A silent, distended abdomen on postoperative day 3 is not "sleeping off anesthesia."

Wound infection in a neutropenic child is subtle: redness may be faint, fever may be the only sign, and dehiscence risk is real. Do not wait for copious pus. Culture, notify surgery, start protocol antibiotics, and keep the wound visible. A 5-year-old on day 8 after delayed neuroblastoma resection with an ANC of 80/µL and a 38.5°C fever has a surgical-site emergency until proven otherwise, even if the dressing looks "pretty clean."

Fertility-preserving surgery

When pelvic or abdominal radiation or gonad-toxic therapy is planned, oophoropexy (ovarian transposition out of the radiation field) and other fertility-preserving procedures belong in the pre-treatment conversation, not after the beam is done. Sperm banking for pubertal boys, ovarian-tissue discussions per institutional fertility programs, and honest documentation that options were offered are nursing advocacy as much as surgical technique. Mention the concept; do not invent a single national age cutoff as ONCC fact. A 13-year-old girl facing pelvic radiation for rhabdomyosarcoma should meet fertility specialists while the ovaries can still be moved, not at a survivorship visit five years later.

The CPHON product is a child whose biopsy tract was planned, whose counts have a peri-operative product plan, whose mediastinal mass is not casually sedated, whose family can care for a flank incision or an ostomy, and whose fertility was not an afterthought.