Surgery for the smallest patients


Because of their skill in repairing or reshaping very small or delicate structures in the body, surgeons are often called "artists." The challenge when the patient is an adult is enormous; imagine how much skill is demanded to operate on a tiny infant or small child.

"To me, what Dr. Ramenofsky does is like a gift of God," says Christine Dominguez, whose son, Michael, was operated on for a rare birth defect by Dr. Max Ramenofsky, director of pediatric surgery at Downstate's University Hospital of Brooklyn.

He performed major surgery on Michael just 48 hours after his birth to correct an incompletely formed rectum that lacked an outside opening. Now, a year-and-a-half later, Michael is an active toddler who can expect to lead a fully normal life.

"It's not just that Dr. Ramenofsky is a wonderful surgeon," Mrs. Dominguez says. "It's the support that he and everyone at the hospital have given my husband and me whenever we go there. Even if I call Dr. Ramenofsky with a question in the middle of the night, he is always respectful and caring."

At Downstate Dr. Ramenofsky, who previously held positions at the University of Pittsburgh and Tufts University School of Medicine, directs a team of three pediatric surgeons. He was attracted to Brooklyn by the hospital's outstanding reputation.

"In 1962, Downstate became the first medical center in the country to offer a pediatric trauma program, and it continues to be one of the best," he says. "Also, I have always wanted to teach--to be involved with the training of young surgeons who want to specialize in working with children."

Training in this specialty is longer and more complex than for general surgery, Dr. Ramenofsky explains. It is not just that organs, blood vessels, and bones are smaller in children, and therefore more difficult to work on. The surgeon must plan differently and use different surgical techniques to allow for the ways in which the child's body will change as it grows.

For example, surgery must be performed in such a way that scar tissue will not impede growth or the development of internal organs. For this reason, surgery often is performed in stages over time, allowing for the child's growth between operations.

This was the case for Matthew LeMeo who, in a rare coincidence, was born about the same time as Michael Domingus, with a similar birth defect. For Matthew, the "pull-through" procedure needed to correct his incomplete rectum was performed when he was four months old, after his intestinal tract had developed well enough for him to profit most from the surgery. In the meantime, he had a colostomy performed at birth, so that his body wastes could be collected in a bag attached to an opening in his abdominal wall.

Following Dr. Ramenofsky's surgery to complete a rectum with an opening in the usual place, Matthew's colostomy was reversed. Since then he has used diapers--like any normal child of his age.

The surgery staff Dr. Ramenofsky directs includes two other full-time attending surgeons, Dr. Brian Gilchrist and Dr. Donald Klotz. Dr. Richard Scriven, who is in training as a pediatric surgery fellow, completes the physician team. They correct a variety of congenital anomalies, as well as performing surgery for such illnesses as inflammatory bowel disease, lung conditions, AIDS, and cancer.

"Recently we have been seeing more cancer patients, both because there seem to be more cancers in children today, and because more referrals are being sent to us based on our reputation," Dr. Ramenofsky says.

Whatever condition they treat, the surgeons, nurses, and other support staff follow certain principles. As much surgery as possible is performed on an outpatient basis. Hospitalized children are sent home just as soon as they are medically ready. And every member of the staff strives to maintain a good, supportive relationship with the child's family.

This is a major lesson Dr. Ramenofsky emphasizes to the young surgeons he trains.

"Infants and children, until they become thinking, verbal individuals, must rely on their parents to interpret their symptoms to the doctor, and the parents will actually give much of the treatment," he says. "How well we communicate with the family is of crucial importance to the child's recovery, so we usually develop long-term relationships. Over time, the parents and children come to think of us as part of the family."


Pix K: Of Dr. Ramenofsky one parent said: "It's not just that he is a wonderful surgeon, its the support that he and everyone else at the hospital have given me. He's always caring and respectful."



Preventing accidents

Another major area of Dr. Ramenofsky's concern is treating--and preventing--childhood injuries.

"Injury is the leading cause of death in children, and the single most lethal cause of injury is the automobile," he emphasizes. Besides being struck by cars, thousands of children are killed or severely injured each year as unrestrained passengers in cars. "I wish we could make people understand just how important it is to strap their children in properly," Dr. Ramenofsky says.

Accidents involving bicycles, skateboards, and in-line skates can also be life-threatening. "Use of helmets could prevent many of the very serious or fatal head injuries we see," Dr. Ramenofsky says. "The head is the heaviest part of a child's body. It is the part most likely to be injured in a fall, partly because a child's brain and skull are still incompletely developed. Any injury to the head is potentially very serious.

"Accidents will always happen because children act without thinking. It is up to parents to protect children by making sure they wear protective equipment."