Inguinal hernia repair (IHR) is a common pediatric operation performed via open or laparoscopic approaches. The objective of this survey study was to assess current approaches to IHR in a national ...sample of pediatric general surgeons.
A REDCap survey was distributed to all pediatric general surgeons at 21 US institutions in 2023. Descriptive statistics were used to analyze responses.
The response rate was 70.0% (145/207) with median fellowship graduation year of 2011. Respondents reported they were primarily taught either an open (73.1%) or laparoscopic (6.9%) technique in fellowship, while 18.6% reported being taught both techniques equally. Overall, 60.7% of respondents reported currently performing both laparoscopic and open IHR, while 27.6% reported performing only open IHR and 11.7% reported performing only laparoscopic IHR. During unilateral open IHR, 75.8% of respondents check for and repair a contralateral inguinal hernia, most commonly by placing a laparoscope via the hernia sac (76.3%). Selective mesh use in adolescents was similar between laparoscopic and open repair approaches. For recurrent hernias, 37.2% of respondents indicated performing the approach that was not performed previously, while 38.6% and 22.8% indicated they routinely perform a laparoscopic or open approach, respectively, regardless of initial repair approach.
Over two thirds of surgeons reported incorporating laparoscopic IHR into their practice despite nearly three-quarters of respondents indicating they were primarily taught an open approach in training. Training in laparoscopic IHR has been increasing over time, and respondents reported a wide variety of laparoscopic and open repair techniques.
IV
What is currently known about this topic?•Current technical approaches for pediatric inguinal hernia repair in the United States have not been described recently for open repair and have not been described for laparoscopic repair. The use of laparoscopy has previously been reported to be increasing based on billing data.
What new information is contained in this article?•There is a wide variation in laparoscopic and open inguinal hernia repair techniques in children. Over two thirds of surgeons incorporate laparoscopic inguinal hernia repair into their practice despite nearly three-quarters of respondents indicating they were primarily taught an open approach in training.
Holistic review (HR) considers applicants’ unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those ...underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS).
Using a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) 2015–2017 were compared to HR 2018–2022. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate.
For 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR.
Holistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort.
IV.
Sleep is essential for postoperative recovery. Prescription opioid can be associated with disordered sleep. There is little research on sleep patterns among adolescents using opioids for ...postoperative pain. Our objective was to identify factors associated with disordered sleep among adolescents undergoing surgery.
Prospective single-center survey-based cohort study of adolescents (13-20y) undergoing eight surgeries commonly associated with an opioid prescription. Participants completed a preoperative survey measuring clinical, mental health, and sociodemographic factors, and postoperative surveys at 30- and 90-days. All surveys administered the Sleep Problems Questionnaire. Repeated measures logistic regression evaluated the impact of surgery on worsening postoperative sleep scores. Linear change model evaluated sleep score trajectories; Poisson regression identified the impact of preoperative disordered sleep on opioid use.
Overall, 167 adolescents (median 15y, 64% female) were included. Twenty-seven (16.2%) reported disordered sleep preoperatively and 41 (24.6%) postoperatively. Prescription opioid use was not associated with development of disordered sleep postoperatively (OR:1.33; 95% CI:0.38–4.68). Adolescents were 2.20 (95% CI:1.42–3.40) times more likely to report disordered sleep postoperatively. Preoperative disordered sleep, time after surgery, and mental health comorbidities were associated with worsening postoperative sleep score trajectories (p < 0.01). Adolescents with preoperative disordered sleep were not more likely to use opioids (OR:2.56, 95% CI:0.76–8.63, p = 0.13) nor did they use more pills (IRR:0.84, 95% CI:0.62–1.15, p = 0.27).
Adolescents were more likely to report disordered sleep postoperatively. Preoperative disordered sleep and mental health comorbidities, but not prescription opioid use, were associated with worsening sleep after surgery. Future efforts to improve adolescent postoperative sleep should address baseline disordered sleep and mental health comorbidities.
Level II.
Prospective cohort study.
Push-PEG (percutaneous endoscopic gastrostomy) with T-fastener fixation (PEG-T) allows one-step insertion of a balloon tube or button, and avoids contamination of the stoma by oral bacteria. However, ...PEG-T is a technically more demanding procedure with a significant learning curve. The aim of the present study was to compare outcomes after PEG-T and pull-PEG in a setting where both procedures were well established.
The study is a prospective cohort study including all patients between 0 and 18 year undergoing PEG-T and pull-PEG between 2017 and 2020 at a combined local and tertiary referral center. Complications and parent reported outcomes were recorded during hospital stay, after 14 days and 3 months postoperatively.
82 (93%) of eligible PEG-T and 37 (86%) pull-PEG patients were included. The groups were not significantly different with regard to age or weight. Malignant disorders and heart conditions were more frequent in the pull-PEG group, whilst neurodevelopmental disorders were more frequent in the PEG-T group (p < 0.001). 54% in both groups had a complication within 2 weeks. Late complications (between 2 weeks and 3 months postoperatively) occurred in 63% PEG-T vs 62% pull-PEG patients (p = 0.896). More parents in the pull-PEG group (49%) reported that the gastrostomy tube restricted their child's activity, compared to PEG-T (24%) (p = 0.01). At 3 months follow-up, more pull-PEG patients (43%) reported discomfort from the gastrostomy compared to PEG-T (21%) (p = 0.03).
Overall complication rates were approximately similar, but pull-PEG was associated with more discomfort and restriction of activity.
Treatment study level II.
•Few studies have compared outcomes after gastrostomy placement with pull-PEG or push-PEG technique, or asked parents/patients about their experiences.•Pull-PEG was associated with more discomfort and restriction of activity than push-PEG. The overall complication rates between pull-PEG and PEG-T were approximately similar.
Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility.
A ...multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015–March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed.
Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room.
Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes.
IV.
Original Clinical Research.
•What is currently known about this topic?
Robotic-assisted is an emerging technique for tumor resection in children but has unproven safety and feasibility.•What new information is contained in this article?
Robotic-assisted minimally invasive surgery for tumor resection in both the thorax and abdomen is safe and feasible, with minimal morbidity and short hospital length of stay.
Simulation based training enables pediatric surgical trainees to attain proficiency in surgical skills. This study aims to identify the currently available simulators for pediatric surgery, assess ...their validation and strength of evidence supporting each model.
Both Medline and EMBASE were searched for English language articles either describing or validating simulation models for pediatric surgery. A level of evidence (LoE) followed by a level of recommendation (LoR) was assigned to each validation study and simulator, based on a modified Oxford Centre for Evidence-Based Medicine classification for educational studies.
Forty-nine articles were identified describing 44 training models and courses. Of these articles, 44 were validation studies. Face validity was evaluated by 20 studies, 28 for content, 24 demonstrated construct validity and 1 showed predictive validity. Of the validated models, 3 were given an LoR of 2, 21 an LoR of 3 and 12 an LoR of 4. None reached the highest LoR.
There are a growing number of simulators specific to pediatric surgery. However, these simulators have limited LoE and LoR in current studies. The lack of NoTSS training is also apparent. We advocate more randomized trials to validate these models, and attempts to determine predictive validity.
Original / systematic review.
1.
Magnets are among the most dangerous foreign objects that a child can ingest. If more than one magnet is ingested, the attraction between loops of the bowel can bring adjacent loops closer together, ...leading to perforation, obstruction, or fistulization. Pediatric magnet ingestion patients often require endoscopic or surgical intervention to retrieve the objects and repair the damage created by the magnets. Due to the risks of surgical intervention, management is done with strict adherence to the rare earth magnet ingestion algorithm. We highlighted a pediatric case of multiple magnet ingestion, and the steps that were taken to manage the patient. Our case highlights the potential for complications and the importance of adherence to the management algorithm in these patients. Epidemiology, mechanisms, algorithms, and outcomes for pediatric magnet ingestion patients were discussed.
Lower socioeconomic status (SES) is linked to poorer outcomes for a variety of health conditions in children, potentially through delay in accessing care. The objective of this study was to measure ...the association between SES and delay in surgical care as marked by presentation with complicated appendicitis (CA).
Children treated for acute appendicitis between 2015-2019 at a large academic children's hospital were reviewed. Patient home addresses were used to calculate travel time to the children's hospital and to determine Area Deprivation Index (ADI), a neighborhood-level SES marker. Multivariable logistic regression models were used to compare the likelihood of CA across ADI while adjusting for confounders.
Of 1,697 children with acute appendicitis, 38.8% had CA. Compared to those with uncomplicated disease, children with CA were younger, lived farther from the children's hospital, and were more likely to have Medicaid insurance and have ED visits in the 30 days preceding diagnosis. Children with CA disproportionately came from disadvantaged neighborhoods (P < 0.007), with 32% from the two most disadvantaged ADI deciles. The odds of CA rose 5% per ADI decile-increase (adjusted odds ratio aOR 1.05, 95%CI 1.01-1.09, P = 0.02). Younger age and >60-min travel time were also associated with CA. Association between ADI and CA remained among younger (<10 y) children (aOR 1.07, 95%CI 1.00-1.15, P = 0.048) and those living closer (<30 min) to the hospital (aOR 1.06, 95%CI 1.01-1.11, p=0.02).
ADI is associated with CA among children, suggesting ADI may be a valuable marker of difficulty accessing surgical care among disadvantaged children.
Postoperative small bowel obstruction (SBO) is an important complication of laparoscopic appendectomy in children, resulting in readmission and potential for intestinal loss. We reviewed our ...experience with early postoperative SBO.
A retrospective review was performed of patients undergoing an appendectomy with subsequent SBO from 2014 to 2018. Patients were excluded if a concurrent gastrointestinal procedure was done during the appendectomy, or if they had previous abdominal surgery.
Of 793 appendectomies performed at our institution during the study period, only six patients met the inclusion criteria for our chart review (7.6 SBO per 1000 appendectomies), ranging in age from 4 to 19 y. Four patients had uncomplicated appendicitis, and all underwent laparoscopic appendectomy within 24 h. Five were discharged postoperatively, with one patient remaining hospitalized for persistent ileus. Median time to representation with SBO was 7 d (range, 2-37). Three patients had indications for urgent exploration and underwent re-exploration shortly after presentation. Three patients underwent initial nonoperative management, but subsequently, all patients failed to progress and required operative exploration. Staples were found to be the culprit lesion in four of six patients, all of which notably initially presented with uncomplicated appendicitis, with two patients found to have ischemic bowel at the time of exploration.
Although rare, pediatric patients with SBO soon after laparoscopic appendectomy should be considered for early operative management, especially if the appendicitis was uncomplicated. When staples are used for appendectomy, stray staples should not be left as they can serve as a nidus for obstruction.
Parents of children with cancer describe interactions with clinicians as emotionally distressing. Patient engagement in treatment discussions decreases decisional conflict and improves decision ...quality which may limit such distress. We have shown that parents prefer to engage surgeons by asking questions, but parents may not know what to ask. Question Prompt Lists (QPLs), structured lists of questions designed to help patients ask important questions, have not been studied in pediatric surgery. We developed a QPL designed to empower parents to ask meaningful questions during pediatric surgical oncology discussions. We conducted a mixed methods analysis to assess the acceptability, appropriateness, and feasibility of using the QPL.
Key stakeholders at an academic children's hospital participated in focus groups to discuss the QPL. Focus groups were recorded and transcribed. Participants were surveyed regarding QPL acceptability, appropriateness, and feasibility. Thematic content analysis of transcripts was performed.
Four parents, five nurses, five nurse practitioners, five oncologists, and four surgeons participated. Seven key themes were identified: (1) QPL as a tool of empowerment; (2) stick to the surgical details; (3) QPLs can impact discussion quality; (4) time consuming, but not overly disruptive; (5) parental emotion may impact QPL use; (6) provide QPLs prior to surgical consultation in both print and digital formats; and (7) expansion of QPLs to other disciplines. Over 70% of participants agreed that the QPL was acceptable, appropriate, and feasible.
Our novel QPL is acceptable, appropriate, and feasible to use with parents of pediatric surgical oncology patients.
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