Utilization of a Single-Site Port as an Adjunct for Multi-Port Robotic-Assisted Surgery in Children.

Introduction: The focused use of a single-site port as an adjunct designed to decrease overall port site number and/or assist with specimen extraction in pediatric robotic surgery has not been fully elucidated. We aimed to describe the feasibility of using the single-site port as an adjunct during multi-port robotic-assisted minimally invasive surgery (RA-MIS). Methods: A single institution retrospective review of pediatric patients who underwent multiport RA-MIS with an adjunctive single-site (SS) port from August 2018 to October 2022 was performed. Demographic, perioperative, and postoperative variables were collected; descriptive analysis was performed. Results: A total of 13 patients were included; 46% were female, and 47% were Caucasian. Median age at surgery was 14.9 years of age (interquartile range [IQR] 10.6, 18); median weight was 61.1 kg (IQR 39.7, 73.6). Eleven patients (85%) underwent splenectomy; 2 patients (15%) underwent adrenalectomy. Four patients had a combined procedure (SS cholecystectomy with multi-port splenectomy [n = 3], multi-port bilateral adrenalectomy [n = 1]). The median total operative time was 197 minutes (IQR 131, 316); median console time was 59 minutes (IQR 40, 126). Two 8 mm robotic ports were utilized for all but 1 patient who required a third 8 mm port. The median length of stay was 2.1 days (IQR 2.0, 3.1). One readmission for fever occurred following a combined cholecystectomy/splenectomy. No hernias or wound infections were identified at the single-site port. Conclusion: Use of a SS port as an adjunct is a feasible option and should be considered for those with splenomegaly or need for combined procedures in different quadrants of the abdomen.

Laparoscopic-Assisted Colonic Derotation in Patients With Hirschsprung Disease.

BACKGROUND: Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention. METHODS: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed. RESULTS: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%). CONCLUSION: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications. TYPE OF STUDY: Original research, retrospective cohort. LEVEL OF EVIDENCE: III.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Original Clinical Research.

Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review.

Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.

Rates of Air Embolism in Pediatric Patients Undergoing Surgical Procedures of the Peritoneum.

Background: Air embolism during laparoscopic surgery is a rare but feared complication in the pediatric population. The objective of this study was to identify rates of air embolus in pediatric patients during hospitalization for laparoscopic or open surgical procedures of the peritoneal cavity. Materials and Methods: Patients 0-18 years old within the Pediatric Health Information System who underwent a predefined, common inpatient laparoscopic or open surgical procedure involving the peritoneal cavity from 2015 to 2020 were studied. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for air embolism were then searched among patients during the same admission. Firth logistic regression was used to compare rates of air embolism in open and laparoscopic cohorts and in patients >1 and ≤1 year. Results: Unadjusted rates of air embolism were higher in patients undergoing open compared with laparoscopic surgery (open: 9/45,080; 20.0/100,000 patients versus laparoscopic: 3/101,892; 2.9/100,000 patients). In patients ≤1 year (45,726), 2 patients undergoing open surgery (2/1,031; 9.5/100,000 patients) and all 3 patients undergoing laparoscopic surgery had an air embolism diagnosis (3/22,329; 13.4/100,000 patients). For laparoscopic surgery, a suggested lower relative risk (RR) of air embolism was demonstrated for children >1 year compared with children ≤1 year (RR: 0.05, P = .05). Conclusion: Air embolism associated with common pediatric surgical procedures of the peritoneum is rare and patients undergoing laparoscopic and open surgery have similar risks for air embolism. Although rare, the risk should be considered during surgical planning and abdominal access, especially in children ≤1 year old.

Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies.

Congenital duodenal obstruction (CDO) occurs due to intrinsic and extrinsic mechanisms but is most often caused by intrinsic duodenal atresia and stenosis. This review will summarize the history, epidemiology, and etiologies associated with the most common causes of CDO. The clinical presentation, complex diagnostic considerations, and current surgical repair options for duodenal atresia and stenosis will also be discussed. Finally, both historical and recent controversies which continue to affect the surgical decision-making in the management of these patients will be highlighted.

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review.

PURPOSE: Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. METHODS: A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. RESULTS: A total of 825 articles were identified in the initial search, and 260 were included in the final review. CONCLUSIONS: Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

Robotic-assisted vertical sleeve gastrectomy in adolescents: Do BMI limits apply?

BACKGROUND: Robotic-assisted vertical sleeve gastrectomy (VSG) in adolescent patients has been shown to have comparable outcomes to laparoscopic VSG. Recent data suggests that metabolic and bariatric surgery (performed using robotic and laparoscopic techniques) in patients with BMI ≥ 50 kg/m2 have a higher risk of adverse events compared to those with BMI < 50 kg/m2. The aim of this study was to compare the outcomes of robotic-assisted VSG in adolescents with a BMI above and below 50 kg/m2. METHODS: A retrospective analysis of all adolescents undergoing robotic-assisted VSG between January 2014 and December 2020. Subjects were categorized based on preoperative BMI; Group 1 (BMI < 50 kg/m2) or Group 2 (BMI ≥ 50 kg/m2). Data collection included patient demographics, preoperative BMI, total operative time, access time (i.e., total time for port-placement), 30 day complications, and 30 day hospital readmissions. Analysis was performed using chi-square, Fisher's Exact, and student t-test. RESULTS: Total of 115 subjects (Group 1 N = 64 and Group 2 N = 51) were included. No differences in age or ethnicity were detected; however, Group 2 had a higher percentage of male patients (27.5% vs. 4.7%, respectively, p = 0.001). Mean operative times (Group 1 = 122.2 min vs. Group 2 = 121.6 min) and access times (Group 1 = 19.1 min vs. Group 2 = 19.7 min) were similar between groups. Thirty day complication rates were similar between groups (p = 0.133); however, there was a higher rate of hospital readmission in Group 1. CONCLUSION: While recent data demonstrate an increased likelihood of adverse events occurring among patients with BMI ≥ 50 kg/m2 undergoing robotic surgery, we observed no differences in intraoperative or early postoperative outcomes based on BMI in this robotic-assisted pediatric cohort.

The cutback revisited - The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula.

BACKGROUND: The repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may leave the neoanus in a position anterior to the center of the sphincter, which theoretically could impair future continence. We devised an adaptation of the cutback anoplasty which we call the posterior rectal advancement anoplasty (PRAA) to treat patients with a rectoperineal fistula that is both narrow in lumen and located within, but at the anterior-most limit of the sphincter complex. MATERIAL AND METHODS: Patient selection, operative steps, and perioperative care of patients undergoing PRAA are detailed. RESULTS: 10 children (6 males, 4 females) underwent PRAA. There were no vaginal wall or urethral injuries. At 6 months postoperatively, all patients were passing stool spontaneously. No patients required dilation of the anoplasty in the postoperative period and there were no anal strictures identified. CONCLUSIONS: A modification of the cutback anoplasty can be performed in patients with a perineal fistula and the distal fistula tract within the sphincter complex. We have demonstrated that this can be performed safely and obviates the need for an anterior rectal wall dissection, thus eliminating the risk of injury to urethra or vagina. LEVEL OF EVIDENCE: IV.

The Use of an Inanimate Simulation Model for the Correction of an Anorectal Malformation in the Training of Colorectal Pediatric Surgery.

INTRODUCTION: An anorectal malformation (ARM) is a congenital malformation that requires surgical correction. To acquire the skills needed to perform this complex procedure, an affordable simulation model has previously been developed and validated. The aim of this study is to evaluate the suitability of this ARM model (with perineal fistula) for training in hands-on workshops. MATERIALS AND METHODS: The ARM model consists of a wooden casing with disposable perineal body. Participants in several international pediatric colorectal hands-on workshops in 2019 and 2020 were asked to participate. They were divided in a target group and an experienced group based on experience. All practiced the posterior sagittal anorectoplasty procedure on the model with multimodality guidance. Subsequently, statements on the suitability of the model for use during hands-on workshops were scored on a 5-point Likert scale. RESULTS: A total of 80 participants were included (43 surgical specialists, 13 pediatric surgery fellows, and 25 residents). Nearly, all statements scored at least a mean of >4.0, all scored significantly better than a neutral opinion. The target group (n = 58) scored higher compared with the experienced group (n = 22) on "transferability of the skills to the clinical setting" (means 4.4 vs. 4.0, p = 0.038); however, the "suitability as a replacement for an animal model" scored significantly lower (means 3.6 vs. 3.9, p = 0.049). No other differences were found. CONCLUSION: This affordable ARM model was regarded a suitable model for training during preclinical hands-on workshops and could be used for the specified steps of the procedure.

Secondary overtriage in a pediatric level one trauma center.

BACKGROUND: Previous studies have explored under- and overtriage, and the means by which to optimize these rates. Few have examined secondary overtriage (SO), or the unnecessary transfer of minimally injured patients to higher level trauma centers. We sought to determine the incidence and impact of SO in our pediatric level one trauma center. METHODS: We performed a retrospective analysis of all trauma activations at our institution from 2015 through 2017. SO was defined as transferred patients who required neither PICU admission nor an operation, with ISS ≤ 9 and LOS ≤ 24 h. We compared SO patients against all trauma activation transfers, and against similar non-transferred patients. RESULTS: We identified 1789 trauma activations, including 766 (42.8%) transfers. Of the transfers, 335 (43.7%) met criteria for SO. Compared to other transfers, SO patients had a shorter mean travel distance (52.9 v 58.1 mi; p = 0.02). Compared to similar patients transported from the trauma scene, SO patients were more likely to be admitted (52.2% v 29.2%; p < 0.001), with longer inpatient stay and greater hospital charges. CONCLUSIONS: SO represents an underrecognized burden to trauma centers which could be minimized to improve resource allocation. Future research should evaluate trauma activation criteria for transferred pediatric patients.

Are routine postoperative dilations necessary after primary posterior sagittal anorectoplasty? A randomized controlled trial.

AIM OF THE STUDY: For the past four decades, routine daily postoperative anal dilation by parents has been the standard treatment following a primary posterior sagittal anorectoplasty (PSARP). However, the clinical benefit of this practice has never been formally investigated. It is known that dilations can have a significant negative psychological impact on patients and families, and therefore, we aimed to study if routine dilations after a PSARP are necessary. METHODS: A prospective, single institution randomized controlled clinical trial was conducted on patients with anorectal malformations (ARM) at our institution between 2017 and 2019. Patients were randomized to either a dilation or non-dilation group following their PSARP. Inclusion criteria included age less than 24 months and all patients undergoing primary repair of their ARM (except for cloaca). Patient characteristics, type of ARM, presence of colostomy, postoperative stricture, need for a skin level revision (Heineke-Mikulicz anoplasty (HMA)), and need for redo PSARP were recorded. The primary outcome of the trial was stricture formation. The secondary outcome included strictures requiring interventions. A p-value of less than 0.05 was considered statistically significant. Institutional approval was obtained for this study and informed consents were obtained from all the patients. RESULTS: 49 patients were included in our study. 5 (21%) in the dilation group and 8 (32%) in the non-dilation group developed strictures (p=0.21). Of these, 3 (13%) patients in the dilation group required HMA, and 4 (16%) patients in the non-dilation group required HMA (p=0.72). 4 patients required a redo operation for strictures: 2 in the dilation arm (these patients despite the plan to do dilations, chose not to do them consistently) and 2 in the non-dilation arm (p=0.59). CONCLUSION: Routine dilations after PSARP do not significantly reduce stricture formation. Based on these results, non-dilation is a viable alternative, and HM anoplasty remains a good back-up plan if a stricture develops. LEVEL OF EVIDENCE: Level I.

Development of a Structured Regional Analgesia Program for Postoperative Pain Management.

OBJECTIVES: We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019. METHODS: A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time. RESULTS: There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups. CONCLUSIONS: We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program.

Trends in robotic surgery utilization across tertiary children's hospitals in the United States.

BACKGROUND: A growing number of tertiary children's hospitals are utilizing robotic surgical technology. We sought to characterize national trends in pediatric surgical robotic case utilization and related drivers. METHODS: Pediatric urology and pediatric surgery (abdominal and thoracic) procedures, performed from January 2010 to December 2019 across 19 U.S. tertiary care children's hospitals, were identified using the Pediatric Health Information System (PHIS). Trends in robot utilization were evaluated by surgical subspecialty, procedure type, and number of individual operating surgeons. RESULTS: Increases were noted in the overall numbers of pediatric surgery (1.3% per quarter, p = 0.005) and urology robotic procedures (2.0% per quarter, p < 0.001), as well as the numbers of pediatric surgeons (7.5% per year, p < 0.001) and pediatric urologists (7.8% per year, p < 0.001) operating robotically. Biliary system and spleen surgery were the most common robotic pediatric surgery procedures (45.5%) and had stable utilization over time (- 0.8% per quarter, 95% CI - 2.3-0.8). Robotic foregut surgery showed the most rapid growth in utilization (2.1% per quarter, 95% CI 0.7-3.6, p = 0.004) in pediatric surgery, while mediastinal/thoracic surgery demonstrated a decrease in utilization (- 4.6%, 95% CI - 7.9-1.2, p = 0.008). Renal pelvis/ureter surgery was the most common robotic urologic procedure (55.8%) and also demonstrated the fastest growth utilization (2.2% per quarter, 95% CI 1.5-2.9, p < 0.001) in urology. CONCLUSIONS: Utilization of robotic-assisted surgery in pediatric surgery and pediatric urology has increased both in case volume and the number of operating surgeons, with foregut and renal pelvis/ureter surgery responsible for the areas of greatest growth.

A comparison of robotic-assisted splenectomy and laparoscopic splenectomy for children with hematologic disorders.

INTRODUCTION: Laparoscopic splenectomy (LS) is the standard of care for hematologic disorders requiring splenectomy. Less is known about the outcomes following robotic-assisted splenectomy (RS) for this indication. Our aim was to describe outcomes of RS to LS in pediatric patients with hematologic disorders in our institution. METHODS: A single institution retrospective review was performed of pediatric patients undergoing LS vs. RS from 2014 to 2019. Patient demographics, diagnosis, spleen size, hospital length of stay (LOS), operative time, post-operative opioid use, and hospital charges were evaluated. Standard univariate analyses were performed. RESULTS: Twenty-four patients were included in the study (14 LS, 10 RS). The mean spleen size at the time of surgery was larger in the RS group compared to LS (14.5 cm vs. 12.2 cm, p = 0.03). Operative time between the two cohorts was comparable (RS 140.5 vs LS 154.9 min). Median LOS for RS was shorter than LS (2.1 vs. 3.2 days, p = 0.02). Cumulative postoperative opioid analgesic requirements were not significantly different between the groups (17.4 mg vs. 30.5 mg). The median hospital charges, including the surgical procedure and hospital stay were higher in the RS group ($44,724 RS vs $30,255 LS, p = 0.01). CONCLUSION: Robotic splenectomy is a safe and feasible option for pediatric patients with hematologic disorders, and was associated with decreased LOS but higher charges compared to laparoscopic splenectomy. Further studies are required to delineate the optimal use and potential benefits of robot-assisted surgical techniques in children. LEVEL OF EVIDENCE: II.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion.

Importance: Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking. Objective: To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery. Evidence Review: Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique. Findings: Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery. Conclusions and Relevance: These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.