Trauma Teams That Train as One Work as One: Invasive Procedure Training in Residency Education.

BACKGROUND: Invasive surgical procedures occur infrequently in an emergency department setting; however, procedural competence is expected from trauma residents. Emergent procedures are challenging to train in a formal manner because of the urgent nature when they present. To supplement education, new and creative teaching tools such as simulation and multidisciplinary training are being used. Our study organized a multidisciplinary simulated learning workshop with surgery and emergency medicine residents for invasive, emergent procedures. MATERIALS AND METHODS: In total, 14 surgical and 36 emergency medicine residents at our institution participated in a simulated learning experience. Ten workshops were organized, with six to seven residents participating in each session. Using a human cadaveric model, all residents were taught by senior-level residents and attendings from both specialties on how to perform uncommonly or anatomically challenging emergent invasive procedures. A pre- and post-laboratory survey was completed by all the residents to assess confidence in performing each of the 13 procedures. RESULTS: All residents (N = 50), who participated in the study, completed pre- and post-laboratory surveys. Comparison of the pre- and post-laboratory confidence levels indicated significant increases in confidence in performing all procedures. Residents stated that this multidisciplinary approach to education in a controlled setting was helpful and fostered a collaborative relationship between both specialties. CONCLUSIONS: Although some surgical procedures remain uncommon in the emergency department, competency is nevertheless expected for appropriate patient care. Using a collaborative simulation-based cadaver laboratory to teach emergent procedures significantly improved residents' confidence while concurrently fostering professional relationships.

Failure to thrive: The socioeconomics of pediatric gastrostomy complications.

PURPOSE: One of the most common procedures in the pediatric population is the placement of a gastrostomy tube. There are significant medical, emotional, and social implications for both patients and caregivers. We hypothesized that socioeconomic status had a significant impact on gastrostomy complications. METHODS: A retrospective chart review was performed. Patient and census data including median household income, unemployment rate, health insurance status, poverty level, and caregiver education level were merged. Statistical tests were conducted against a 2-sided alternative hypothesis with a 0.05 significance level. Outcomes examined were minor and major complications in association with socioeconomic variables. RESULTS: Patients with mechanical complications were younger, weighed less, and had a 72% greater chance of having commercial insurance. Patients with Medicare/self-pay were three times more likely to have a minor complication. The average unemployment rate was 23% greater in families with a major complication. Individuals with a minor complication came from community tracts with a lower percentage of families below the poverty level. CONCLUSION: An association between socioeconomic factors and gastrostomy complications was identified. Insurance status and employment status were more significant predictors than poverty level. Further work with variables for targeted interventions to provide specific family support will allow these children and families to thrive. LEVEL OF EVIDENCE: Level II prognosis study.

Engaging the patient and family in the surgical safety process utilizing.

BACKGROUND: Owing to the vulnerable nature of children, parental/caregiver engagement in surgical safety is a crucial aspect of care. Historically, the surgical safety process has been isolated from parent involvement. The digital, tablet-based surgical safety application, SafeStart, requires parent participation and provides multiple instances of verification of patient safety information from preoperative clinic visit, to perioperative care, and into the operating room. METHOD: The SafeStart application was utilized for 100 pediatric general surgery patients in an IRB approved prospective study. Parent assessments of the surgical consent and safety processes were collected in pre- and postoperative surveys with a 100% response rate. Standard consent forms were used and compared as a control. RESULTS: Only 31% of parents had knowledge of the surgical safety checklist process prior to their exposure to the study. 96% of the parents reported that the SafeStart patient portal was easy to use. A majority would prefer SafeStart to the standard consent process. CONCLUSION: The SafeStart program connected the surgical safety process from the preoperative clinic visit through postoperative care. Parent's preferred SafeStart to the standard surgical safety checklist and consent process, felt that they were instrumental in protecting their child's safety, and would recommend SafeStart for the surgical care of others. LEVEL OF EVIDENCE: II.

Adopting Single-Incision Laparoscopic Appendectomy in Children: Is It Safe During the Learning Curve?

Introduction: Laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. The single-incision laparoscopic surgery (SILS) approach has gained widespread acceptance. This study evaluates the learning curve of contemporarily trained surgeons adopting SILS appendectomy and, more specifically, the safety of the operation during the early phase of this learning curve. Methods: A retrospective review of 974 consecutive pediatric patients younger than 18 years of age, who underwent an appendectomy at a single institution from 2005 to 2018, was performed. Nonperforated and perforated appendicitis cases were included. A subgroup analysis was performed on SILS appendectomy. Outcomes measured included length of operating room and anesthesia time, as well as complication rate. A log-logistics and a Loess smoothing model were used. Results: A total of 438 single-incision laparoscopic appendectomies were reviewed. A trend toward faster operative times was observed for all surgeons as case numbers increased. The odds of still being operated on decreased by 0.997 for each additional case. Based on a 95% confidence band and this experienced time as the standard, we expect adopting surgeons to reach this experienced level after 51 cases. During the early SILS appendectomy learning curve, there was no significant difference in complication rate compared with multiport laparoscopy. Conclusion: As expected, the more single-incision cases were performed, the shorter the operative times. More importantly, there was no increase in complication rate during the learning stage of single-incision appendectomies in either perforated or nonperforated appendicitis.

A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children.

BACKGROUND: With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse. METHODS: A retrospective chart review of 327 consecutive pediatric patients evaluated for appendicitis between October 2014 and September 2015 at our institution was performed. Data on clinical, radiographic, and histopathologic findings were reviewed. Diagnostic accuracy of US and white blood cell (WBC) values was determined. An algorithm was created. RESULTS: 327 (100%) patients received an ultrasound for suspected appendicitis. WBC of 10,000/µl was determined to be the primary discriminant for management and ultrasound utilization. If a WBC ≥10,000/µL had been utilized as criteria for imaging, 49.5% fewer patients would have received an ultrasound. CONCLUSIONS: Clinical exam, WBC count, and surgery consultation prior to ultrasonography can lessen then need for ultrasound utilization in children with suspected appendicitis.

Single center protocol driven care in 150 patients with gastroschisis 1998-2017: collaboration improves results.

PURPOSE: The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed. METHODS: A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed. RESULTS: 150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables-time to extubation, days to initiate feeds, days to full feeds, and length of stay. CONCLUSION: Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.

Treatment of subcutaneous abscesses in children with incision and loop drainage: A simplified method of care.

PURPOSE: The aim of this study was to expand on our previous report of 115 patients after more than a decade-long experience using incision and loop drainage for pediatric subcutaneous abscess management. This report comprises the largest consecutive series of pediatric abscess patients from a single institution ever recorded. METHODS: A retrospective study was performed of all pediatric patients who underwent incision and loop drainage of subcutaneous abscesses at our institution between January 2002 and December 2014. TECHNIQUE: Two sub 5mm incisions were made at the periphery on the abscess. The abscess cavity was probed to break down loculations and drain pus. The abscess cavity was irrigated with normal saline. A loop drain was passed through one incision and brought out through the other. A simple absorbent dressing was applied over the drain. RESULTS: Five hundred seventy-six consecutive patients underwent loop drainage procedures. Mean values are as follows: age, 3.84years; duration of symptoms, 6.17days; postoperative length of stay (with 4 outliers excluded), 0.69days; drain duration, 8.38days; and number of postoperative visits, 1.28. Twenty-six patients had reoperations (4.5%), 2 of which were planned staged excisions of pilonidal cysts and 1 because of accidental home removal. CONCLUSIONS: Micro-incisions and loop drainage is a safe and effective treatment modality for subcutaneous abscesses in children. The findings eliminate the need for repetitive wound packing and simplify postoperative wound care. Loop drainage offers shorter time to discharge, lower recurrence rates, and minimal scarring. Additionally, there is expected cost reduction. We recommend this minimally invasive procedure to be the standard of care for subcutaneous abscesses in children. TYPE OF STUDY: Treatment study - retrospective review. LEVEL OF EVIDENCE: Level IV - case series with no comparison group.

Diagnostic accuracy of endoscopic ultrasound in pancreatic neuroendocrine tumors: a systematic review and meta analysis.

AIM: To detect pancreatic neuroendocrine tumors (PNETs) has been varied. This study is undertaken to evaluate the accuracy of endoscopic ultrasound (EUS) in detecting PNETs. METHODS: Only EUS studies confirmed by surgery or appropriate follow-up were selected. Articles were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model). RESULTS: Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (n = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNETs was 87.2% (95%CI: 82.2-91.2). EUS had a pooled specificity of 98.0% (95%CI: 94.3-99.6). The positive likelihood ratio of EUS was 11.1 (95%CI: 5.34-22.8) and negative likelihood ratio was 0.17 (95%CI: 0.13-0.24). The diagnostic odds ratio, the odds of having anatomic PNETs in positive as compared to negative EUS studies was 94.7 (95%CI: 37.9-236.1). Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (P = 0.16), indication no publication bias. The P for χ² heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSION: EUS has excellent sensitivity and specificity to detect PNETs. EUS should be strongly considered for evaluation of PNETs.

Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum.

Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.

Nuss procedure: decrease in bar movement requiring reoperation with primary placement of two bars.

BACKGROUND: The Nuss procedure, first reported in 1998, is currently the treatment of choice for pectus excavatum. The most significant bar-related complication documented is bar movement, requiring reoperation in 3.4%-27% of reports. Our report compares the initial placement of one Nuss bar versus two to prevent bar displacement. SUBJECTS AND METHODS: An Institutional Review Board-approved, retrospective chart review was performed of all Nuss procedures performed from November 2000 through February 2010. Since November 2006, all initial Nuss procedures were started with the intent of placing two bars. Haller index, patient demographics, duration of surgery, length of stay, postoperative wound infections, and bar movement requiring reoperation were collected and compared for the one-bar versus two-bar patient populations. RESULTS: In total, 85 Nuss procedures (58 with one-bar and 27 with two-bar primary Nuss procedures) were analyzed. Two attending pediatric surgeons performed all the procedures. Reoperation for bar movement when one bar was initially placed occurred in 9 patients (15.5%). No patients with initial placement of two bars required operative revision for a displaced Nuss bar (15.5% versus 0%, P=.05). Patient age and Haller index were not statistically different between groups. CONCLUSIONS: Our data demonstrate improved bar stability with no reoperative intervention when pectus excavatum is initially repaired with two Nuss bars. Primary placement of two bars has now become standard practice in our institution for correction of pectus excavatum by the Nuss procedure and would be our recommendation for consideration by other centers.

Simultaneous carriage of multiple genotypes of Staphylococcus aureus in children.

The co-existence of multiple genotypes in colonization by Staphylococcus aureus has not been fully investigated. The aim of this study was to evaluate the heterogeneity of S. aureus carriage in children. We evaluated 125 nasal and perianal swab samples that were positive for S. aureus from 76 children scheduled for elective surgery. For each sample, at least four colonies with the same or different morphotypes were selected for analysis. Multiple-locus variable-number tandem-repeat fingerprinting was used to determine the genetic relatedness and to characterize the clonality of the S. aureus strains. Of the 125 swabs, 91 (73 %) contained meticillin-sensitive S. aureus (MSSA), 8 (6 %) contained meticillin-resistant S. aureus (MRSA), and 26 (21 %) contained MSSA and MRSA simultaneously. A total of 738 S. aureus strains were evaluated with a mean of 6 colonies (range 4-15) picked from each culture. Of the 125 swabs, 32 (26 %) samples contained two genetically distinct S. aureus strains and 6 (5 %) contained three different genotypes. Multiple S. aureus strains simultaneously carried by individual children were genetically unrelated to each other. We concluded that the co-existence of multiple genotypes of S. aureus was common. The significance of multiple carriage is yet to be determined, but this intraspecies interplay could be important to pathogenicity and virulence in S. aureus.

Transumbilical laparoscopically assisted appendectomy: an alternative minimally invasive technique in pediatric patients.

INTRODUCTION: Transumbilical laparoscopically assisted appendectomy (TULAA) has been reported in the literature as an alternative to traditional three-port laparoscopic appendectomy (LA). Our study compares outcomes between LA and the one-trocar transumbilical technique in a single institution over a concurrent time frame for all cases of pediatric appendicitis. METHODS: An Institutional Review Board-approved retrospective chart review of all appendectomies from July 2007 through June 2009 was performed. All appendectomies were performed either laparoscopically or transumbilically. One surgeon predominantly used the TULAA method, whereas the other 2 surgeons used strictly the LA method. No cases were converted to open. Categorization of specimens as normal, acute, or ruptured was based on pathology reports. Outcomes analyzed for each group included surgical duration, cost, length of stay, fever (>101.5F), wound infection, ileus, and postoperative abdominal-pelvic abscess. RESULTS: A total of 131 appendectomies were performed by 3 surgeons, 83 were LA and 48 were TULAA. For all stages of appendicitis, outcomes differed significantly only for operating room cost, with the TULAA being significantly less expensive. All other outcomes were similar between the two techniques. CONCLUSION: Our study suggests that TULAA is a reasonable alternative to the standard minimally invasive technique for appendicitis in both acute and ruptured situations. All analyzed complications were similar between the groups, suggesting that TULAA is an acceptable surgical method in pediatric patients for all stages of appendicitis.

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children.

PURPOSE: The aim of the study was to evaluate outcomes after a minimally invasive approach to pediatric subcutaneous abscess management as a replacement for wide exposure, debridement, and repetitive packing. METHODS: A retrospective study was performed of all children who underwent incision and loop drainage for subcutaneous abscesses between January 2002 and October 2007 at our institution. TECHNIQUE: Two mini incisions, 4-5 mm each, were made on the abscess, as far apart as possible. Abscess was probed, and pus was drained. Abscess was irrigated with normal saline; a loop drain was passed through one incision, brought out through the other, and tied to itself. An absorbent dressing was applied over the loop and changed regularly. RESULTS: One hundred fifteen patients underwent drainage procedures as described; 5 patients had multiple abscesses. Mean values (range) are as follows: age, 4.25 years (19 days to 20.5 years); duration of symptoms, 7.8 days (1-42 days); length of hospital stay, 3 days (1-39 days); duration of procedure, 10.8 minutes (4-43 minutes); drain duration, 10.4 days (3-24 days); and number of postoperative visits, 1.8 (1-17). Bacterial culture data were available for 101 patients. Of these, 50% had methicillin-resistant Staphylococcus aureus, 26% had methicillin-sensitive Staphylococcus aureus, and 9% streptococcal species. Of the 115 patients, 5 had pilonidal abscesses, 1 required reoperation for persistent drainage, and 1 had a planned staged excision. Of the remaining 110 patients, 6 (5.5%) required reoperation-4 with loop drains and 2 with incision and packing with complete healing. CONCLUSION: The use of loop drains proved safe and effective in the treatment of subcutaneous abscesses in children. Eliminating the need for repetitive and cumbersome wound packing simplifies postoperative wound care. Furthermore, there is an expected cost savings with this technique given the decreased need for wound care materials and professional postoperative home health services. We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.

Laparoscopic Ladd's procedure: treatment of choice for midgut malrotation in infants and children.

INTRODUCTION: Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development. Ladd's procedure, as a correction of these anomalies, has traditionally been performed by laparotomy. In our institution, the laparoscopic Ladd's (LL) procedure was introduced in May 2004 and soon became the standard approach. MATERIALS AND METHODS: A retrospective analysis of all Ladd's procedures in children in our institution between September 1998 and June 2008 was performed. Outcomes between the open (OL) and LL procedures were compared. RESULTS: A total of 156 children underwent Ladd's procedure during the study period. There were 120 open and 36 laparoscopic procedures. Overall, 75% of patients in each group were symptomatic, most commonly with emesis and pain. Duration of surgery was similar in both groups. Time to starting feeds, and amount of time to attain full feeding, was significantly less in the LL group. Postoperative length of stay was significantly less in the patients having LL. Conversion rate to OL from LL was 8.3%. CONCLUSIONS: LL can be performed safely in selected patients with no increase in complications. Short-term results are superior to OL and can be achieved without any increase in operative duration.

All-terrain vehicle safety and use patterns in central Illinois youth.

CONTEXT: All-terrain vehicles' (ATVs) popularity and associated injuries among children are increasing in the United States. Currently, most known ATV use pattern data are obtained from injured youth and little documented data exist characterizing the typical ATV use patterns and safety practices among American children in general. PURPOSE: To describe the typical ATV safety and use patterns of rural youth. METHODS: A cross-sectional anonymous mail survey was conducted of youth participants (ages 8-18) in the 4-H Club of America in four Central Illinois counties. Questions examined ATV use patterns, safety knowledge, safety equipment usage, crashes, and injuries. FINDINGS: Of 1,850 mailed surveys, 634 were returned (34% response rate) with 280 surveys (44% of respondents) eligible for analysis. Respondents were principally adolescent males from farms or rural locations. Most drove < or =1 day per week (60.2%) and used ATVs for recreation (36%) or work (22.6%) on farms and/or private property (53.4%). Most never used safety gear, including helmets (61.4%), and few (14.6%) had received safety education. Of the 67% who experienced an ATV crash, almost half (44%) were injured. Children with safety training had fewer crashes (P= .01), and those riding after dark (P= .13) or without adult supervision (P= .042) were more likely injured. CONCLUSIONS: ATV use is common in a rural 4-H population. Most child ATV users were adolescent boys, had little safety training and did not use safety equipment or helmets. ATV injury prevention efforts should focus on these areas.

A prospective study of methicillin-resistant Staphylococcus aureus colonization in children scheduled for elective surgery.

BACKGROUND: Staphylococcus aureus is a major cause of surgical wound infections. To obtain contemporary data on S aureus, we performed a prospective study of colonization and infection in children scheduled for elective surgical procedures. METHODS: A nasal swab and clinical information were obtained at the presurgical outpatient visit. At operation, nasal and perianal swabs were obtained. S aureus were isolated and characterized. RESULTS: We enrolled 499 patients from June 2005 to April 2007. Wound classes were 1 (73%), 2 (22%), 3 (5%), and 4 (0.2%). Prophylactic antibiotics were administered for 153 (31%). Postoperative length of stay ranged from 0 (77%) to 6 days, with 19 (4%) staying 4 days or more. Screening cultures grew S aureus for 186 procedures (36.6%); of these, 141 were methicillin-resistant S aureus (MRSA) (76% of all staphylococcal cultures or 28% of all procedures). Most MRSA had Staphylococcal Chromosomal Cassette mec type II and resistance to clindamycin-typical for hospital-associated strains. There were 10 (2%) surgical site infections, including 4 methicillin-sensitive S aureus, 1 MRSA, 2 with no growth, and 2 with no cultures. CONCLUSION: Methicillin-resistant S aureus colonization was common in asymptomatic children. Most strains appeared to be health care-associated and resistant to clindamycin. Wound infection rate remained low despite the high prevalence of staphylococcal colonization.

Management of blunt splenic injury in children: evolution of the nonoperative approach.

BACKGROUND: Nonoperative management of blunt splenic injury (BSI) was first proposed at our institution in 1948. Since that time, treatment of patients with BSI has evolved from routine splenectomy to an aggressive spleen-preserving philosophy. This report summarizes our institutional experience for the last 50 years. METHODS: All children (0-18 years) admitted to our pediatric trauma center with BSI during 4 eras (1956-1965, 1972-1977, 1981-1986, and 1992-2006) were retrospectively reviewed for demographics, injury patterns, management, and complications. RESULTS: During the 4 eras captured for the last 5 decades, 486 children experienced BSI. The mean age was 10 years with 347 males (71%). Nonoperative management rate increased from 42% to 97% with improvement in splenic salvage rate (42%-99%). Mean length of stay decreased from 17 to 5 days. In patients with isolated splenic injuries (50%), nonoperative management rate increased (36%-100%) and fewer received transfusions (60%-1%). Overall mortality rate improved (19%-6.6%, 8%-0.7% in isolated injuries). CONCLUSION: The management of BSI in children has changed dramatically for the last 50 years. This study clearly demonstrates the safety of nonoperative management and documents progressively lower rates of splenectomy and transfusion, shorter hospitalization, and an extremely low risk of mortality.

Practice makes perfect: progressive improvement of laparoscopic pyloromyotomy results, with experience.

INTRODUCTION: Pyloric stenosis can now be treated effectively with laparoscopic pyloromyotomy (LP). Few large outcome studies have been published regarding the laparoscopic technique. In this paper, we describe our experience with the first 185 consecutive LPs. MATERIALS AND METHODS: An institutional review board-approved retrospective outcomes analysis was performed on our first 185 consecutive LPs. Previous publications comparing open pyloromyotomy (OP) and LP are reviewed. Our hypothesis is that, with experience, the outcome of LP will equal or surpass that of OP. RESULTS: A total 185 infants underwent LPs during the study period. The infants had median values of age: 33 days; body weight: 4 kg; surgery duration: 25 minutes; postoperative length of stay (LOS): 25.5 hours; and total LOS: 45 hours. There were 7 complications (3.78%): 4 incomplete pyloromyotomies (2.2%), 1 pyloric mucosal perforation (0.5%), 1 delayed duodenal perforation (0.5%), and 1 wound infection (0.5%). There has been a progressive reduction in the time required for surgery, from a median of 29 minutes in the first 60 cases to 21.5 in the last 65. Postoperative LOS has fallen from a median of 26 hours in the first half to 24.5 in the later half. Complications occurred primarily in the first third of our cases. CONCLUSIONS: We are able to demonstrate that, with experience, one can expect progressive improvement in the outcomes following LP in infants. Our surgery duration and complications in the last 65 cases are better than most published results for OP or LP.

Complications associated with the Nuss procedure: continued evolution of the learning curve.

BACKGROUND: We report unusual and/or significant complications encountered during and after the Nuss Procedure for pectus excavatum. METHODS: This was a retrospective review that was approved by the institutional review board, with parental consent. RESULTS: Seven patients had unique and/or significant complications as follows: (1) laceration of an internal mammary artery during bar placement requiring emergent minithoracotomy; (2) hemopericardium 10 weeks postoperatively after blunt chest trauma requiring exploration of the pericardium and clot evacuation; (3) almost complete recurrence of the pectus excavatum deformity immediately after bar removal; (4 and 5) immediate/early postoperative bar displacement requiring re-operation and placement of 2 bars each; and (6 and 7) almost complete neo-ossification of the Nuss bar, making removal challenging. CONCLUSIONS: The Nuss procedure has met with near-universal acceptance. Complications are just being reported. We describe 7 events to add to the evolving literature as the entire pediatric surgery community participates in the initial learning curve.