Defining digital surgery: a SAGES white paper.

BACKGROUND: Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas. METHODS: This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology. RESULTS: In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth. CONCLUSION: Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.

The use and timing of angioembolization in pediatric blunt liver and spleen injury.

BACKGROUND: Nonoperative management (NOM) is the standard of care for the management of blunt liver and spleen injuries (BLSI) in the stable pediatric patient. Angiography with embolization (AE) is used as an adjunctive therapy in the management of adult BLSI patients, but it is rarely used in the pediatric population. In this planned secondary analysis, we describe the current utilization patterns of AE in the management of pediatric BLSI. METHODS: After obtaining IRB approval at each center, cohort data was collected prospectively for children admitted with BLSI confirmed on CT at 10 Level I pediatric trauma centers (PTCs) throughout the United States from April 2013 to January 2016. All patients who underwent angiography with or without embolization for a BLSI were included in this analysis. Data collected included patient demographics, injury details, organ injured and grade of injury, CT finding specifics such as contrast blush, complications, failure of NOM, time to angiography and techniques for embolization. RESULTS: Data were collected for 1004 pediatric patients treated for BLSI over the study period, 30 (3.0%) of which underwent angiography with or without embolization for BLSI. Ten of the patients who underwent angiography for BLSI failed NOM. For patients with embolized splenic injuries, splenic salvage was 100%. Four of the nine patients undergoing embolization of the liver ultimately required an operative intervention, but only one patient required hepatorrhaphy and no patient required hepatectomy after AE. Few angiography studies were obtained early during hospitalization for BLSI, with only one patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours. CONCLUSION: Angioembolization is rarely used in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally used in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Enteral access and reflux management in neonates with severe univentricular congenital heart disease: literature review and proposed algorithm.

Neonates with severe congenital heart disease undergoing surgical repair may face various complications, including failure to thrive. Feeding tube placement and fundoplication are often performed to combat poor growth in neonates. With the variety of feeding tubes available and controversy surrounding when fundoplication is appropriate, there is no current protocol to determine which intervention is necessary for this patient population. We aim to provide an evidence-based feeding algorithm for this patient population. Initial searches for relevant publications yielded 696 publications; after review of these studies and inclusion of additional studies through external searches, a total of 38 studies were included for qualitative synthesis. Many of the studies utilized did not directly compare the different feeding modalities. Of the 38 studies included, five studies were randomized control trials, three studies were literature reviews, one study was an online survey, and the remaining twenty-nine studies were observational. There is no current evidence to suggest that this specific patient population should be treated differently regarding enteral feeding. We propose an algorithm to assist optimal feeding for neonates with congenital heart disease. Conclusion: Nutrition remains a vital component of the care of neonates with congenital heart disease; determining the optimal feeding strategy for these patients can be approached like other neonates.

Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis.

BACKGROUND: Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding. METHODS: Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure. RESULTS: Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001). CONCLUSION: Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin. LEVEL OF EVIDENCE: Level II Prognostic Study.

Virtual curriculum delivery in the COVID-19 era: the pediatric surgery boot camp v2.0.

PURPOSE: We evaluated the impact of a virtual Pediatric Surgery Bootcamp curriculum on resource utilization, learner engagement, knowledge retention, and stakeholder satisfaction. METHODS: A virtual curriculum was developed around Pediatric Surgery Milestones. GlobalCastMD delivered pre-recorded and live content over a single 10-h day with a concluding social hour. Metrics of learner engagement, faculty interaction, knowledge retention, and satisfaction were collected and analyzed during and after the course. RESULTS: Of 56 PS residencies, 31 registered (55.4%; 8/8 Canadian and 23/48 US; p = 0.006), including 42 learners overall. The virtual BC budget was $15,500 (USD), 54% of the anticipated in-person course. Pre- and post-tests were administered, revealing significant knowledge improvement (48.6% [286/589] vs 66.9% [89/133] p < 0.0002). Learner surveys (n = 14) suggested the virtual BC facilitated fellowship transition (85%) and strengthened peer-group camaraderie (69%), but in-person events were still favored (77%). Program Directors (PD) were surveyed, and respondents (n = 22) also favored in-person events (61%). PDs not registering their learners (n = 7) perceived insufficient value-added and concern for excessive participants. CONCLUSIONS: The virtual bootcamp format reduced overall expenses, interfered less with schedules, achieved more inclusive reach, and facilitated content archiving. Despite these advantages, learners and program directors still favored in-person education. LEVEL OF EVIDENCE: III.

Diagnostic Laparoscopy for Abdominal Trauma in Infants and Children: How We Do It.

Although once thought to be a point of contention, the use of minimally invasive surgery for the hemodynamically stable pediatric trauma patients has grown dramatically since its conception in the 1970s and becoming a widely acceptable option for select patient populations. An accumulation of literature over the decades has continued to support laparoscopy for both diagnostic and therapeutic purposes in the pediatric trauma patients as laparoscopy is likely to decrease morbidity, hospital cost, and negative laparotomy rates. In this review, we describe what we believe to be the critical aspects of diagnostic laparoscopy in the setting of pediatric trauma.

Surgical telementoring: Feasibility, applicability, and how to.

Surgical training does not end at the conclusion of residency training. Expansions in medical technology and surgical technique have created a steep learning curve for the young attending surgeon. The emergence of intraoperative telementoring has allowed experienced surgeons to guide learners through complex surgical cases remotely with the assistance of streaming video technology. Here, we describe the basics of telementoring, financial and legal considerations, and recommend hardware specifications for optimal use.

Opportunities for Regulatory Changes to Promote Pediatric Device Innovation in the United States: Joint Recommendations From Pediatric Innovator Roundtables.

OBJECTIVE: The purpose of this report is to provide insight from pediatric stakeholders with a shared desire to facilitate a revision of the current United States regulatory pathways for the development of pediatric healthcare devices. METHODS: On August 5, 2020, a group of innovators, engineers, professors and clinicians met to discuss challenges and opportunities for the development of new medical devices for pediatric health and the importance of creating a regulatory environment that encourages and accelerates the research and development of such devices. On January 6, 2021, this group joined regulatory experts at a follow-up meeting. RESULTS: One of the primary issues identified was the need to present decision-makers with opportunities that change the return-on-investment balance between adult and pediatric devices to promote investment in pediatric devices. DISCUSSION/CONCLUSION: Several proposed strategies were discussed, and these strategies can be divided into two broad categories: 1. Removal of real and perceived barriers to pediatric device innovation; 2. Increasing incentives for pediatric device innovation.

Virtual Education in Pediatric Surgery during the COVID-19 Era: Facing and Overcoming Current Challenges.

The novel coronavirus disease 2019 (COVID-19) pandemic has impacted our way of living in an unprecedented manner. Medical professionals at all levels have been forced to adapt to the novel virus. The delivery of surgical services and the subsequent learning opportunities for surgical residents have especially been disrupted and the pediatric surgical community has not been exempted by this. This article highlights the challenges imposed by the pandemic and outlines the various learning modalities that can be implemented to ensure continued learning opportunities throughout the pandemic and beyond. Furthermore, it aims to show how the utilization and expansion of technologies maintain and further increase the communication, as well as the exchange of and access to knowledge among peers. Virtual education-, application-, and simulation-based learning and social media, as well as telemedicine and online conferences, will play a considerable role in the future of surgical specialties and surgical education.

Commentary on shifting paradigms: The top 100 most disruptive papers in core pediatric surgery journals.

This is a commentary on the manuscript by Sullivan G, Skertich N, Gulack B, et al., titled "Shifting Paradigms: The Top Most Disruptive Papers in Core Pediatric Surgery Journals".

Can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method.

BACKGROUND/PURPOSE: In an effort to standardize educational experience, address future physician shortages, and improve quality of care to patients, many surgical specialties are discussing how to maximize exposure to index cases. One solution being explored is telementoring, which requires a well-developed educational curriculum with intraoperative objectives. The American College of Surgery Telementoring Task Force selected anorectal malformation and posterior sagittal anorectoplasty (PSARP) for the repair of imperforate anus as the initial educational focus for this pilot. The purpose of this study was to obtain international consensus on intraoperative learning objectives for a complex surgical procedure. METHODS: A multidisciplinary team of medical educators and pediatric surgery experts created an outline of essential curricular content and intraoperative learning objectives for PSARP in three clinical scenarios. Twelve international subject matter experts were identified meeting strict inclusion criteria. Intraoperative checklists were revised using the modified-Delphi process. RESULTS: After five rounds of modifications to the intraoperative checklists, international consensus was achieved for three different clinical scenarios requiring a PSARP: perineal or vestibular fistula, low prostatic fistula, and bladder neck fistula. CONCLUSIONS: A modified-Delphi approach was successful in generating guidelines for surgical techniques that can be used to standardize intraoperative teaching and expectations for trainees. TYPE OF STUDY: Diagnostic study LEVEL OF EVIDENCE: Level V (expert opinion).

Early vasopressor administration in pediatric blunt liver and spleen injury: An ATOMAC+ study.

BACKGROUND: No prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI). METHODS: A planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors <48 h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure. RESULTS: Of 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AOR = 7.6 [p < 0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AOR = 11.4 [p = 0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12 h after injury. Vasopressor administration at any time was not associated with NOM failure. CONCLUSION: After propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM. LEVEL OF EVIDENCE: Level III prognostic and epidemiological, prospective.