Simple diverticulectomy is adequate for management of bleeding Meckel diverticulum.

PURPOSE: It is unclear whether simple diverticulectomy, rather than segmental bowel resection (SBR), is adequate treatment for gastrointestinal bleeding (GIB) secondary to Meckel diverticulum (MD). There is concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed. This study seeks to determine if diverticulectomy is satisfactory treatment for bleeding MD. METHODS: A multi-institution, retrospective review was performed for patients with a diagnosis of MD and GIB who underwent simple diverticulectomy or small bowel resection. Exclusion criteria were comorbid surgical conditions and other causes of GIB. The primary outcome was post-operative bleeding during the initial hospitalization. Secondary outcomes were bleeding after discharge, transfusion or additional procedure requirement, re-admission, and overall complications. RESULTS: There were 59 patients who met study criteria (42 diverticulectomy, 17 SBR). One patient in the SBR group had early post-operative bleeding (p = 0.288). There was one re-admission (p = 0.288) and three total complications in the SBR group (p = 0.021). There were no cases of bleeding or other complications in the diverticulectomy group. CONCLUSION: This study suggests that simple diverticulectomy is adequate for treatment of GIB caused by MD. Furthermore, diverticulectomy appears to have a lower overall complication rate.

Rural surgeons would embrace surgical telementoring for help with difficult cases and acquisition of new skills.

BACKGROUND: Surgical telementoring, consisting of an expert surgeon guiding a less experienced surgeon through advanced or novel cases from a remote location, is an evolving technology which has potential to become an integral part of surgical practice. This study sought to apprise the attitudes of rural general surgeons toward the possible benefits and applications of surgical telementoring in their practices. METHODS: A survey assessing demographics and attitudes toward telementoring was e-mailed to members of the American College of Surgeons (ACS) Advisory Council for Rural Surgery and posted to the ACS website in areas targeting rural surgeons. A link to a webpage with a description of surgical telementoring and brief demonstrative video were included with the survey. RESULTS: There were 159 respondents, with 82.3 % of them practicing in communities smaller than 50,000 people. Overall, 78.6 % felt that telementoring would be useful to their practice, and 69.8 % thought it would benefit their hospitals. There was no correlation between years of practice and perceived usefulness of surgical telementoring. When asked the single most useful, or primary, application of surgical telementoring there was a split between learning new techniques (46.5 %) and intraoperative assistance with unexpected findings (39.0 %). When asked to select all applications in which they would be interested in using telementoring from a list of possible uses, surgeons most frequently selected: intraoperative consultation for unexpected findings (67.7 %), trauma consultation (32.9 %), and laparoscopic colectomy (32.9 %). CONCLUSIONS: Surgical telementoring is on the verge of widespread use but industry and surgical societies remain ambivalent about supporting its implementation due to concerns over lack of interest. This study demonstrates interest among rural surgeons. While there are differing opinions regarding compensation of the telementoring, the most common, single interest in the use of surgical telementoring was for learning new techniques or skill sets.

Treatment of routine adolescent inguinal hernia vastly differs between pediatric surgeons and general surgeons.

BACKGROUND: Surgical treatment of inguinal hernias in adolescents is controversial as these patients do not fit into the traditional pediatric and adult populations. We aimed to compare the preferences of adult general surgeons and pediatric surgeons in managing adolescents by conducting a survey through social media. METHODS: A poll was posted on the International Hernia Collaboration Group Facebook page as well as the Facebook page for the authoring pediatric surgeon. The poll gave scenarios of a 16-year-old male with an inguinal hernia and asked surgeons to select one of five listed procedures to repair the hernia: high ligation (open or laparoscopic), mesh repair (open or laparoscopic) or open muscle repair. The four scenarios differed in the diameter of the internal ring (1 vs. 4 cm) and the BMI of the patient (20 vs. 35). Fisher's exact test was implemented for statistical analysis. RESULTS: In total, 43 (67 %) adult surgeons and 21 (33 %) pediatric surgeons responded. In the routine adolescent (normal BMI, small defect), 65 % of adult surgeons chose adult-type repairs (mesh or muscle repairs) whereas 86 % of pediatric surgeons chose pediatric-type repairs (high ligation). When the size of the defect increased, 100 % of adult surgeons and 81 % of pediatric surgeons selected an adult-type repair, suggesting agreement. When the patient was obese, there was a tendency to prefer laparoscopy. In all patient scenarios, the answers were significantly different between pediatric and adult surgeons (p < 0.05). CONCLUSION: For the same routine adolescent inguinal hernia, pediatric surgeons and adult general surgeons choose a different procedure. This finding suggests that further study is needed to determine the optimal treatment for inguinal hernias in adolescents, as the type of practitioner to whom the patient is referred, rather than the disease process itself, currently dictates treatment.

Creation of an animal model for long gap pure esophageal atresia.

INTRODUCTION: Long gap pure esophageal atresia (LGPEA) is a congenital disorder in which the esophagus is in discontinuity, and the proximal and distal ends cannot be anastomosed in a primary fashion. No animal model for pure esophageal atresia exists. Here we describe a survival animal model for LGPEA, which will ultimately serve to test novel devices and techniques to restore continuity. METHODS: A non-survival study was first conducted in six rabbits to refine a protocol for the survival model. An open gastrostomy tube was placed, followed by a partial esophagectomy. Next, a survival study was performed with seven rabbits in which the same procedures were performed. Finally, the procedure was optimized in domestic swine. RESULTS: Despite developing the techniques and gaining valuable information in the non-survival study, none of the rabbits in the survival portion of the study lived beyond post-operative day four. Due to this complication with the rabbit, the LGPEA model was attempted in a porcine model. The pig survived to post-operative day ten, and was healthy enough to be used for further study. CONCLUSION: A porcine model of long gap pure esophageal atresia was developed which is effective and feasible to be used for testing new methods of treatment of LGPEA.

Same-day discharge after incision and drainage of soft-tissue abscess in diaper-age children is safe and effective.

PURPOSE: Many pediatric centers admit patients following incision and drainage (I&D) of soft-tissue abscesses. The purpose of this study is to assess the safety and efficacy of the same-day discharge following I&D. METHODS: Retrospective review was performed of children aged 3 months-4 years who underwent operative I&D of an abscess followed by same-day discharge. Patients receiving antibiotics within 2 weeks of presentation were excluded. Treatment failure was defined as readmission or repeat procedure related to the initial abscess. Statistical analysis was performed using Wilcoxon Rank-Sum and Fisher's Exact tests. RESULTS: There were 442 procedures performed in 408 patients. Mean age was 1.8 years. Fever was noted in 25.8%. Of those who had a white blood cell (WBC) count drawn, 59.7% had leukocytosis. Mean time from procedure to discharge was 2.3 h, and 85.0% were discharged with oral antibiotics. Treatment failure occurred in four (0.9%) and ten (2.3%) patients at 14 and 30 days, respectively. Mean WBC count was higher in the 14-day treatment failure group (24.1 versus 16.3; p = 0.10). In patients with leukocytosis, there were 2 (1.4%) treatment failures compared to none in those without leukocytosis. CONCLUSION: Same-day discharge after I&D of abscess in diaper-age children is safe and effective.

Creation of a neopylorus after pyloric exclusion using a "double-endoscope" technique.

OBJECTIVE: Pyloric exclusion may be implemented in the setting of a high-grade duodenal or pancreatic injury. After exclusion, the pylorus should spontaneously open in 3-6 weeks. However, we present the case of a critically ill 17-year-old male with a gunshot wound to the abdomen that underwent stapled pyloric exclusion with gastrostomy and jejunostomy tube placement who did not achieve pyloric patency after 5 months, and describe an innovative "double-endoscope" technique to correct it. METHODS: A gastroscope was inserted through the mouth into the stomach, and an endoscope was inserted retrograde through the jejunostomy site to the duodenum. The closed pylorus was seen from both ends with transillumination. A needle knife was pushed through the membrane with clear visualization from the contralateral side. A balloon dilation catheter was then passed over a guidewire, and the neopylorus was sequentially dilated. A gastrojejunostomy tube was placed to ensure patency of the neopylorus. Postoperative imaging showed no evidence of leak or pneumoperitoneum. Serial endoscopic dilations were performed every 1-4 weeks to prevent restricturing. RESULTS: The patient recovered well. After the first follow-up endoscopic dilation, he was eating a regular diet and had no retained food products. After four endoscopic dilations, the patient remained symptom free and the pylorus was widely patent. His gastrostomy and jejunostomy tubes were removed. CONCLUSIONS: Here we presented a rare complication of pyloric exclusion and an innovative approach that used a "double-endoscope" technique and serial endoscopic dilations to establish and maintain a neopylorus, avoiding the morbidity of a major surgical procedure.

Abundance models improve spatial and temporal prioritization of conservation resources.

Conservation prioritization requires knowledge about organism distribution and density. This information is often inferred from models that estimate the probability of species occurrence rather than from models that estimate species abundance, because abundance data are harder to obtain and model. However, occurrence and abundance may not display similar patterns and therefore development of robust, scalable, abundance models is critical to ensuring that scarce conservation resources are applied where they can have the greatest benefits. Motivated by a dynamic land conservation program, we develop and assess a general method for modeling relative abundance using citizen science monitoring data. Weekly estimates of relative abundance and occurrence were compared for prioritizing times and locations of conservation actions for migratory waterbird species in California, USA. We found that abundance estimates consistently provided better rankings of observed counts than occurrence estimates. Additionally, the relationship between abundance and occurrence was nonlinear and varied by species and season. Across species, locations prioritized by occurrence models had only 10-58% overlap with locations prioritized by abundance models, highlighting that occurrence models will not typically identify the locations of highest abundance that are vital for conservation of populations.

Documenting stewardship responsibilities across the annual cycle for birds on U.S. public lands.

In the face of global environmental change, the importance of protected areas in biological management and conservation is expected to grow. Birds have played an important role as biological indicators of the effectiveness of protected areas, but with little consideration given to where species occur outside the breeding season. We estimated weekly probability of occurrence for 308 bird species throughout the year within protected areas in the western contiguous USA using eBird occurrence data for the combined period 2004 to 2011. We classified species based on their annual patterns of occurrence on lands having intermediate conservation mandates (GAP status 2 and 3) administered by the Bureau of Land Management (BLM) and the United States Forest Service (USFS). We identified species having consistent annual association with one agency, and species whose associations across the annual cycle switched between agencies. BLM and USFS GAP status 2 and 3 lands contained low to moderate proportions of species occurrences, with proportions highest for species that occurred year-round or only during the summer. We identified two groups of species whose annual movements resulted in changes in stewardship responsibilities: (1) year-round species that occurred on USFS lands during the breeding season and BLM lands during the nonbreeding season; and (2) summer species that occurred on USFS lands during the breeding season and BLM lands during spring and autumn migration. Species that switched agencies had broad distributions, bred on high-elevation USFS lands, were not more likely to be identified as species of special management concern, and migrated short (year-round species) to long distances (summer species). Our findings suggest cooperative efforts that address the requirements of short-distance migratory species on GAP status 2 lands (n = 20 species) and GAP status 3 lands (n = 24) and long-distance migratory species on GAP status 2 lands (n = 9) would likely benefit their populations. Such efforts may prove especially relevant for species whose seasonal movements result in associations with different environments containing contrasting global change processes and management mandates.

Single institution review of Mini-ACE® low-profile appendicostomy button for antegrade continence enema administration.

PURPOSE: Malone antegrade continence enemas (MACE) provide a conduit in which the patient can achieve improved continence, be clean of stool, and gain independence in maintaining bowel function. The Mini-ACE® is a low-profile balloon button that is used to facilitate the administration of antegrade enemas. We sought to describe our practice and short-term outcomes. METHODS: This work is a retrospective review of the Mini-ACE® appendicostomy button from April 2019 to March 2021, with follow-up concluding in October 2021. Patient demographics, colorectal diagnoses, and outcomes were examined. RESULTS: Forty-three patients underwent Mini-ACE® placement; 22 (51%) were male. The average age at Mini-ACE® insertion was 9.2 years (range 3-20 years). The most common diagnoses were functional constipation in 19 (44%), anorectal malformation in 15 (35%), and Hirschsprung disease in 3 (7%), spinal differences 3 (7%). There were no intra-operative complications, but 5 (12%) required prolapse resection. The median length of stay was two days (IQR 1, 4). Patients achieved self-catheterization at 4.5 [3,7] months from MACE creation, with 38 children (88%) reporting excellent success in remaining clean of stool. CONCLUSION: The Mini-ACE® appears to be a safe and low-profile option for antegrade continence enema access. Further research is needed directly comparing complications and patient satisfaction rates between different MACE devices and overall quality of life. LEVEL OF EVIDENCE: Level IV.

A role for the NAD-dependent deacetylase Sirt1 in the regulation of autophagy.

We demonstrate a role for the NAD-dependent deacetylase Sirt1 in the regulation of autophagy. In particular, transient increased expression of Sirt1 is sufficient to stimulate basal rates of autophagy. In addition, we show that Sirt1(-/-) mouse embryonic fibroblasts do not fully activate autophagy under starved conditions. Reconstitution with wild-type but not a deacetylase-inactive mutant of Sirt1 restores autophagy in these cells. We further demonstrate that Sirt1 can form a molecular complex with several essential components of the autophagy machinery, including autophagy genes (Atg)5, Atg7, and Atg8. In vitro, Sirt1 can, in an NAD-dependent fashion, directly deacetylate these components. The absence of Sirt1 leads to markedly elevated acetylation of proteins known to be required for autophagy in both cultured cells and in embryonic and neonatal tissues. Finally, we show that Sirt1(-/-) mice partially resemble Atg5(-/-) mice, including the accumulation of damaged organelles, disruption of energy homeostasis, and early perinatal mortality. Furthermore, the in utero delivery of the metabolic substrate pyruvate extends the survival of Sirt1(-/-) pups. These results suggest that the Sirt1 deacetylase is an important in vivo regulator of autophagy and provide a link between sirtuin function and the overall cellular response to limited nutrients.

Esophageal Atresia: State of the Art in Translating Experimental Research to the Bedside.

Long-gap esophageal atresia is one of the most challenging diseases in the field of pediatric surgery. There is no optimal therapy, and thus many potential therapies and techniques are being actively explored, both in animal models and in neonates. This article will review the available experimental treatment options with a focus on novel techniques.

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia.

BACKGROUND: Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept. METHODS: Five pigs weighing between 35 and 65 kg were used. In all pigs, a percutaneous endoscopic gastrostomy (PEG) tube was placed, and a right thoracotomy was performed. Esophageal atresia was simulated by transecting the esophagus with a cutting stapler, and magnets were placed endoscopically to approximate the two ends of the esophagus. In the first pig, the tissue within the magnetic ring was excised endoscopically to achieve immediate patency. In the second pig, approximation of the blind esophageal ends was reinforced with 3-4 externally-placed sutures but immediate patency was not performed. In the last three pigs, both external suture reinforcement and immediate patency were performed. The pigs survived for 10-14 days and received nutrition through PEG tube. At necropsy, an esophagram was performed, the specimen was explanted and a leak test was performed. RESULTS: The first pig died in the early postoperative period from a leak owing to separation of the magnets. The second pig died from aspiration before the anastomosis formed. The last three pigs survived until the study endpoint. The third pig had a contained leak owing to the staple line being placed between the magnets; this was not clinically significant. The last two pigs had well-formed anastomoses. Burst tests showed no leak when injecting saline up to 30 mmHg. CONCLUSION: Magnamosis is technically feasible for esophagoesophageal anastomoses. A survival model for pure esophageal atresia was developed and refined in pigs. Further work in this area may lead to clinical use in humans.

Telemedicine in pediatric surgery.

IMPORTANCE: Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. OBJECTIVE: To review the current spectrum, potential strategies, and implementation process of telemedicine in pediatric surgery. DESIGN: Review and opinion design. SETTING: n/a. PARTICIPANTS: n/a. MAIN OUTCOMES AND MEASURES: n/a. RESULTS: n/a. CONCLUSIONS AND RELEVANCE: Telemedicine is an emerging approach with the potential to facilitate efficient, cost-effective delivery of pediatric surgical services. BRIEF ABSTRACT: Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. The objectives of this review are to explore common terms in telemedicine, provide an overview of current legislative and billing guidelines, review the current state of telemedicine in surgery and pediatric surgery, and provide basic themes for successful implementation of a pediatric surgical telemedicine program. TYPE OF STUDY: Review. LEVEL OF EVIDENCE: Level V.

Prospective observational study to assess the need for postoperative antibiotics following surgical incision and drainage of skin and soft tissue abscess in pediatric patients.

BACKGROUND: Post-operative antibiotics are often utilized for skin and soft tissue infection (SSTI) requiring surgical incision and drainage (I&D). We propose that antibiotics are unnecessary following I&D. METHODS: Patients aged 3months to 6years with SSTI of the buttocks, groin, thigh, and/or labia requiring I&D were prospectively enrolled. The primary outcome was the proportion of patients requiring re-drainage and/or antibiotics for SSTI recurrence, within 30days. Follow-up consisted of a 30-day phone call, with optional 2-week office visit, combined with chart review for patients lost to follow-up. A one-sample binomial proportion with 95% confidence interval (CI) was used to examine non-inferiority for rate of treatment success, using previously published success rates for patients receiving antibiotics post-operatively (95.9%, with a 7% margin of equivalence). RESULTS: A total of 92 patients were enrolled. All patients received pre-operative antibiotics. There was one treatment failure (success rate 0.989, CI 0.941-0.999). The recurrence rate was noninferior to previously-published data for patients receiving postoperative antibiotics (p<0.001). Subgroup analysis of patients who completed 30-day follow-up yielded a success rate of 0.973, CI 0.858-0.999 and evidence of non-inferiority (p=0.04). CONCLUSIONS: Post-operative management excluding antibiotics should be considered for patients who undergo I&D for SSTI. LEVEL OF EVIDENCE: Level II (prospective cohort study with <80% follow-up).

Creation of an Esophageal Atresia Animal Model Using a Bifurcated Esophagus to Maintain Digestive Tract Continuity.

INTRODUCTION: We previously developed a porcine model of long gap pure esophageal atresia (EA) to aid in the creation of novel devices and techniques for treatment of EA. Shortcomings of the model included difficulty decompressing the proximal esophageal pouch (leading to recurrent aspiration) and a requirement for gastrostomy tube (G-tube) feeds. Therefore, we sought to create a porcine model with a bifurcated esophagus wherein one portion of the esophageal lumen retained patency and the other part mimicked EA. METHODS: After G-tube placement, thoracotomy was performed with subsequent partial stapled transection of the esophagus in a transverse manner, followed by longitudinal, partial stapled transection of the esophagus proximally and distally. Magnets were placed in the esophageal pouches. RESULTS: Proximal and distal esophageal pouches were created while preserving a parallel, narrower segment of continuous esophagus. G-tube feeds were used initially, but the animal ultimately tolerated full nutrition by mouth. The magnets successfully restored esophageal continuity. The animal regained much of the initial weight lost and survived to planned euthanasia. Necropsy revealed anastomosis formation without evidence of leak. CONCLUSIONS: A bifurcated porcine esophagus model was successfully devised, simulating EA while allowing the animal to receive oral feeds and clear oral secretions. This model is anticipated to promote animal well-being and ease of care during future investigations, as well as a platform for the safe development of new therapies for EA.

Assessing the Adequacy of Absorbable Braided Suture for Laparoscopic High Ligation in Rabbits.

PURPOSE: Our previous work demonstrated that intentional peritoneal injury reduces the incidence of recurrence of a patent processus vaginalis even after removal of the suture. Therefore, the necessity of permanent suture has been brought into question because of the risk of suture granuloma formation. The purpose of this study was to evaluate the efficacy of absorbable, braided versus permanent, braided suture in a rabbit survival model of laparoscopic percutaneous ligation of the processus vaginalis with intentional peritoneal injury. MATERIALS AND METHODS: Eighteen New Zealand White rabbits underwent bilateral subcutaneous endoscopically assisted ligation (SEAL) of the internal ring. Before SEAL, peritoneal injury was caused with endoscopic shears. Each animal was randomized to receive absorbable braided suture on one side and permanent braided suture on the contralateral side. The rabbits were survived for 8 weeks to allow for complete hydrolysis of the absorbable suture. Necropsy was performed during which the integrity of the repair was assessed with insufflation of carbon dioxide up to 30 mm Hg. McNemar's test for paired data was performed for statistical analysis. RESULTS: Seventeen rabbits survived 8 weeks. One rabbit died in the early postoperative period because of urinary tract obstruction. After insufflation, four (24%) recurrences were present in the absorbable group and two (12%) recurrences were present in the permanent group. This difference was not statistically significant (P = .50). Both rabbits with a recurrence on the side with permanent suture also had a recurrence with absorbable suture on the contralateral side. In all rabbits, the permanent suture was identified, whereas there was no visual evidence of absorbable suture. CONCLUSIONS: A trend toward a higher recurrence rate with the use of absorbable braided suture was present, although, in this study, the finding was not statistically significant. Caution should be used when considering implementation of absorbable suture for laparoscopic inguinal hernia repair.

Dynamic conservation for migratory species.

In an era of unprecedented and rapid global change, dynamic conservation strategies that tailor the delivery of habitat to when and where it is most needed can be critical for the persistence of species, especially those with diverse and dispersed habitat requirements. We demonstrate the effectiveness of such a strategy for migratory waterbirds. We analyzed citizen science and satellite data to develop predictive models of bird populations and the availability of wetlands, which we used to determine temporal and spatial gaps in habitat during a vital stage of the annual migration. We then filled those gaps using a reverse auction marketplace to incent qualifying landowners to create temporary wetlands on their properties. This approach is a cost-effective way of adaptively meeting habitat needs for migratory species, optimizes conservation outcomes relative to investment, and can be applied broadly to other conservation challenges.

Use of 5-mm Laparoscopic Stapler to Perform Open Small Bowel Anastomosis in a Neonatal Animal Model.

PURPOSE: While adult bowel anastomoses are typically performed with staplers, neonatal small bowel anastomoses have traditionally been performed in a hand-sewn manner due to the large size of surgical staplers. The purpose of this study was to compare stapled anastomosis using a newly available, 5-mm laparoscopic stapler to a hand-sewn anastomosis in an open animal model. METHODS: Twenty anastomoses were performed by two general surgery residents (10 stapled and 10 hand-sewn) in an adult New Zealand white rabbit. The small bowel was divided with a scalpel. Surgical technique was alternated between single-layer hand-sewn and stapled anastomoses. Each anastomosis was resected for ex vivo testing. Measurements collected were outer diameter of the bowel before division, time to perform the anastomosis, anastomosis inner diameter (ID), and leak test. IDs were measured by cutting the anastomosis in cross-section, taking a photograph, and measuring the diameter by computer software. In addition, the surgeons qualitatively evaluated the anastomoses for hemostasis and overall quality. Statistical significance was determined using the Student's t-test. RESULTS: There were statistically significant differences between stapled and hand-sewn anastomosis, respectively, for average operative time (4 minutes 2 seconds versus 16 minutes 6 seconds, P < .01) and anastomosis ID (8.2 versus 3.7 mm, P < .01). There was one leak in the stapled group, which occurred at overlapping staple lines closing the enterotomy. A second stapled anastomosis required suture reinforcement, again at the enterotomy closure, due to operator error. Starting diameter, leak rate, hemostasis, and anastomosis quality were not statistically significant. CONCLUSION: In a neonatal open animal model, a 5-mm stapled anastomosis is an acceptable alternative to hand-sewn small bowel anastomosis. The stapler is faster and creates a larger diameter anastomosis, however, there was one leak when closing the enterotomy in the stapled group and overlapping staple lines should be avoided.

Pediatric surgery - a changing field: national trends in pediatric surgical practice.

BACKGROUND: Over the last decade, our institution has experienced a relative increase in the number of mundane cases, such as appendectomy and incision and drainage of abscess, versus index (complex) cases. We sought to determine if this trend is present at the national level. METHODS: A retrospective review of surgical case volume at 36 freestanding children's hospitals was performed between January 2004 and December 2013 using the Pediatric Health Information System (PHIS) database. Procedures were classified as "mundane" or "index", and 10 procedures of each type were selected for analysis. Results were reported as a percentage of total cases. Statistical analysis of linear trends was performed with the Mann-Kendall test. RESULTS: Overall, index procedures had a significant downward trend (p<0.01), whereas mundane procedures had a significant upward trend (p<0.01). Individually, 5 mundane procedures had significant upward trends, and 3 had downward trends. Five index procedures had significant downward trends, and none had an upward trend. CONCLUSION: The field of pediatric surgery is undergoing change with mundane procedures constituting an increasing proportion of the surgical caseload, while complex procedures are proportionately decreasing. These trends may be useful to inform decisions regarding future pediatric surgery workforce planning.

Trans-Atlantic Telementoring with Pediatric Surgeons: Technical Considerations and Lessons Learned.

PURPOSE: Although surgical residency training is a structured, regulated system for surgical skill acquisition, after residency or fellowship, no good method exists for practicing surgeons to learn new, developing techniques. Because 1-2-day simulation courses are probably inadequate for teaching a new technique and because it is often unrealistic for a practicing surgeon to leave his or her practice for an extended period of time, surgical telementoring may be a solution by allowing an expert to support a trained surgeon through the learning curve of a new procedure while overcoming geographic distance. In the past we have presented 6 cases of transcontinental telementoring with pediatric surgeons in the United States. We have since expanded the concept to trans-Atlantic telementoring and performed 2 cases with pediatric surgeons in France. MATERIALS AND METHODS: The two telementors and one of the two telementees had previously met through a professional society but had never operated together before this experience. The first procedure was an interval laparoscopic appendectomy to test the process. The second procedure was a thoracoscopic total thymectomy. The technology consisted of the VisitOR1® telementoring robot (Karl Storz GmbH & Co. KG, Tuttlingen, Germany). RESULTS: Both procedures were completed successfully with high satisfaction from both the telementors and telementees. Latency was low, and there was no loss of connection. The telestration and laser pointer features of the robot facilitated the telementoring experience. Challenges included lack of a prior surgical relationship between the mentees and mentors that limited the depth of advice but did not impair the quality of the surgery, as well as poor audio quality that was overcome using headsets. CONCLUSIONS: From this experience, several challenges were identified and addressed. Telementoring may be an effective means of improving adoption of new surgical techniques, ultimately improving patient care.