Survey on Robot-Assisted Surgical Techniques Utilization in US Pediatric Surgery Fellowships

Contemporary Trends in Laparoscopy and Ovarian Sparing Surgery for Ovarian Torsion in the Pediatric Population

PURPOSE

Although total oophorectomy (TO) was historically performed in cases of nonviable-appearing ovaries, considerable evidence has demonstrated equivalent outcomes after ovarian sparing surgery (OSS) as well as long-term fertility preservation benefits. This study sought to compare outcomes of OSS and TO for patients with ovarian torsion.

METHODS

Females <21 years old admitted for ovarian torsion were identified from the Nationwide Readmissions Database (2016-2018) and stratified by OSS or TO. Propensity score-matched analysis (PSMA) utilizing >50 covariates (demographics, medical comorbidities, ovarian diagnoses, etc.) was constructed between those receiving TO and OSS.

RESULTS

There were 3,161 females (median 15 [12-18] years) with ovarian torsion, and concomitant pathologies included cysts (42%), benign masses (25%), and malignant masses (<1%). Open approaches were more common (52% vs. 48% laparoscopic), and ovarian resection (OSS or TO) was performed in 87% (39% OSS and 48% TO). OSS was more commonly performed with laparoscopic detorsions (60% vs. 40% TO), while TO was more frequent in open operations (59% vs. 41% TO; both p < 0.001). No differences in overall readmissions (7% OSS vs. 8% TO) or readmissions for recurrent torsion (<1% overall) and ovarian masses (<1%) were observed (both groups <1%; p = 0.612). After PSMA, laparoscopy was still utilized less frequently with TO (39% vs. 53%; p < 0.001) despite similar rates of malignant masses.

CONCLUSIONS

Overall, these data offer additional support for the current practice guidelines that give preference to OSS as the primary method of treatment for pediatric ovarian torsion in the majority of cases.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study.

Learning Curves in Pediatric Robot-Assisted Pyeloplasty: A Systematic Review

Background: Robot-assisted surgery demands a specific skillset of surgical knowledge, skills, and attitudes from the robotic surgeon to function as part of the robotic team and for maximal utility of the assistive surgical robot. Subsequently, the learning process of robot-assisted surgery entails new modes of learning. We sought to systematically summarize the published data on pediatric robot-assisted pyeloplasty (pRALP) to decipher the learning process by analyzing learning curves. Methods: This review followed the PRISMA guidelines. PubMed, EMBASE, Web of Science, and Scopus databases were systematically searched for ‘learning curve’ AND ‘pediatric pyeloplasty’. All studies presenting outcomes of learning curves (LC) in the context of pRALP in patients < 18 years of age were included. Studies comparing LC in pRALP versus open and/or laparoscopic pyeloplasty were also included; however, those solely focusing on LC in non-robotic approaches were excluded. The methodological quality was assessed using the Newcastle and Ottawa scale. Results: Competency was non-uniformly defined in all fifteen studies addressing learning curves in pRALP. pRALP was considered safe at all stages. Proficiency in pRALP was reached after 18 cases, while competency was estimated to demand 31 operated cases with operative duration as outcome variable. Conclusions: Pediatric RALP is safe during the learning process and ‘learning by doing’ improves efficiency. Competencies with broader implications than time must be defined for future studies.

Multiple perceptions of robotic-assisted surgery among surgeons and patients: a cross-sectional study

Limited data exist regarding knowledge and perceptions of surgeons and patients about robotic-assisted surgery (RAS) in the Middle East. This study aimed to explore perceptions of surgeons and patients about RAS. A questionnaire-based survey was distributed among surgeons of different specialties and patients. Between March and September 2019, 278 and 256 surveys were completed by surgeons and patients, respectively (95.2% and 94.8% response rate, respectively). The surgeons' self-reported experience with technology was related to the level of comfort with computers and computer literacy. Most surgeons have heard of RAS availability, and the majority agreed to its introduction into the healthcare system. However, only 75 (27%) of the surgeons thought that the surgeon has complete control over the robot, and 69 (25%) surgeons were not sure of the level of control the surgeon has over the robot reflecting poor knowledge about this technology. Less than a third of patient respondents have heard of RAS. However, half of them would consider it should they need to undergo surgery. When compared to open surgery, 23 (9%), 26 (10%), and 94 (37%) patient respondents thought that RAS caused less pain, had fewer complications, and was faster than conventional surgery, respectively. Knowledge and perceptions about RAS are limited among surgeons and patients in Kuwait. Efforts should focus on increasing awareness.

Retroperitoneal mesothelial cyst misdiagnosed as a congenital choledochal cyst for an infant patient: A case report and literature review

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Mesothelial cyst (MC) is very uncommon in clinic, which could occur in peritoneal, retroperitoneal or even pleural cavity.

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Retroperitoneal MC around hepatoduodenal ligament for an infant has never been reported before.

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We hereby described an infant patient with retroperitoneal MC who was misdiagnosed as congenital choledochal cyst.

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A local resection for the whole lesion under the da Vinci surgical system was unexpectedly performed during the operation.

Introduction

Mesothelial cyst (MC) is very uncommon in clinic, which could occasionally occur in peritoneal, retroperitoneal or even pleural cavity.

Presentation of case

We hereby described an infant patient with retroperitoneal MC who was misdiagnosed as congenital choledochal cyst by both radiologists and clinicians. A choledochal cyst resection with hepatojejunostomy under the da Vinci surgical system was routinely prepared for this patient but a local resection for the whole lesion was unexpectedly performed during the operation. The diagnosis of retroperitoneal MC was confirmed by the pathological analysis from surgical specimens.

Discussion

MC in small size is usually asymptomatic and sometimes detected by imaging examinations which manifests a well-boundary, watery-density and cystic lesion with no enhancement and is often misdiagnosed as lymphangioma or pancreatic pseudocyst. For pediatric patients, MC can occur in the diaphragm and liver in the literature, while retroperitoneal MC around hepatoduodenal ligament for an infant has never been mentioned before. We reported the first case of a retroperitoneal MC around hepatoduodenal ligament for an infant who was preoperatively misdiagnosed as choledochal cyst surgically treated by the da Vinci surgical system.

Conclusion

Retroperitoneal MC around hepatoduodenal ligament should also be considered and resected for an infant.

Robotic Approach for Median Arcuate Ligament Release in Pediatrics

Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.

Who moved my fellow: changes to Accreditation Council for Graduate Medical Education fellowships in pediatric surgery and what may be yet to come

PURPOSE OF REVIEW

Over the past 15 years, the Accreditation Council for Graduate Medical Education (ACGME) has significantly altered the regulatory framework governing fellowship training in pediatric surgery. The daily experiences of pediatric surgical trainees have been impacted by these changes, but training program directors and faculty have not developed a consistent approach to managing this shift. This review highlights the changes, which have occurred, analyzes the current state of fellowship training, and proposes potential strategies for management.

RECENT FINDINGS

The implementation of work hour restrictions, increased supervision requirements, the milestone evaluation program and most recently, enforcement of required critical care experience, have caused significant changes in the curriculum. Pediatric surgical trainees record more total cases, and more minimally invasive surgical (MIS) cases, in particular, than ever before. A subset of this increase may result from trainees performing cases previously assigned to general surgery residents. Teaching cases performed by fellows have decreased. Although the relationship between these shifts in training experience and the didactic curriculum is not clear, we also note that the Pediatric Surgery Certifying Examination failure rate has increased, approaching 20% in recent years.

SUMMARY

It is unclear whether the changes in Pediatric Surgery training programs have been effective, or (conversely) have led to unintended consequences. Paradigm shifts in our training model may be required to address the changes in surgical education and skill acquisition, so that well tolerated, competent and skillful pediatric surgeons continue to enter the workforce.