Open and laparoscopic inguinal hernia repair in children: A regional experience.

PURPOSE: The optimal approach for pediatric inguinal hernia repair continues to be debated. We conducted a regional retrospective study to assess rates of recurrence and metachronous hernias after open repair (OPEN) and laparoscopic repair (LAP) METHODS: A retrospective cohort study was conducted at two children's hospitals that serve a region of approximately 4 million people. All patients < 14 years old undergoing OPEN or LAP by pediatric surgeons during a 5-year period (2011 - 2015) were analyzed after a minimum follow up of 4 years. Cox proportional regression was used to compare the effect of surgical approach on hernia recurrence and metachronous contralateral hernias. RESULTS: A total of 1,952 patients, 587 female (30%) and 1365 male (70%), had 2305 hernias repaired. Median post operative follow up time was 6.6 years (range 4-9 years). OPEN and LAP were performed for 1827 (79%) and 478 (21%) hernias, respectively. There were no significant differences in rate of prematurity, age at repair, or frequency of emergent repair. LAP was associated with a lower incidence of metachronous contralateral hernias compared to OPEN (1.4% vs 3.8%, p = 0.047), and a higher incidence of recurrence (9% vs 0.9%, p < 0.001). After adjusting for confounders, LAP had a higher rate of recurrence than OPEN (hazard ratio 10.4, 95% CI 6-18.1).The recurrence rate did not decrease over the study period (p = 0.731). CONCLUSION: Laparoscopic inguinal hernia repair in children resulted in a modest decrease in the incidence of metachronous hernias, at the cost of a significant increase in recurrence. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Hand Sewn Anastomosis Skill Acquisition and In Vivo Transfer Using 3D-Printed Small Bowel Simulator.

INTRODUCTION: General surgery residents need to master the hand-sewn bowel anastomosis (HSBA) technique. However, practice opportunities outside of the operating room are rare, and commercial simulators are often costly. The objective of this study is to assess the efficacy of a new, affordable silicone small bowel simulator, made with a three-dimensional (3D) printed mold, as a training tool to learn this technique. METHODS: This was a single-blinded pilot randomized controlled trial comparing two groups of eight junior surgical residents. All participants completed a pretest using an inexpensive, custom developed 3D-printed simulator. Next, participants randomized to the experimental group practiced the HSBA skill at home (eight sessions), while those randomized to the control group did not receive any hands-on practice opportunities. A posttest was done using the same simulator as for the pretest and practice sessions, and the retention-transfer test was performed on an anesthetized porcine model. Pretests, posttests and retention-transfer tests were filmed and graded by a blinded evaluator using assessments of technical skills, quality of final product, and tests of procedural knowledge. RESULTS: The experimental group significantly improved after practicing with the model (P = 0.01), while an equivalent improvement was not noted in the control group (P = 0.07). Moreover, the experimental group's performance remained stable between the posttest and the retention-transfer test (P = 0.95). CONCLUSIONS: Our 3D-printed simulator is an affordable and efficacious tool to teach residents the HSBA technique. It allows development of surgical skills that are transferable to an in vivo model.

Development and Initial Assessment of a Novel and Customized Bile Duct Simulator for Handsewn Anastomosis Training.

Simulation-based medical education allows for the training and maintenance of healthcare skills in a safe and controlled environment. In this technical report, the development and initial evaluation of a bile duct anastomosis simulator are described. The simulator was developed using additive manufacturing techniques such as three-dimensional (3D) printing and silicone work. The final product was produced by maxSIMhealth, a research lab at Ontario Tech University (Oshawa, ON, Canada), and included four individual silicone bile ducts, based on the expert opinions from surgeons at the Centre Hospitalier de l'Université de Montréal (Montreal, QC, Canada), and a 3D-printed maxSIMclamp, which was described in a previous report. The evaluation was conducted by nine individuals consisting of surgeons, surgical residents, and medical students to assess the fidelity, functionality, and teaching quality of the simulator. The results from the evaluation indicate that the simulator needs to improve its fidelity by being softer, thinner, and beige. On the other hand, the results also indicate that this simulator is extremely durable and can be used as a training tool for surgical residents with some minor improvements.

Bowel obstruction following pediatric abdominal cancer surgery.

INTRODUCTION: Pediatric bowel obstruction after intra-abdominal cancer surgery is relatively frequent. Few publications have specifically addressed this significant complication. The purpose of this study was to assess the frequency, etiology and treatment options of bowel obstructions following abdominal cancer surgery in children using our institutional database. MATERIALS AND METHODS: We retrospectively analyzed a single tertiary pediatric hospital database over a 10-year period. The clinical characteristics of patients with and without bowel obstruction were compared using bivariate analyses. The details of the conservative and operative management of bowel obstructions were evaluated. RESULTS: Out of 130 eligible patients, 18 (13.8%) developed bowel obstruction in a mean follow-up of 5.7 years. Patients who developed bowel obstruction were more likely to have received preoperative radiation therapy (16.7 vs 2.7%, p = 0.036) and had longer operative time (398 vs 268 min, p = 0.022). Non-operative management was successful in 39% of patients (7/18). When patients needed surgical intervention, minimally invasive approach was attempted and successfully performed in 36% of cases (4/11), none of which required conversion to laparotomy nor presented with recurrent bowel obstruction. CONCLUSION: Bowel obstruction is a frequent complication after abdominal cancer surgery in children. Conservative management is frequently successful. For patients requiring surgical treatment, laparoscopy remains a valuable option and should be considered in selected cases.

Development and Initial Assessment of a Novel Customized Deep Laceration Simulator for Suturing Training.

Suturing of different layers, such as deep lacerations, is a challenging clinical skill for residents. Currently, there is a lack of general suturing instructions and practice in undergraduate medicine curricula which would add to the education required during residency and could be impactful to patient safety. Therefore, in order to adequately prepare trainees for clinical practice, training in suturing needs to be made more robust and executable. One way to facilitate this is to provide easy access to equipment that can offer good educational value while allowing for adequate repetition of suturing deep lacerations outside of clinical settings, similar to how it has been done for superficial lacerations. Simulation-based medical education addresses this by training residents in healthcare skills in a safe and controlled environment. Our technical report aims to describe the development and initial evaluation of a deep laceration simulator designed to train residents in suturing. The simulator was made using additive manufacturing techniques such as three-dimensional printing and silicone. Feedback on the simulator was provided by Centre Hospitalier de l'Université de Montréal clinicians from various specialties and residents. The simulator was assessed mainly as being easy to use, durable, and having anatomically accurate characteristics. The main improvements suggested were to make the skin thinner, divide the epidermis and dermis, add a fascia, and create a looser and friable layer of fat. Overall, the respondents rated the simulator as a good educational tool with a few minor adjustments.

Development and Learner-Based Assessment of a Novel, Customized, 3D Printed Small Bowel Simulator for Hand-Sewn Anastomosis Training.

Hand-sewn bowel anastomosis (HSBA) is an essential skill for surgical residents to learn, as it is used in numerous surgical procedures. However, the opportunities to practice this skill before attempting it on patients are limited. Practice on simulators can help improve this technique, but there is a paucity of realistic, cost-efficient simulators for the acquisition of HSBA skills. This technical report describes the development of our simulator that consists of a small bowel manufactured from silicone and a 3D-printed clamp system to hold the bowel in place. Our simulator was co-designed by a clinical team of surgeons and then assessed for perceived acceptability and effectiveness by 16 junior residents in various surgical specialties at our faculty. A majority of the learners rated our simulator to be a good or very good learning tool for HSBA, although they suggested some minor improvements. Overall, our silicone small bowel model appears to be an effective and inexpensive way to acquire this surgical skill.

Multimodal Treatment Including Intracavitary Chemotherapy for Recurrent Pediatric Pleuropulmonary Blastoma.

Pleuropulmonary blastoma (PPB) is a rare pediatric cancer, and although there have been improvements in its treatment approach, recurrences retain a very poor prognosis. Here, we report a case of a 30-month-old female who survived recurrent PPB after undergoing surgery, adjuvant chemotherapy, intrapleural cisplatin infusion, and targeted therapy through whole exome sequencing (WES). Intrapleural cisplatin infusion and target therapy appear to be safe and can be considered in a multimodal approach for the management of recurrent PPB.