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Laparoscopic common bile duct exploration (LCBDE) decreases overall costs and length of stay in patients with choledocolithiasis. However, utilization of LCBDE remains low. We sought to evaluate a previously developed general surgery LCBDE simulator among a cohort of pediatric surgical trainees. The study purpose was to evaluate the content validity of an LCBDE simulator to support or refute its use in pediatric surgery education.After IRB exempt determination, 30 participants performed a transcystic LCBDE using a previously developed simulator and evaluated the simulator using a self-reported 28-item instrument. The instrument consisted of two primary domains (Quality and Ability to Perform) that were rated using twenty-five 4-point rating scales and one 4-point global rating scale. Validity evidence relevant to test content was evaluated using a many-facet Rasch model. Interitem consistency was estimated using Cronbach's alpha. P .05 was considered statistically significant.The highest combined observed averages were for the Value subdomain (OA = 3.79), whereas the lowest ratings were for the Physical/visual attributes subdomain (OA = 3.19). The averaged global rating was 3.14, consistent with this simulator can be considered for use in pediatric LCBDE training, but could be improved slightly. Rasch indices were favorable and supported evidence relevant to test content. Interitem consistency estimates were also favorable, with α values of 0.94 and 0.56 for Qualities and Ability, respectively.Overall, participants rated the LCBDE simulator highly valuable for pediatric surgical education and felt that it could be used as an educational tool with minor modifications.

Thoracoscopic repair of a congenital diaphragmatic hernia (CDH) in the neonate is controversial due to reports of increased hernia recurrence. A multicenter review on thoracoscopic CDH repair was conducted to evaluate outcomes and to identify factors that are associated with recurrence.A multicenter retrospective review was conducted from 2009 to 2015 in neonates who were treated for CDH with thoracoscopic repair. Demographics, preoperative, intraoperative, including repair techniques, and postoperative variables were analyzed by using descriptive statistics. Comparative analysis was performed between those patients who were repaired entirely thoracoscopically with hernia recurrence and those without.One hundred nine infants, of whom 57% were male with an average gestational age at time of surgery of 39.6 ± 4.6 weeks and a weight of 3.4 ± 1.1 kg, were included. The median age at repair was 5 days (range: 3-9), 61% patients required vasopressor support, and 1.8% patients required extracorporeal membrane oxygenation (ECMO) cannulation before repair. Forty-five percent were repaired on high-frequency oscillatory ventilation (HFOV). Repair was completed thoracoscopically in 83 patients (76%), 68 (82%) were repaired primarily, 15 (18%) were repaired with a patch, and 50 (60%) had extracorporeal/rib fixation sutures. Recurrence occurred in 7 (8.4%) of those completed thoracoscopically. Factors found to be significant for recurrence included: vasopressor therapy (P = .02), repair on HFOV (P = .04), and the presence of the spleen in the chest (P = .04). There was no significant difference identified between technical variations in repair.These data suggest that thoracoscopic repair of CDH is feasible in carefully selected patients. However, there is currently no evidence to support a standardized surgical approach to thoracoscopic repair.

Mandates for improved patient safety and increasing work hour restrictions have resulted in changes in surgical education. Educational courses increasingly must meet those needs. We sought to determine the experience, skill level, and the impact of simulation-based education (SBE) on two cohorts of pediatric surgery trainees.After Institutional Review Board (IRB) exempt determination, a retrospective review was performed of evaluations for an annual advanced minimally invasive surgery (MIS) course over 2 consecutive years. The courses included didactic content and hands-on skills training. Simulation included neonatal/infant models for rigid bronchoscopy-airway foreign body retrieval, laparoscopic common bile duct exploration, and real tissue diaphragmatic hernia (DH), duodenal atresia (DA), pulmonary lobectomy, and tracheoesophageal fistula models. Categorical data were analyzed with chi-squared analyses with t-tests for continuous data.Participants had limited prior advanced neonatal MIS experience, with 1.95 ± 2.84 and 1.16 ± 1.54 prior cases in the 2014 and 2015 cohorts, respectively. The 2015 cohort had significantly less previous experience in lobectomy (P = .04) and overall advanced MIS (P = .007). Before both courses, a significant percentage of participants were not comfortable with DH repair (39%-42%), DA repair (50%-74%), lobectomy (34%-43%), and tracheoesophageal fistula repair (54%-81%). After course completion, 60% of participants reported improvement in comfort with procedures and over 90% reported that the course significantly improved their perceived ability to perform each operation safely.Pediatric surgery trainees continue to have limited exposure to advanced MIS during clinical training. SBE results in significant improvement in both cognitive knowledge and trainee comfort with safe operative techniques for advanced MIS.

Thoracoscopic lobectomy in infants requires advanced minimally invasive skills. Simulation-based education has the potential to improve complex procedural skills without exposing the patient to undue risks. The study purposes were (1) to create a size-appropriate infant lobectomy simulator and (2) to evaluate validity evidence to support or refute its use in surgical education.In this Institutional Review Board-exempt study, a size-appropriate rib cage for a 3-month-old infant was created. Fetal bovine tissue completed the simulator. Thirty-three participants performed the simulated thoracoscopic lobectomy. Participants completed a self-report, 26-item instrument consisting of 25 4-point rating scales (from 1=not realistic to 4=highly realistic) and a one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (inter-item consistency) was estimated using Cronbach's alpha.Experienced surgeons (observed average=3.6) had slightly higher overall rating than novice surgeons (observed average=3.4, P=.001). The highest combined observed averages were for the domain Physical Attributes (3.7), whereas the lowest ratings were for the domains Realism of Experience and Ability to Perform Tasks (3.4). The global rating was 2.9, consistent with "this simulator can be considered for use in infant lobectomy training, but could be improved slightly." Inter-item consistency for items used to evaluate the simulator's quality was high (α=0.90).With ratings consistent with high physical attributes and realism, we successfully created an infant lobectomy simulator, and preliminary evidence relevant to test content, response processes, and internal structure was supported. Participants rated the model as realistic, relevant to clinical practice, and valuable as a learning tool. Minor improvements were suggested prior to its full implementation as an educational and testing tool.

Thoracoscopic diaphragmatic hernia (DH) repair has a high recurrence rate. Effective simulation modeling may improve technical performance for thoracoscopic DH repair. The study purpose was to evaluate measures of validity evidence for a low-cost thoracoscopic DH simulator.Synthetic diaphragm/intestine was connected to a to-scale left-sided neonatal rib cage and then covered with synthetic skin. Forty participants evaluated the DH repair simulator, using survey ratings that were analyzed for test content and internal structure validity evidence.Observed averages (on a scale of 0-5) for the domains were 4.6 for Relevance, 4.5 for Value, 4.3 for Physical attributes, 4.0 for Realism of experience, 3.8 for Realism of materials, and 4.2 for Ability to perform. The highest observed averages were "relevance to practice" and "value, testing tool," whereas the lowest ratings were realism, intestines and realism, diaphragm. The observed average of global opinion ratings was 2.84/4.0, indicating the simulator can be considered for teaching thoracoscopic DH repair but could be improved. Experienced surgeons (more than eight DH repairs, at least four thoracoscopic repairs) had higher overall ratings than inexperienced surgeons (4.4 versus 4.1, P=.001).We successfully created a thoracic space relevant to a thoracoscopic DH repair and completed the model using inexpensive, readily accessible materials. After participants performed a simulated thoracoscopic DH repair, their ratings indicated the simulator was relevant to clinical practice and valuable as a learning tool but still requires improvements. Improvements and additional evaluation of validity evidence (content, internal structure, response processes, and relationship to other variables) are necessary prior to full implementation of this model as an educational tool.

Gastrostomy tube placement is associated with frequent postoperative complications. The aims of this study were to 1) determine the incidence of postoperative gastrostomy complications and 2) determine if patient demographics, comorbidities, or operative technique could predict these complications.A retrospective review was conducted on children who underwent gastrostomy tube placement from June 2006 through August 2009. Patient demographics, comorbidities, operative technique, health care visits, and complications were collected. Data were analyzed by chi-squared analysis (P 0.05 significant).One hundred and fifty-nine patients were evaluated, with the majority of patients5 years of age (129/159). Ninety-four patients underwent open gastrostomy, 31 laparoscopic gastrostomy, and 34 laparoscopic-assisted gastrostomy. Granulation tissue was the most common postoperative complication, occurring in 58% of patients (93/159). The majority of patients with granulation tissue had full resolution by the fourth postoperative month. Tube dislodgement was the second most common complication, occurring 69 times in 44 of the patients (28%) and resulting in 59 emergency department (ED) visits. Overall, gastrostomy complications resulted in 100 ED and 462 clinic visits. Ninety-three percent (93/100) of ED visits resulted in discharge home from the ED. Gender, age, insurance status, and operative technique were not predictive of complications.Granulation tissue and tube dislodgement are the most common complications after gastrostomy placement in children. Gender, age, insurance status, and operative technique were not predictive of complications. Emergency department utilization is high in children with gastrostomy tubes.

During repair for duodenal atresia, it has been emphasized that inspection of the small bowel to identify a second atresia is required. The laparoscopic approach for repair of duodenal atresia has been criticized for its limitation to perform this step. Given that duodenal atresia and jejunoileal atresias do not share common embryologic origins, we question the validity of this concern. Therefore, we conducted a multicenter retrospective review of duodenal atresia patients to quantify the incidence of jejunoileal atresia in this population.After institutional review board approval (IRB #07-12-187X), a retrospective review was conducted on all patients who have undergone duodenal atresia repair at seven institutions over the past 7-12 years. Demographics and the presence or absence of a jejunoileal atresia were recorded.Four hundred eight patients with duodenal atresia were identified. The mean gestaational age was 36.3 ± 2.9 weeks, and the mean weight was 2.5 ± 0.8 kg. Mean age at operation was 19 days (range, 1-1314). There was a 28% incidence of trisomy 21. Two patients (0.5%) were identified as having a second intestinal atresia, and both were type IIIb. One patient was diagnosed at the time of duodenal atresia repair; the other was a delayed diagnosis. Both patients did well after repair.In this, the largest series of duodenal atresia patients compiled to date, the rate of a concomitant jejunoileal atresia is less than 1%. This low incidence is not high enough to mandate extensive inspection of the entire bowel in these patients, and a second atresia should not be a concern during laparoscopic repair of duodenal atresia.