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Background/Purpose In Hirschsprung disease (HD) surgery, confirming ganglionic bowel is essential. A faster diagnostic method than the current frozen biopsy is desirable. This study investigated whether aganglionic and ganglionic intestinal wall can be distinguished from each other by ultra high frequency ultrasound (UHF ultrasound). Methods In an HD center during 2019, intestinal walls of recto-sigmoid specimens from HD patients were examined ex vivo with a 70 MHz UHF ultrasound transducer. Data from four sites were described. Histopathologic analysis was compared to the ultrasonography outcome at each site. Each patient's specimen served as its own control. Results 11 resected recto-sigmoid specimens (median 20 cm long [range 6.5–33]) with transition zones of 5 cm (2–11 cm) were taken from children aged 22 days (13–48) weighing 3668 g (3500–5508); 44 key sites were analyzed. There was full concordance for 42/44 (95%) key sites and 10 of 11 (91%) specimens. The specimen with discordance of two key sites contained a segment of aganglionosis (3 cm) and a transition zone (1 cm): the site discordance was limited to the transition zone ends. Conclusions This first report on UHF ultrasound in recto-sigmoid HD shows promising results in identifying aganglionosis, transition zones and ganglionic bowel. Further in vivo studies are required.

AIM Information about healthy children's urinary tract symptoms is scarce but would be helpful in children with congenital urinary tract conditions. The aim of this study was to develop and evaluate a Lower Urinary Tract Dysfunction (LUTD) questionnaire. METHODS A 15-item questionnaire based on definitions by the International Children's Continence Society (ICCS) about urinary tract function, was given to children 4-15 years old with no gastrointestinal or urinary tract conditions. The study was approved ethically. RESULTS The response rate was 82% (311/377), 50% (n = 155) were girls. Children were of the age groups 3.5-7 years (n = 136), 8-12 years (n = 127), and 13-15 years (n = 48). More girls than boys reported urinary tract infections (20% vs 3%, p

Background/aim: Diagnostic efficacy, defined as the percentage of rectal suction biopsy (RSB) specimens sufficient enough to determine the absence of ganglia cells in Hirschsprung’s disease (HD) diagnosis, has been reported to be low, requiring repeated biopsies. The aim was to explore whether RSB diagnostic efficacy was influenced by the child’s weight and to ascertain whether RSB efficacy differed between aganglionic and ganglionic tissue. Materials and Methods: Efficacy analyses were conducted in a national HD-center’s register on children 0–15 kg, examined between 2011–2019. First-time RSB diagnostic efficacy was correlated to the children’s weight and final HD diagnosis. Results: Among the 84 children who had first-time RSB, the overall diagnostic efficacy was 85% (71/84). The efficacy was higher among children weighing less than the identified cut-off of 9.0 kg (89% in 0–9.0 kg versus 62% in 9.01–15.0 kg, p = 0.026). Among children diagnosed with HD, 96% (26/27) weighed 0–9.0 kg. In this weight group, the diagnostic efficacy was lower in aganglionosis compared to ganglionosis (77%; 20/26 versus 96%; 43/45), p = 0.045). Conclusions: The RSB diagnostic efficacy was significantly higher in children weighing less than 9.0 kg and was less in aganglionic compared to ganglionic tissue. Therefore, weight can be useful to predict RSB diagnostic efficacy.

Diagnostic efficacy, defined as the percentage of rectal suction biopsy (RSB) specimens sufficient enough to determine the absence of ganglia cells in Hirschsprung's disease (HD) diagnosis, has been reported to be low, requiring repeated biopsies. The aim was to explore whether RSB diagnostic efficacy was influenced by the child's weight and to ascertain whether RSB efficacy differed between aganglionic and ganglionic tissue.Efficacy analyses were conducted in a national HD-center's register on children 0-15 kg, examined between 2011-2019. First-time RSB diagnostic efficacy was correlated to the children's weight and final HD diagnosis.Among the 84 children who had first-time RSB, the overall diagnostic efficacy was 85% (71/84). The efficacy was higher among children weighing less than the identified cut-off of 9.0 kg (89% in 0-9.0 kg versus 62% in 9.01-15.0 kg,The RSB diagnostic efficacy was significantly higher in children weighing less than 9.0 kg and was less in aganglionic compared to ganglionic tissue. Therefore, weight can be useful to predict RSB diagnostic efficacy.

Background/Purpose Urinary tract function in children with Hirschsprung disease (HD) is rarely considered. Aim: to evaluate the prevalence of urinary tract anomalies and dysfunction in children with HD compared to controls. Methods This was an observational cross sectional case–control study. Children with HD who underwent transanal endorectal pull-through technique (TERPT) from 2005 to 2017 were invited to participate. Ultrasound of the urinary tract was performed postoperatively. Children > 4 years were asked to answer a urinary tract function questionnaire. Controls were age-matched healthy children. Ethical approval was obtained. Results Seventy two children with HD and TERPT were included. Ultrasound was performed in 58 children (83%) post-TERPT. Ten anomalies were diagnosed in six children (10%). Structural anomalies included abnormal kidney size (7%), renal agenesis (2%), prominent calyces (2%) and renal pelvis anomaly (25). Probable acquired anomalies included hydronephrosis (2%), hydroureter (2%) and parenchymal damage (2%). One child had a prior nephrectomy owing to a Wilms' tumor. All 37 children > 4 years (27 boys and 10 girls), median aged 8 years (range 4–12), answered the questionnaire as did 284 healthy controls (144 boys and 140 girls). Boys with HD reported a higher frequency of enuresis: 65% versus 9% (p = 0.001) and urinary tract infections: 18% versus 3% (p = 0.012). Girls with HD reported enuresis more frequently (60%) than healthy girls (7%) (p = 0.001). Children with HD with constipation reported enuresis more frequently (p = 0.038). Conclusions Urinary tract anomalies and dysfunction deserve attention in the follow-up of children with HD. We suggest screening for urinary tract anomalies and urinary tract symptoms in follow-up of children with HD. Type of study Treatment study. Level III.

Background: The benefit of haptic feedback in laparoscopic virtual reality simulators (VRS) is ambiguous. A previous study found 32% faster acquisition of skills with the combination of 3 D and haptic feedback compared to 2 D only. This study aimed to validate perception and effect on performance of haptic feedback by experienced surgeons in the previously tested VRS. Material and methods: A randomized single blinded cross-over study with laparoscopists (>100 laparoscopic procedures) was conducted in a VRS with 3 D imaging. One group started with haptic feedback, and the other group without. After performing the suturing task with haptics either enabled or disabled, the groups crossed over to the opposite setting. Face validity was assessed through questionnaires. Metrics were obtained from the VRS. Results: The haptics for ‘handling the needle’, ‘needle through tissue’ and ‘tying the knot’ was scored as completely realistic by 3/22, 1/22 and 2/22 respectively. Comparing the metrics for maximum stretch damage between the groups revealed a significantly lower score when a group performed with haptics enabled p = .027 (haptic first group) and p Conclusion: Haptic feedback in VRS has limited fidelity according to the tested laparoscopic surgeons. In spite of this, significantly less stretch damage was caused with haptics enabled.

Anorectal malformations (ARM) are a spectrum of congenital malformations, specifically defined by the absence of a normal anal opening. These conditions are treated surgically by posterior sagittal anorectoplasty and, in cases with perineal fistulas, perineal skin advancement is required to cover the tissue defect. Complications involving wound dehiscence are frequent, and may be due to stretching of the skin, although the exact cause has not been determined. We have used laser speckle contrast imaging to monitor the surgical repair of a recto-prostatic ARM in a 5-week-old boy, and found that perfusion is reduced upon stretching the perineal skin. The lack of oxygen and nutrients to the wound edge may impair healing and increase the risk of infection. The use of perfusion monitoring during surgical reconstruction of ARM may facilitate surgical decision-making and reduce complications in the future.

Background. Laparoscopic skills training and evaluation outside the operating room is important for all surgeons learning new skills. To study feasibility, a video box trainer tracking 4-dimensional (4D) metrics was evaluated as a laparoscopic training tool. Method. Simball Box is a video box trainer with authentic surgical instruments and camera with video recording, equipped with 4D motion analysis registered through trocars using machine vision technology. Residents attending a 3-day laparoscopy course were evaluated performing a laparoscopic surgical knot at start, middle, and end. Metrics were obtained. Feedback data were presented in reference to expert/tutorial performance. Results. Ten right-handed residents were included. Median time (range) to finish the task was 359 (253-418), 129 (95-166), and 95 (52-156) seconds; 655%, 236%, and 174% of tutorial performance, with significance pre-/midcourse ( P < .0001), pre-/postcourse ( P < .0001), and mid-/postcourse ( P = .0050). Combined median total instrument motion decreased pre-/midcourse from 1208 (845-1751) to 522 cm (411-810 cm); P = .042 to 405 cm (246-864 cm) postcourse; pre-/postcourse P < .0001; 673%, 291%, 225% of tutorial performance. Total angular distance in radians (range) was 150 (87-251), 65 (42-116), and 50 (33-136) with significance pre-/midcourse ( P = .022) and pre-/postcourse ( P = .0002). Right-handed average speed (cm/s) increased: 1.94 (1.11-2.27) pre-, 2.39 (1.56-2.83) mid-, 2.60 (1.67-3.19) postcourse with significance pre-/midcourse ( P = .022) and pre-/postcourse ( P = .002). Average acceleration (mm/s2) and motion smoothness (µm/s3) failed to show any difference. Conclusion. For laparoscopic training and as a promising evaluation device, Simball Box obtained metrics mirroring progression well.

Introduction To assess differences in initial symptoms, treatments, and bowel function between children with Hirschsprung's disease (HD) with or without a cognitive dysfunction (CD). Materials and Methods The study included children with HD who underwent transanal endorectal pull-through. A retrospective chart review was performed to collect data on patient characteristics, diagnosis, and treatment. Data on bowel symptoms in children older than 4 years without a colostomy were compiled during a cross-sectional, patient-reported follow-up. Results Fifty-three children with HD were included; of these, 12 (23%) had CD. The median birth weight was lower, frequency of vomiting as the presenting symptom was lower, and time until the first contact with a pediatric surgeon was higher in children with CD than in those without (3,295 vs. 3,623 g, p = 0.013; 28 vs. 66%, p = 0.02; and 4 days vs. 1 day, p = 0.048, respectively). At follow-up, 5 (15%) of 33 children aged over 4 years had CD. More children without CD had some ability to hold back defecation and sense the urge to defecate than those with CD (p = 0.002 and p = 0.001, respectively). Conclusion HD children who have CD present with different initial symptoms, have a delay in the first consultation with a pediatric surgeon, and experience poorer bowel function outcomes than HD children without CD. Therefore, HD children with CD should receive special attention in both clinical practice and research.

Objective The aim was to document empirical observations about antecedents to and practices of unsuitable behaviours amongst surgical trainees and develop an interview guide that could be used for the selection process. Design A mixed methods design was adopted combining a survey distributed to senior surgeons and heads of departments, followed by semi-structured interviews with experienced surgeons. Setting All surgical departments and hospitals in The South Swedish Health Care Region. Participants The survey was completed by 54 of 83 eligible surgeons above 50years of age, and 4 of 7 heads of surgical departments. Semi-structured interviews with 13 surgeons representing local, regional, and university hospitals from the same cohort. Results Forty-six (85%) surgeons and four of seven heads of departments responded that they had come across surgical trainees deemed unsuitable to train and work as a surgeon. All heads of department and 31 of 54 of the surgeons believed tendencies towards unsuitability are evident early during training. From the survey, 107 statements described reasons for finding a trainee unsuitable. Qualitative analysis of the interviews and free-text answers of the survey led to identification of 11 problem domains with associated “warning signs”. An interview guide to help detect unsuitability tendencies in candidates during selection procedures was constructed. Conclusions Experienced surgeons have quite consistent views on what makes a person unsuitable as a surgeon. Their views have been systematized into 11 problem domains, and a set of ‘warning signs’ for unsuitable behaviours and traits has been developed. Early detection of these signs and traits is important for the individual, the work environment, and patient safety. A recommendation for a minimum framework for selection including the constructed interview guide is presented.

BACKGROUND: The study investigated whether 3D vision and haptic feedback in combination in a virtual reality environment leads to more efficient learning of laparoscopic skills in novices.MATERIAL AND METHODS: Twenty novices were allocated to two groups. All completed a training course in the LapSim(®) virtual reality trainer consisting of four tasks: 'instrument navigation', 'grasping', 'fine dissection' and 'suturing'. The study group performed with haptic feedback and 3D vision and the control group without. Before and after the LapSim(®) course, the participants' metrics were recorded when tying a laparoscopic knot in the 2D video box trainer Simball(®) Box.RESULTS: The study group completed the training course in 146 (100-291) minutes compared to 215 (175-489) minutes in the control group (p = .002). The number of attempts to reach proficiency was significantly lower. The study group had significantly faster learning of skills in three out of four individual tasks; instrument navigation, grasping and suturing. Using the Simball(®) Box, no difference in laparoscopic knot tying after the LapSim(®) course was noted when comparing the groups.CONCLUSIONS: Laparoscopic training in virtual reality with 3D vision and haptic feedback made training more time efficient and did not negatively affect later video box-performance in 2D. [Formula: see text]. (Less)

Purpose. Congenital heart disease (CHD) is reported to be associated with Hirschsprung disease (HD). The aim was to evaluate any differences between children with HD with and without CHD, respectively, with regard to patient characteristics, medical care, and patient reported bowel function. Method. This is a retrospective chart study and a cross-sectional long-term follow-up of patients older than 4 years old, including all children with HD operated on with transanal endorectal pull-through (TERPT) at a tertiary center of pediatric surgery. Information about patient characteristics, diagnostics, surgery, and medical care was compiled. At long-term follow-up, bowel function was assessed by Bowel Function Score. Results. Included were 53 HD-patients, 13 with CHD and 40 without CHD. Children with CHD more commonly presented with failure to thrive; 4 (23%) compared to those without CHD (0%) (p<0.01). In the long-term follow-up, including 32 patients (6 with CHD), constipation was more commonly reported by children with CHD 5 (83%) than by children without CHD 4 (27%) (p=0.01). No differences were shown in the other parameters such as fecal control and incontinence. Conclusion. HD-patients with CHD more commonly presented with failure to thrive and more frequently reported constipation than HD-patients without CHD. The findings indicate that HD-patients with CHD might need special consideration in their initial care and long-term follow-up.

BackgroundApproximately 15 % of surgical patients in hospital are affected of an adverse event, which is a medical error caused by the health care system. Laparoscopy is the preferred surgical technique in common procedures. Societal changes with shorter working hours, patient safety and ethics demand optimisation of resources toachieve the goal of educating competent surgeons within a reasonable time frame. Errors related to procedures is more often due to communicational skills and lack of situational awareness than pure technical skills. Laparoscopic simulation creates a safe training environment to spare patients being operated on by surgeons atthe steepest part of their learning curve. Selection of surgical trainees by testing different areas of technical and non-technical competence and personality traits is uncommon in the surgical community.Aim.The aim of the research project is to investigate laparoscopic simulators used for training and potential unsuitable behaviour of surgical trainees as defined for the selection process.MethodsThree studies were conducted with surgical novices, trainees and experienced surgeons by using laparoscopic simulators. Trainee and expert performance were investigated for simulator feasibility, effect of training of novices with sense of touch (haptics) and 3D vision, and opinion of experienced surgeons in using a virtual reality (VR) simulator.A mixed methods design with questionnaires and interviews with experienced surgeons was used to identify unsuitable behaviour and traits in trainees.ResultsThe Simball® Box is a new type of laparoscopic simulator which showed good feasibility and has the potential to mirror the technical progression with metrics. LapSim® Haptic Virtual Reality simulator with 3D and haptics shortens the acquisition of basic skills in novices with 32 %. Experienced surgeons considered that haptics inLapSim® had limited fidelity, but in spite of this, produced less stretch damage to the simulated tissue with haptics enabled. Experienced surgeons have quite consistent views on what makes a person unsuitable as a surgeon. This knowledge have been systematized in 11 problem domains and a list of early “warning signs” in addition to astructured interview guide.SignificanceThe findings from the studies concerning laparoscopic simulators have increased the knowledge of their usefulness and effectiveness and could assist in the construction of training curricula. The findings from the study on unsuitable behaviour could increase awareness and suggest the possibility to identify these signs early during training and initiate actions to remediate. The interview guide could contribute to increased quality and transparency amongst candidates applying for a trainee position.