INTRODUCTION:The optimal timing of inguinal hernia repair (IHR) in premature infants remains unclear. Our study aims to compare recurrence rates between IHRs performed before and at/after 55 weeks postmenstrual age (PMA). METHODS:A multicenter retrospective cohort study was conducted of premature infants who underwent IHR at ≤1 year of age between 1/2017-12/2019. The primary outcome was inguinal hernia recurrence, defined as recurrence requiring surgical re-repair. Demographic, clinical, perioperative and postoperative variables were analyzed. Multivariable logistic regression was performed to identify factors associated with recurrence. RESULTS:A total of 2,412 premature infants underwent 3,808 IHRs: 3,292 (86.4%) hernias were repaired early (before 55 weeks PMA), and 516 (13.6%) were repaired late (after 55 weeks PMA). Incarceration rates were similar between the groups (9.4% vs. 8.2%, p=0.422), as were the proportion of repairs performed laparoscopically (30.0% vs. 31.2%, p=0.594). Patients undergoing early repair were more frequently admitted postoperatively (81.2% vs. 27.2%, p<0.001). There were no significant differences in hernia recurrence (1.2% vs. 0.8%, p=0.358) or time to recurrence (3 months [IQR 2.0, 9.0] vs. 9 months [IQR 4.3, 11.5], p=0.218) between early and late repair groups. On multivariable regression, laparoscopic repair (OR 1.910 [95% CI 1.018, 3.581], p=0.044) and concurrent procedure (OR 2.046 [95% CI 1.034, 4.047], p=0.040) were independently associated with a higher risk of recurrence, while late repair was not (OR 0.749 [95% CI 0.259, 2.165], p=0.593). CONCLUSION:Time of repair was not an independent predictor of hernia recurrence. Therefore, recurrence risk alone should not drive the decision for early repair; rather timing should be individualized based on patient physiology, anesthetic considerations, and reliability of follow-up.

PURPOSE:This study aimed to investigate effect of surgeon annual case volume on pediatric inguinal hernia recurrence rates. METHODS:Surgeons' individual annual case volumes were calculated from a retrospectively collected data set of pediatric inguinal hernia repairs including 21 hospitals from 2017 to 2019. Quartiles were defined based on surgeons' annual case volumes for each year: Lower Volume = Q1-3 and Higher Volume = Q4. Descriptive statistics and bivariate regression were utilized for analysis. RESULTS:For all repair techniques, there were 207 surgeons accounting for 548 surgeon-years with 8519 operations. For all repairs, Higher Volume was defined as > 22 operations per year. On regression analysis, presence of a ventriculoperitoneal shunt, peritoneal dialysis, laparoscopic technique, and surgery performed by a lower volume surgeon were associated with recurrence risk. For open repairs, there were 193 surgeons, 465 surgeon-years, and 5726 operations. Higher Volume was defined as >18 operations per year. On regression analysis, history of an omphalocele, a connective tissue disorder, and tracheostomy dependence contributed to recurrence risk, while surgeon volume did not. For laparoscopic repairs, there were 136 surgeons, 306 surgeon-years, and 2793 operations. High Volume was defined as >14 operations per year. On regression analysis, presence of a ventriculoperitoneal shunt and surgeon laparoscopic volume was associated with recurrence risk. CONCLUSIONS:Annual surgical volume is an important determinant of recurrence following laparoscopic inguinal hernia repair. As surgeons integrate both laparoscopic and open techniques in their practice, caution should be taken to maintain adequate volume and proficiency in each technique. IRB APPROVAL:This study was IRB reviewed and approved (IRB 22-350). LEVEL OF EVIDENCE:III.

INTRODUCTION:Metal hypersensitivity is a type-IV delayed-type hypersensitivity reaction that may contribute to complications in orthopedic surgeries. While its clinical relevance remains uncertain, immune responses to implants have been documented. Pediatric spinal deformity correction and pectus excavatum repair often involve the use of metal implants that contain known allergens, including nickel, cobalt, and chromium. Despite extensive adult data, prevalence in pediatric spine surgery remains underexplored. METHODS:This retrospective cohort study reviewed pediatric patients who underwent posterior spinal fusion with instrumentation or the Nuss procedure for pectus excavatum repair between 2014 and 2020. The spine cohort underwent selective preoperative screening based on a self-reported metal sensitivity questionnaire, while the pectus cohort received routine preoperative Patch Metal Allergy Testing (PMAT). Statistical analyses, including Fisher's Exact Test and logistic regression, were performed to compare hypersensitivity prevalence and associated risk factors. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for categorical comparisons. RESULTS:Of 796 spinal fusion patients, 118 (14.8%) underwent PMAT, yielding a 3.3% hypersensitivity rate. In contrast, 815 of 864 pectus excavatum patients completed PMAT, yielding a 12.8% hypersensitivity rate. Patients in the spine cohort were older (median age 15 vs. 14 years; p < 0.01) and more likely to be female (64.2% vs. 22.7%; OR = 6.11, 95%CI: 4.91-7.60; p < 0.0001). Despite this, they were significantly less likely to test positive for metal hypersensitivity (OR = 0.23, 95%CI: 0.15-0.36; p < 0.0001). When viewed from the pectus cohort perspective, this corresponds to 4.33 times higher odds of PMAT positivity. CONCLUSION:The lower prevalence in spine patients likely reflects differences in PMAT determination rather than true population differences. This study highlights the potential underdiagnosis of hypersensitivity in the spine cohort when using selective screening, compared to routine testing in the pectus cohort. Determining higher yield screening criteria for spine surgery may result in detection rates more comparable to those found in the pectus cohort. Further research is needed to refine preoperative screening protocols and evaluate the clinical impact of metal hypersensitivity in pediatric orthopedic surgery.

AimDelays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis.MethodsWe conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi‐structured interviews based on an iteratively revised interview guide were conducted in‐person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis.ResultsWe reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self‐identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme – accessing care – describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made.ConclusionWe identify four major themes from the patient and family perspective, each with multiple sub‐themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.

Introduction There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers. Methods We conducted phone surveys 30 days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control. Results We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1 month to 246 months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal. Conclusions Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

OBJECTIVEA paucity of formal leadership training programs exists for residents, and outcomes of those are limited in reporting. Based on a robust needs assessment, our program created a longitudinal cohort curriculum, Future Surgical Leaders, for residents and fellows of all levels to provide training in nontechnical skills. Our objective was to evaluate surgical resident short-term outcomes and satisfaction with the Future Surgical Leaders (FSL) curriculum.DESIGNParticipants were sent a brief survey after each session of the curriculum from October 2020 to February 2022. The data was compiled after seventeen months of delivery. Likert Scale responses and text comments were analyzed with a 2-sample t-test and 2-way analysis of variance.SETTINGAcademic tertiary institution.PARTICIPANTSGeneral surgery residents.RESULTSSurvey response rate from 54 sessions among all postgraduate year levels was 73%. Overall, 96% of residents/fellows either “agreed” or “strongly agreed” that the topics of the FSL curriculum were important to learn during surgical training. Only 24% of learners knew “a lot” or “a great deal” about the topics prior to the session which rose to 73% afterwards (p < 0.01). Each postgraduate year class showed statistically significant increase in knowledge. About 80% of learners wanted to investigate these topics further. Open comment questions identified themes requesting delivery of specific sessions earlier in residency training and positive overall attitudes toward the FSL curriculum.CONCLUSIONSFSL is a satisfactory means of teaching leadership skills to surgical residents. Residents recognize the need to develop leadership skills prior to entering practice and want to learn more. The FSL curriculum may be considered for application at other surgical training programs.

ObjectiveWe sought to characterize the impact of a child’s sociodemographic characteristics on their odds of delayed diagnosis and perforation in pediatric appendicitis.Study DesignWe performed a single center, retrospective cohort study of all pediatric appendicitis admissions between 2016 to 2021. Using a multivariable model, we evaluated for associations between delayed diagnosis and perforation and a child’s sociodemographic characteristics, including their age, gender, race and ethnicity, insurance status, and their home census-tract Material Community Deprivation Index value.ResultsThe study included 3248 patients. The median age was 12.1 years (IQR 9.5-14.9). Most patients were male (60.3%), identified as non-Hispanic White (78.0%), and had private insurance (55.4%). The delayed diagnosis and perforation rates were 6.4% and 25.1%, respectively. Delayed diagnosis cases had a higher perforation rate (56% compared to 21.5%, p <0.001). On adjusted analysis, older age decreased the odds (OR 0.91, CI 0.87-0.94) of delayed diagnosis, while female sex (OR 1.50, CI 1.13-2.00), and socioeconomic disadvantage (OR 1.56 for Q4 vs Q1, CI 1.00-2.43) increased the odds. Furthermore, older age (OR 0.91, CI 0.89-0.93) decreased the odds of perforation, while NH-Black (OR 1.72, CI 1.3-2.29) or Hispanic (OR 1.60, CI 1.24-2.08) compared to NH-White identification, and socioeconomic disadvantage (OR 1.43 Q4 vs Q1, CI 1.12-1.83) increased the odds.ConclusionsOur reported delayed diagnosis rate is higher than recent literature, highlighting the need to consider visits that occur across different healthcare settings. We further identify sociodemographic factors, including socioeconomic status, that impact a child’s risk of delayed diagnosis and perforation.

Racial and ethnic disparities in medical care have been documented in both adult and pediatric population [ [1] Mathews T.J. Driscoll A.K. Trends in infant mortality in the United States, 2005-2014. NCHS Data Brief. 2017; : 1-8 PubMed Google Scholar , [2] Montoya-Williams D. Williamson V.G. Cardel M. Fuentes-Afflick E. Maldonado-Molina M. Thompson L. The hispanic/latinx perinatal paradox in the United States: a scoping review and recommendations to guide future research. J Immigr Minority Health. 2021; 23: 1078-1091 Crossref PubMed Scopus (28) Google Scholar ]. This disparity has been related to socioeconomic disadvantage, poor access to health care, poor quality of delivered care, and discrimination, resulting in worse health [ [2] Montoya-Williams D. Williamson V.G. Cardel M. Fuentes-Afflick E. Maldonado-Molina M. Thompson L. The hispanic/latinx perinatal paradox in the United States: a scoping review and recommendations to guide future research. J Immigr Minority Health. 2021; 23: 1078-1091 Crossref PubMed Scopus (28) Google Scholar ]. Previous literature on disparities has compared black and white infants without including Hispanic infants [ [2] Montoya-Williams D. Williamson V.G. Cardel M. Fuentes-Afflick E. Maldonado-Molina M. Thompson L. The hispanic/latinx perinatal paradox in the United States: a scoping review and recommendations to guide future research. J Immigr Minority Health. 2021; 23: 1078-1091 Crossref PubMed Scopus (28) Google Scholar ]. Other studies have shown that Hispanic adults have better health and educational outcomes despite many socioeconomic risk factors and health status. This epidemiologic phenomenon is referred to “Hispanic Paradox” [ [2] Montoya-Williams D. Williamson V.G. Cardel M. Fuentes-Afflick E. Maldonado-Molina M. Thompson L. The hispanic/latinx perinatal paradox in the United States: a scoping review and recommendations to guide future research. J Immigr Minority Health. 2021; 23: 1078-1091 Crossref PubMed Scopus (28) Google Scholar , [3] Ruiz J.M. Steffen P. Smith T.B. Hispanic mortality paradox: a systematic review and meta-analysis of the longitudinal literature. Am J Publ Health. 2013; 103: e52-e60 Crossref PubMed Scopus (260) Google Scholar ]. The objective of the present study was to use appendicitis (a previous marker for disparities) to determine if this Paradox applies to children's health.

Necrotizing fasciitis is a rare disease within pediatric population, occurring in .08 per 100 000 children. 1 Only a few case reports and case series exist in the literature. Unlike adults, affected children are generally immuno-competent and infection has been shown to be secondary to skin trauma, puncture sites, varicella lesions, or underlying skin conditions. Neonatal soft tissue infections are rarer and often secondary to omphalitis, balanitis, mastitis, fetal scalp monitoring, or postoperative complications, with omphalitis being the most common cause. 1 There are few reports of primary necrotizing infection without a known causative source. Treatment of necrotizing fasciitis requires early diagnosis, initiation of broad-spectrum antibiotics, and wide surgical debridement. Neonatal necrotizing fasciitis has an overall mortality rate estimated around 59%. 2 We present a case of a premature neonate with primary necrotizing fasciitis of the chest after 2 weeks of life. We employed a novel approach to healing a dif fi cult, complex chest wound with exposed ribs and pleura, after debridement of the primary infection. A

Quinn, Kristen MD; Runge, Louis T BS; Parrado, Raphael MD; Talley, Cynthia Leigh MD, FACS; Streck, Christian J MD, FACS; Abbott, Andrea M MD, FACS Author Information

Minimally invasive repair of pectus excavatum (MIRPE) has become the procedure of choice to treat pectus excavatum. The frequency of complications is variable but remains low on most recent reports [ [1] Nuss D. Minimally invasive surgical repair of pectus excavatum. Semin Pediatr Surg. 2008; 17: 209-217 Crossref PubMed Scopus (155) Google Scholar , [2] Nuss D. Kelly R.E. Indications and technique of Nuss procedure for pectus excavatum. Thorac Surg Clin. 2010; 20: 583-597 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar ]. In rare instances such as metal allergy, the bar or bars must be replaced despite adequate an repair. Metal allergy to surgical stainless steel is estimated to occur in 1.2 to 6.6% of patients [ [3] Galazka P. Leis K. Kroczek K. et al. Metal allergy after the Nuss procedure for pectus excavatum: a review. Postepy Dermatol Alergol. 2020; 37: 848-852 Crossref PubMed Scopus (5) Google Scholar , [4] Notrica D.M. The Nuss procedure for repair of pectus excavatum: 20 error traps and a culture of safety. Semin Pediatr Surg. 2019; 28: 172-177 Crossref PubMed Scopus (10) Google Scholar ]. Reoperation poses a challenge owing to adhesions, risk of lung injury, or potential cardiac and aortic injury. We present a technique that is easy to reproduce and valuable for bar replacements when there is no need for further correction.

Background Appendicitis is the most common abdominal surgical emergency in children. With the rise of the Coronavirus-19 pandemic, quarantine measures have been enforced to limit the viral transmission of this disease. The purpose of this study was to identify differences in the clinical presentation and outcomes of pediatric acute appendicitis during the Coronavirus-19 pandemic. Methods A single-institution retrospective assessment of all pediatric patients (<18 years old) with acute appendicitis from December 2019 to June 2020 was performed at a tertiary care children's hospital. Patients were divided into two groups: (1) the Pre-COVID group presented on or before March 15, 2020, and (2) the COVID group presented after March 15, 2020. Demographic, preoperative, and clinical outcomes data were analyzed. Results 45 patients were included with a median age of 13 years [IQR 9.9 - 16.2] and 35 males (78%). 28 patients were in the Pre-COVID group (62%) and 17 in the COVID group (38%). There were no differences in demographics or use of diagnostic imaging. The COVID group did have a significantly delayed presentation from symptom onset (36 vs 24 hours, P < .05), higher Pediatric Appendicitis Scores (8 vs 6, P = .003), and longer hospital stays (2.2 vs 1.3 days, P = .04). There were no significant differences for rates of re-admission, re-operation, surgical site infection, perforation, or abscess formation. Conclusion During the Coronavirus-19 pandemic, the incidence of pediatric acute appendicitis was approximately 40% lower. These children presented in a delayed fashion with longer hospital stays. No differences were noted for postoperative complications.

Posterior knee dislocations (PKD) in children are uncommon but may be associated with vascular injury. The purpose of this study is to characterize the frequency of vascular injury in PKD as well as define patient characteristic, procedures, types of treating hospitals, and clinical outcomes. This study utilized the National Trauma Data Set (NTDS) from the American College of Surgeons on years 2015 and 2016. All demographic and clinical data on pediatric patients (≤18 years) with the ICD codes for PKD were obtained. 44 PKD were identified. The median age was 17 years [IQR 15,18], 70% male; 49% white. The mean body mass index was 29.6 [IQR 23-38]. We found that vascular injury was present in 16 patients (36%); 14 (30%) underwent repair (eight with saphenous vein graft) and fasciotomies in eight patients. Nerve injury was present in five patients (11%). Lower extremity amputation was performed in three patients (7%).

Introduction: Ovarian fibrothecoma is a rare subtype of ovarian sex-chord stromal tumor canoni-cally described in peri-menopausal and post-menopausal women. There have been some cases reported in young adults; however, there have not been any cases documented in the adolescent patient population.Case report: We present the youngest recorded case of an ovarian fibrothecoma. A 13 year old fe-male presented with pelvic pain and non-specific symptoms. Diagnostic workup showed a mixed -density ovarian mass and tumor markers within normal limits. A right ovarian mass was resected without complication. The final pathology revealed a fibrothecoma.Conclusion: This case identifies a new type of ovarian mass that can present in adolescents and should be considered during the workup for adolescents with ovarian masses.

BACKGROUND:We sought to evaluate the unique benefits and challenges the virtual recruitment and interviewing platform had on general surgery residency applicants. METHODS:Applicants who interviewed for a categorical position at our institution during the 2021 and 2022 Match season were contacted to participate in the anonymous online survey focused on applicant behavior related to the virtual interview format. Data were analyzed using chi-square and paired t-tests. RESULTS:A response rate of 56.7 ​% (n ​= ​135) was achieved. Applicants accepted a median of 17 (IQR 13-20) interviews in 2021 and 15 (IQR 11-19) interviews in 2022. More than half (54 ​%) of applicants indicated they applied to more programs, and 53 ​% accepted more interviews, because of the virtual format. The greatest advantages of the virtual interviews as cited by applicants were saving money (96.3 ​%), saving time (49.6 ​%), and avoiding travel risks (43.7 ​%). The top limitations of virtual interviews were less exposure to current residents and faculty (61.5 ​%), to the city or location of the program (58.5 ​%), and difficultly comparing programs (57.8 ​%). The 2022 Match cycle included use of the supplemental application; however, 85 ​% of applicants did not feel that the supplemental improved their overall application. Some applicants (20 ​%) who "signaled" programs did not receive an interview offer from any of the programs they signaled. CONCLUSION:The transition to virtual interviews saved applicants time and money but limited their exposure. Future efforts to maintain virtual interviews will need to be balanced against the intangible benefit of human interaction and observing a program's culture.

Background: Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture’s demographics, clinical characteristics, and treatment patterns. Methods: Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates. Results: There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%). Conclusions: Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates. Level of Evidence: Level III, retrospective study.

Introduction: The COVID-19 pandemic necessitated an exclusively virtual 2021 residency application cycle. We hypothesized that residency programs' online presence would have increased utility and influence for applicants. Methods: Substantial surgery residency website modifications were undertaken in the summer of 2020. Page views were gathered by our institution's information technology office for comparison across years and programs. An anonymous, voluntary, online survey was sent to all interviewed applicants for our 2021 general surgery program match. Five-point Likert-scale questions evaluated applicants' perspective on the online experience. Results: Our residency website received 10,650 page views in 2019 and 12,688 in 2020 (P = 0.14). Page views increased with a greater margin compared to a different specialty residency program's (P < 0.01). From 108 interviewees, 75 completed the survey (69.4%). Respondents indicated our website was satisfactory or very satisfactory compared to other programs (83.9%), and none found it unsatisfactory. Applicants overall stated our in-stitution's online presence impacted their decision to interview (51.6%). Programs' online presence impacted the decision to interview for nonWhite applicants (68%) but signifi-cantly less for white applicants (31%, P < 0.03). We observed a trend that those with fewer than this cohort's median interviews (17 or less) put more weight on online presence (65%), compared to those with 18 or greater interviews (35%). Conclusions: Applicants utilized program websites more during the 2021 virtual application cycle; our data show most applicants depend on institutions' websites to supplement their decision-making; however, there are subgroup differences in the influence online presence has on applicant decisions. Efforts to enhance residency webpages and online resources for candidates may positively influence prospective surgical trainees, and especially those underrepresented in medicine, to decide to interview. Published by Elsevier Inc.

Ovarian teratoma is the most common ovarian tumor in children with an overall incidence of 2.6 cases per 100,000 girls per year. Diagnosis and management are challenging due to its nonspecific presentation, malignancy determination, and need to conserve fertility. A previously healthy 5-month-old female infant presented with fever, abdominal distension, and nonbilious emesis, and an 8.2 × 6.8 × 6.1-centimeter pelvic mass originating from the left adnexa was found on imaging. Due to concern for malignancy and torsion, exploratory laparotomy and ovarian-sparing surgery (OSS) with resection of the mass were performed. Histology showed a grade 1 teratoma. This case illustrates a challenging diagnosis and its symptom overlap with other etiologies in infants. The keys to diagnosing and managing this entity are including ovarian pathology in the differential diagnosis and performing OSS whenever possible. Furthermore, ultrasound follow-up is needed to monitor for ipsilateral and contralateral ovarian tumors later in life.