Preface

This issue of Seminars in Pediatric Surgery deviates a bit from the usual format. Rather than focusing on a specific pediatric surgical condition or on a disease process, it is focused on the tools and technology of our specialty in the near to mid-term future. Make no mistake about it, our field has changed and will continue to evolve based on tools and technology.

Just as Doctors William E. Ladd or Robert Gross would be startled with the tools and technologies of our operating rooms and NICUs today, so too we can expect to be startled years from now. Although the future details may be fuzzy, the directionality and broad concepts outlined in this issue are not. It is important to recognize that the future is not a place that we are going to; rather it is a place that we as pediatric surgeons are privileged to create, first in what we think and then in what we do. At the end of the day, ours is an activist specialty brought to its present shape by our past and modern day leaders and innovators.

Our subspecialty discipline is inextricably linked to many other surgical disciplines included under the very broad definition of Surgery. Just as technologies developed in adult surgery, such as laparoscopy, have been taken up by pediatric surgeons, so too pediatric surgery has led the way for our adult-based colleagues in nonoperative management of solid organ trauma, endorectal pull-through procedures, and many others. Thus, the topics covered in this issue come from many surgical compass points: general surgery, neurosurgery, minimally invasive surgery, as well as from biomedical science and the field of engineering. Surgeons and engineers think very much alike; therefore, the more we talk, the better both disciplines will be.

In the opening article, the editor reflects on key lessons learned from a pre-eminent pediatric surgical innovator, Dr. Mark M. Ravitch. Dr. Ravitch’s incisive thoughts on the essence of our discipline and his clear definitions should dissuade all of us from self-definition by the phrase “big hole, big surgeon.”

Surgical care is not just about operations; there is an extraordinary legacy of advancements in patient care from our discipline. No team is better able to comment on extracorporeal life support than Drs. Hirschl, Skinner, and Bartlett, the University of Michigan team founded by Dr. Bartlett and now under the exceptional leadership of Dr. Ron Hirschl. Dr. Bartlett’s contributions to the field are legendary; indeed, his honorary membership in APSA speaks to his contributions. Perhaps more importantly, many of us Bartlett disciples have taken consistent and ongoing inspiration from his consistent and creative innovations in life support devices.

The field of transoral peritoneal surgery (TOPS or NOTES) is currently under exploration. After all, the distance between GI mucosa (the usual realm of the gastroenterologist) and the serosa (the usual realm of the surgeon) is no more than 5 mm. Whether there is a role for trans-gastric or trans-rectal cholecystectomy remains to be seen; exploration of this concept may yield dividends not yet perceived. Drs. Shafi, Mery, and Dutta have given us an exceptional glimpse into this arena. For all those who would dismiss this out-of-hand as frivolous, remember the same was said about laparoscopic cholecystectomy less than 20 years ago.

Surgical procedures are all about working on an image. The most commonly used image is that that we see directly with our eye but now frequently see as a digital screen image. What if surgeons could see differently? The field of molecular imaging and radioimmunoguided surgery truly permits surgeons to see differently. Drs. Mery and Shafi have wonderfully summarized this field that has, for the most part, found utility in endocrine surgery. There should be little doubt based on early experiences in several pediatric surgical pathologies that there is more to come.

If a surgical procedure is indeed about an image and then some sort of manipulation, image guidance, navigation, and surgical robotics is a logical step. Based on navigation systems initially designed for intracranial applications, the field of image guidance and navigation with potential applications in the thorax and the abdomen has been nicely laid out by Drs. Dutta and Albanese. Current surgical robot experience and the natural marriage of the two may some day create a far greater autonomy in robotic milling machines based on three-dimensional imaging and registration.

The second half of this Seminars explores further the intersecting fields of engineering and surgery. Whether it is biomaterials, the engineering of tissue, or the harsh realities of translating discoveries to improve patient care, these topics represent important knowledge for all of us. Gary Binyamin, a PhD Chemical Engineer with broad practical knowledge in materials science, has laid out a thorough primer of materials, their properties, and the potential impact on new medical and surgical devices.

In an era of intense debate around stem cells, the state of California has passed Proposition 71, a $3 billion state-orchestrated effort to make sense (and perhaps cents) out of stem cells. The role of stem cells in tissue repair, regeneration, engineering, and malignant transformation is handled with clarity by Drs. Karl Sylvester (a recipient of the APSA Foundation Grant) and two surgical residents, Drs. Monika Tartaria and Scott Perryman.

If ever there was a “black box,” the Food and Drug Administration (FDA) is one. Although the FDA does not regulate surgical procedures, it certainly evaluates virtually all of the tools and devices that we use. Jessica Connor, a Stanford Engineering Masters candidate, has clearly outlined the fundamental components of the FDA, its component branches, its classification of devices, and the byzantine labyrinth of approval.

In many ways, the background of Dr. Michael Gertner represents an ideal hybrid for a surgical innovator. With a Masters in Engineering from MIT, an MD and then surgical residency at UCSF, Dr. Gertner is uniquely positioned at the intersection between engineering and surgical science. He is the recipient of a T35 award, one of the Top 100 Innovators under the Age of 35 by Technology Review Magazine, and he has laid out a clear pathway for how one goes from a concept, perhaps scribbled on a napkin, to improvements in patient care.

Given growing specialization and the current RVU treadmill, we believe that the surgeon innovator is an endangered species. Yet when one considers the enormous patient benefits of balloon catheters, laparoscopic tools, robots, radiosurgery, and beyond, we believe that that endangered species needs to be rescued and resuscitated. Accordingly, the rationale and development of a 2-year training program for mid-level surgical residents in the process of innovation is described.

In this era, when the front pages of The New York Times and The Wall Street Journal portray our surgical colleagues as shills for industry or worse, it is incumbent on us to understand and seize the moral high ground. In particular, the ethical conduct of innovation in children is most stringent. Drs. Dan Riskin and Michael Longaker have written both knowledgeably and thoughtfully in this appropriate final note to this issue of Seminars.

It is important to note the critical nature of our educational programs to the further innovation in the care of our patients. Whereas we are all students in some way, shape, or form, the overwhelming presence of research fellows and trainees in the authorship of this Seminars speaks volumes of their capability and their importance to the future of our specialty and the care of our patients.

I am deeply grateful to all of the authors for their time, effort, and diligence in sharing their perspectives, knowledge, and insight with us all. I count them all among both my colleagues and my friends.

I would like to express my deep personal appreciation to Dr. Jay Grosfeld who prevailed on me during a cocktail hour moment of weakness at the Halsted Society in the Fall of 2005 to assemble this Seminars in Pediatric Surgery. Dr. Grosfeld’s contributions to the field are legendary and he has, indeed, set a standard in pediatric surgical excellence that may never be equaled. I’m personally grateful to him for his example and for his encouragement in this issue.

Finally, the restless spirit of inquisitiveness and curiosity, and the willingness to look for a better way, were the defining characteristics of Arnold M. Salzberg, MD, my mentor, role model and friend. For all that, and more, I am forever grateful.