Innovation to Equity: Five Advances That Redefined Children's Surgery in the Past 50 Years

1.

Over the last 50 years, advances in children's surgery have improved outcomes and reduced morbidity and mortality for many congenital and acquired conditions. These advances extend beyond the operating room and encompass technological innovations, non‐operative care and global health initiatives. Surgical progress includes minimally invasive surgery, neonatal surgery, organ transplantation, correction of complex congenital defects, and the integration of medical technologies like robotics. This article reviews some important achievements that have contributed to better care for children with surgical pathology and shed some light on its evolution.

2. Evolution of Children [Pediatric] Surgery as a Separate Discipline

The term “Pediatrics” was coined in Europe in the second half of the 19th century with children's hospitals all appearing in the western world. Children's surgery appeared in the early part of the 20th century with surgeons dedicating their practices to children only. Prior to this, most surgeons only had 10% of children in their practice for economic, academic and “empire‐building” amongst other reasons [1]. Before the 19th century, Children's surgery was recorded in several articles and books mainly on correction of surgical birth defects [2, 3, 4]. Associations were formed in High Income Countries [HIC] with the aim of advancing children's surgery, teaching, and training, research, advising children's surgery specialists and developing international connections. Surgeons from Low and Middle‐Income Countries [LMIC] developed pure children surgical practices much earlier than their HIC partners due to the sheer volume of cases and lack of specialists. This said that they were still within the administration of adult surgeons. In the late 20th century LMIC began developing children's surgery as a specialty with the ethos that disease patterns in LMICs differ from HICs, and prioritizing safety first for children, teaching, training, regular LMIC networking and further exchange of ideas with international colleagues [5, 6]. To date the specialty of children's surgery has made huge progress clinically and academically, and now in the 21st century with the formation of organizations such as Global Initiative for Children's Surgery [GICS] [7] in advocating for children's surgery internationally and with policy makers. Publications by LMIC authors have described disease patterns and their treatment with the limited resources available [8]. Universally we, children surgeons often say, “Children are not small adults” but better said in 1928 by an HIC author that “the adult may be safely treated as a child, but the converse can lead to disaster” [9].

3. Innovations in Surgical Techniques

The last 50 years of children's surgery have been a period of profound innovation that shifted “big is better” to “less is more.” Technological innovations have contributed immensely to reshaping the landscape of care, and reduce morbidity and mortality from children's surgical conditions. From minimally invasive approaches to cutting‐edge robotic and fetal intervention, AI‐driven surgical decision‐making, fluorescence‐guided imaging, 3D printing for preoperative planning and augmented reality in surgery, these advancements remarkably changed patients' and parents' attitude toward surgery, making surgery less fearsome and more tolerable by offering benefits such as less pain, shorter hospital stays, and quicker recovery. Miniaturization of instruments also allowed surgeons to perform complex procedures even in newborns and small infants. Minimally invasive surgery grew in adult gynecology and surgical practice in the 1980s and quickly extended to children thereafter. Now, minimally invasive approaches have spread across all ages and dimensions of children's surgery for both congenital and acquired diseases, also with increased use of robotic approaches in some well‐resourced centers [10]. Although robotic‐assisted surgery took minimally invasive surgery to the next level, it is yet to be made universal [11, 12, 13]. Several other surgical techniques have reduced morbidity related to surgery. Posterior sagittal anorectoplasty in patients with anorectal malformations allowed for the precise identification and utilization of a child's own sphincter muscles, dramatically improving continence rates [14]. The Foker process for long‐gap esophageal atresia allowed the native esophagus to stretch and eventually be joined together avoiding the long‐term complications associated with tissue interpositions [15]. The Nuss procedure for pectus excavatum significantly reduced pain, blood loss, and recovery time [16].

Artificial intelligence including machine learning, deep learning, computer vision, and natural language processing is also rapidly reshaping the armamentarium of children's surgery. While current applications primarily support clinical decision making, future prospects include precision surgery, improved global access and enhanced training.

4. Diagnostics and Scientific Advances and Medical Therapies

Minimally invasive approaches have spread across all ages and dimensions of children's surgery for both congenital and acquired diseases, also with increased use of robotic approaches in some well‐resourced centers [10]. Meanwhile, fetal surgery developed in 1981 for prenatal urinary obstruction but then quickly expanded for numerous other congenital conditions [17]. As important, the multidisciplinary approach to the fetus with surgical conditions became adopted by leading centers globally. In the last several decades, gene editing has allowed the reversal of some diseases early in gestation with expanding indications, led by children surgeon‐scientists [18]. The application of total parenteral nutrition in children has extended lives for children who cannot be enterally fed, while extracorporeal membrane oxygenation has saved lives of children first with congenital diaphragmatic hernia, then other acquired conditions [19, 20]. Technical innovations have also transformed surgical practice across diseases, ranging from silo coverage of abdominal wall defects to air enema reduction of intussusception, and variations in timing and approaches to solid tumors. Innovations have also meant in some cases doing “less surgery”‐ such as splenic preservation rather than splenectomy for splenic trauma‐ for improved patient outcomes [21]. Variations in timing and approaches to solid tumors have also changed practice globally as the natural course of disease has been better defined and medical therapies have been made more accessible globally, and contextualized for LMICs. However, significant disparities in access to these innovations persist between HICs and LMICs making these innovations not universally accessible. Innovation in LMICs is often a story of adaptation, ingenuity, and capacity building creating sustainable solutions that fit the local context. Low‐cost 3D printing, portable low‐cost, point‐of‐care ultrasound machines are increasingly used [22]. Twinning programs and telemedicine by collaborative partnerships between advancement in hospitals in HICs and LMICs facilitated knowledge transfer and training. The true children's surgery will come from bridging the gaps and making these innovations accessible to every child, regardless of their geographic location. LMIC clinicians have achieved similar outcomes as high income countries for some conditions, with fewer human and physical resources, ranging from congenital diseases to emergencies and oncologic conditions by “doing more with less” and improvising lower cost solutions and extending the health workforce to nurses and community‐level providers and caregivers [23, 24].

5. Team Based Care and Patient Safety in Children Surgery

Children are a vulnerable group due to their anatomical, physiological and psychological characteristics and so they need more careful attention to their health and well‐being [25]. Surgery in children often demands meticulous and coordinated safety measures to prevent surgical complications. Multidisciplinary team care approach plays a vital role in reducing patients' suffering and improving surgical outcomes. Literature demonstrates that team‐based care has been proven effective in diverse settings like general surgery, oncology and chronic medical conditions, from diagnostic accuracy to providing evidence‐based treatment [26]. This teamwork involves different healthcare professionals including children surgeons, pediatricians, nurses, anesthesiologists, general physicians, and other allied health workers [27]. For example, the SAFE [Safer Anesthesia from Education] children anesthesia course is an effective way to deliver training and has helped to strengthen emergency and essential surgical care for children as a component of universal health coverage [28]. Team‐based care ensures proper communication, shared goals, and coordinated actions among team members, which are essential for minimizing surgical risks and improving outcomes [26]. A simple example of team‐based case is the surgical safety checklist developed by the World Health Organisation [WHO] [29]. The multidisciplinary team‐based approach to pediatric surgical care also emphasizes the need for the active involvement of the patient's families in ensuring ongoing health care needs. Effective communication between the healthcare team and patient's family is crucial before and after performing surgical procedures. This can help reduce fear and anxiety of the families, build trust in the healthcare system and thus develop a safe environment for surgery [27].

6. Children's Surgery as a Global Health Priority

The “problems of the too's” succinctly describes the state of children's surgery for much of the 20th and early 21st centuries. Too many children, too far from care, too poor to afford care, presenting too late, in an environment of too few acceptable service providers, with too little being done [30]. Coined by Poenaru, the phrase accurately described the burden of and response to children's surgical needs globally. Since the Lancet commission on Global Surgery in 2015, the needle has begun to shift. Not only is there broader understanding and acceptance of the critical role of affordable, safely and timely surgical care as a global public health priority, but so too, the need to tackle problems of children's surgical care to achieve these goals.

Evidence for the prioritization of children's surgery is overwhelming. In LMICs that account for approximately half of the global population, with the greatest expected rates of future population growth, and where children routinely account for half of the entire population, an estimated 85% require surgery by the age of 15 [31, 32, 33]. Children's surgical interventions compare extremely well, and often favorably, with established public health priorities such as anti‐retro viral therapy in terms of cost per disability adjusted life year saved [31, 33]. Children with untreated surgical disease have the potential for lifelong disability that impacts affected individuals, their families, and entire economies. In Africa, approximately 6% of non‐health gross domestic product [GDP] is lost due to childhood mortality [33]. Given the health and economic impact of targeted, and cost effective interventions the argument for the prioritization of children's surgery is unquestionable. Historical attempts to address the burden of children's surgical disease through ad hoc north‐south partnerships, disease specific interventions by non‐governmental and faith based organizations, and short term surgical camps were unable to and will not address the unmet burden of disease in a sustainable and scalable manner going forward. The inclusion of children's surgery in the framework for National Surgical, Obstetric and Anesthetic Plans [NSOAPs] at the World Health organization [WHO], and GICS's Optimal Resources for Children's Surgery [OreCS] framework are concrete examples of evidence based advocacy and sustainable, scalable and locally informed and driven solutions that recognize children's surgery as a global health priority [34]. However, they require creative and sustained resource mobilization from diverse stakeholders. The foundations for children's surgery as a pillar of universal health coverage and global child health have been established, creating the possibility for a future in which children with surgical disease are treated safely, timely, and in a culturally appropriate manner. Global Children's Surgery Day is celebrated annually on February 26th. It is an initiative spearheaded by the Global Initiative for Children's Surgery [GICS], advocating for access to safe, quality surgical care for children worldwide.

7. Conclusion

The evolution of children's surgery over these years exemplifies how surgical care to children is shaped not only by new operative techniques but also by multidisciplinary integration, technological innovation, training, systems improvement and global health perspectives. As we look forward, the mission remains to translate these advances so that all children, regardless of geography or socioeconomic status, can receive safe and effective surgical care. Continued efforts in research, advocacy, and global collaboration are essential to address these disparities and further enhance the quality of children's surgical care globally.

Author Contributions

Tahmina Banu: conceptualization, writing – original draft, methodology, writing – review and editing, resources. Nirav Patel: writing – original draft, methodology, writing – review and editing, data curation, resources. Tanvir Kabir Chowdhury: writing – original draft, methodology, writing – review and editing, data curation, resources. Doruk Ozgediz: conceptualization, writing – original draft, methodology, writing – review and editing, resources. Kokila Lakhoo: conceptualization, writing – original draft, methodology, writing – review and editing, resources.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.