Teaching impact in pediatric minimal access surgery : Personal perspective from “ Fellow ”

“self ” established programs. In many other pediatric surgery centers, teaching the “glamour” of MAS is quite dependent on a program director’s vision. Integration of MAS training into the secondary residency/fellowship curriculum of pediatric surgeons is the inevitable goal. MASminded education and research through adequate training will pay dividends and “manufacture” competent, contemporary trainees. National Pediatr ic Surgery Associations should be responsible for setting criteria that consider the MAS for accreditation with maintaining the international standards of these teaching programs.

Address for correspondence: Dragan Kravarusic, Alberta Children's Hospital, 1820 Richmond Road, SW, Calgary, Alberta, Canada T2T 5C7.E-mail: dkravarusic@yahoo.com The global objective of this paper is to review from the "Fellow" perspective, the current status of pediatric minimal access surgery (MAS) in terms of teaching feasibility, safety and impact on standard practice paradigms.In the pediatric general surgery field, surgeons are dealing with a wide range of pathology that includes thoracic, abdominal, urological and gynecological procedures.The learning curve is slow because of a relatively small volume of patients.

INTRODUCTION
Ever since its entry more than two decades ago, minimal access surgery (MAS) introduced a sweeping revolution in surgical practice.Worldwide, the volume of MAS procedures has rapidly increased in recent years and consequently, recent general surgery graduates are seeking MAS fellowships in record numbers.The field of pediatric surgery is no exception and there are numerous patients who can benefit from this approach. [1,2]S is a natural extension of traditional surgical treatment, but the techniques and dexterity required to master these procedures are a separate set of skills.

MATERIALS AND METHODS
The global objective of this paper is to review from the "Fellow " perspective, the current status of ) .
2 Kravarusic D: Teaching impact in pediatric

Ovarian detorsion Nephrectomy Total
The great majority (90.32%) of relevant thoracic MAS: Minimal access surgery procedures were performed thoracoscopically.Lung biopsy was the most common performed procedure variable percentage (45%).(In total, 258 from 573 (18 cases) with excellent results and a zero conversion procedures.)All 24 cholecystectomies were  ) .

Kravarusic D: Teaching impact in pediatric
Selection for laparoscopic appendectomy was focused to a certain group of patients (obesity, female adolescents and patients with uncertain diagnosis) who were especially suitable for such a modality.Laparoscopic cecostomy for bowel management of incontinent or severely constipated patients (mostly spina bifida group) were performed in 6 cases.This approach is very well-established at this hospital, with MAS training programs.Computer-generated virtual reality systems allow sensory interaction and provide "hand-eye coordination" models which are especially useful for self-assessment in simulation-based surgical skills training. [3,4][7][8] MAS in animal laboratories has been recognized as well as a method of teaching, long term follow-up and documentation of improved developing and refining surgical techniques which quality of life.From six laparoscopic bowel resections contribute to a beneficial outcome in patients.
[9] (4 for Crohn's disease and 2 total colectomies for However, pediatric MAS workshops are quite rare and familial adenomatous polyposis syndrome) with attendance at a 1 or 2 day workshop does not extracorporal anastomosis, we had conversion in 2 translate into expert practice and is not sufficient to cases (33.3%) due to insufficient visualization and be considered as credentialing activity.So the only probably lack of experience.However, the general way to reach competency in pediatric MAS, is the departmental approach is to continue with acquisition and safe performance of sufficient volume performing these procedures in selected, suitable and a range of relevant procedures.An operation can patients, to overcome pitfalls and maintain progress be reduced to its component steps, which can be in MAS.Laparoscopic pull-through for imperforate learned and mastered over a number of separate anus was done in two cases, after diverting colostomy operations on different patients. [10]Supervised was performed in the postnatal period.One case was operating with structured objective assessment and converted after a time-consuming attempt to release feedback remains an essential part of surgical training, severe adhesions, in a child who previously had a V-because it includes all of the variables encountered P shunt for hydrocephalus.The other child had an in surgery. [11,12]neventful surgery and this result encouraged us to continue with this modality in suitable cases of high The intent of this discussion is to acquaint how imperforate anus with fistula.Laparoscopic high important it is to teach trainees, what can and should ligation for varicocele (12 cases) and Fowler-Stephens be done via MAS in the pediatric population.Today's operation (18 cases) for undescended, intra-parents are bringing their children in for surgical abdominal testicle, were routine MAS procedures that consultation after profound "search" on the internet replaced almost all "open" approaches for such for a specific problem.They are well informed about pathology.From the so-called "gynecological therapeutic options and require the best possible procedures", all cases were done as "urgent" cases of acute abdominal pain with peritoneal signs and uncertain diagnosis.Nine cases of ovarian cysts (ruptured or hemorrhagic) and one case of ovarian torsion were successfully treated in a timely manner.Laparoscopic hand-assisted bilateral nephrectomy performed for persistent post transplant polyuria in 2 patients with juvenile nephronophthisis was safe, was tolerated very well and allowed out-patient follow-up of these patients who were otherwise dependent on intravenous infusion.

DISCUSSION
Various workshops have been developed in adult medical care.An important issue that must be kept in mind, is that just because a procedure can be done technically, does not mean that it is better for the patient.The MAS technique must be at the very least and as safe and effective as the procedure it purports to replace.
The surgeon must be fluent with conventional surgical methods in situations when the MAS approach is not feasible or results in problems that require rapid conversion to "open" operation.Nevertheless, there is a learning curve and the potential for a higher complication rate is one of the most uncomfortable facts that teaching staff have to face, especially when this is judged against the excellent results of many Without open-minded and supporting staff/ consultants as leaders, surgical residents/fellows are unable to gain skills and make any progress, unless Kravarusic D: Teaching impact in pediatric prospective studies will allow determination of standard guidelines for MAS teaching in the pediatric population.
by open surgery.Some senior pediatric surgeons are reluctant to promote MAS skills when they are already highly proficient in open surgery.

Table 1 : The spectrum of MAS procedures with comparison to relevant conventional "open" procedures during the same period of time.
pediatric minimal access surgery in terms of teaching feasibility, safety and impact on standard practice paradigms of a single institution.The Alberta Children's Hospital is a pediatric tertiary care facility for patients from the neonatal period, to late adolescence.This report is a retrospective review of all MAS procedures performed in the pediatric general surgery department, from June 2004 to June 2005.The selection of patients and procedures in this series Appendectomy and the patient's medical condition.All surgeries were Cholecystectomy performed by the single pediatric surgery fellow, with Gastrostomy insufficiency and malignancy.A total of 314 MAS procedures were performed in sampling Bowel resection's for Crohn's/FAP 311 patients, of which 56 were thoracoscopic and Pull through for Imperforated anus 258 laparoscopic [Table1].The range included 28