Aesthetics and Innovation in Paediatric Surgery
Adrian Bianchi
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The Royal Manchester Children's
Hospital's Adrian Bianchi was
chosen by the graduating fellows
in paediatric surgery as this year's
Simpson-Ein lecturer because
of his many innovations and his
emphasis on aesthetics. He used
Michelangelo's maxim that "the
marble not yet carved contains the
form" to capture the concept that
children speak implicitly to surgeons, telling them what
the goal of surgery should be. We should imitate the
plasticity of the developing brain to imagine the future
roles of the child. Bianchi intuitively hears the neonate
with esophageal atresia saying, "I want to be able to eat
and swallow like the other children." The dilated hypertrophied
proximal pouch and the atretic distal remnant
can be brought together. This traditional way of restoring
continuity results in a wineglass-shaped esophagus,
too narrow to allow normal swallowing. To fulfill the
child's wish, Bianchi creates a rotation flap from the
upper pouch, enlarging the distal segment.
Hearing the wish of a beautiful newborn girl to someday
be a model can inspire a surgeon to switch from a
traditional thoracotomy to an axillary crease incision
to approach intrathoracic problems. A circumumbilical
incision similarly leaves no visible unsightly scar after
treatment of a range of intestinal problems from atresia
to pyloric stenosis. Gastroschisis can be treated by slow,
patient reduction in a single step, without intubation or
general anaesthesia, followed by closure using the umbilical
cord "as the bottle cap" with an excellent cosmetic
outcome. Mr. Bianchi took us through a series of procedures
for intestinal atresia, including his longitudinal
intestinal lengthening and tailoring procedure (LILT)
splitting the dilated segment on its dual blood supply,
tailoring it to a smaller diameter, and anastomosing the
newly formed and lengthened segments. Subsequent
reversal of a segment to slow transit, dilation of segments
to enlarge them by raising the intraluminal pressure and
treatment with clonidine to decrease intestinal secretion
will reward a patient surgeon's persistence with a satisfactory
functional outcome.
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The Bianchi aesthetic approach includes scrotal incisions
for hernias or undescended testes instead of laparoscopy
or traditional repairs. Mr. Bianchi favours cross-training
on multiple services during residency to develop a variety
of skills and a transdisciplinary rather than a multi-disciplinary
approach to patients. He defines surgery as an art
form that affects the lives of others and his Simpson-Ein
Lecture ably fulfilled this definition.
Paediatric surgery fellow Cassandra Kelleher asked
"How can I innovate like this, especially if I am practicing
in the United States?" Mr. Bianchi emphasized that
the innovative procedure should be reasonable, wellplanned
and endorsed by colleagues, performed with
supportive staff of nurses and anaesthesia, and parents
must be convinced of the rationale. In brief, his solution
to innovation is informed consent and collegial
endorsement. Nevertheless, he warned, "Innovators
must lift their heads above the parapets of conventional
practice. By doing so they make themselves vulnerable
targets for professional criticism and public opprobrium."
The Hospital for Sick Children has been a leader in
innovation. Jack Langer praised the contributions of
James Simpson in, among other things, introducing
non-operative management of splenic injury, and
Sigmund Ein for his many contributions to patientcentred
care and the understanding of the natural history
and treatment of paediatric surgical diseases. The
Hospital for Sick Children's policy (1) on innovation contains
the elements prescribed by our visiting lecturer and
incorporated into the practice of our paediatric surgeons
in all disciplines over many years. Siggy Ein spoke for
his family, and the Simpson family in attendance: "As a
student and colleague of Jimmy Simpson, I know that he
would be proud of the lecture we heard today."
M.M.
(1) Zlotnik Shaul R, McDonald M, Langer JC. Facilitating
Innovation in the Clinical Setting: A Pathway for
Operationalizing Accountability Healthcare Quarterly,
2009;12(3):60-65.
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