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Aesthetics and Innovation in Paediatric Surgery

Adrian Bianchi
Adrian Bianchi

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.

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."


(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.

Liquid contrast: funnel anastomosis
Flap transposed and inset
Flap tubed to enlarge distal segment

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