Pediatric surgery involves the diagnostic, operative, and postoperative surgical care of children with congenital and acquired anomalies and diseases [1]. There is no universal definition of a pediatric surgeon, as some are recognized through specific board certification while others have developed a niche based on clinical experience alone [2]. The journey to become a surgeon that operates on this special population is tedious but rich in history.

2. The Future Direction of the Simulation-Based Training of Pediatric Surgeons

As pediatric surgical simulation training continues to evolve, the future needs of the field should include the creation of more models tailored to pediatric surgery, the expansion of video gaming technology to clinical areas of limited training exposure, and more implementation of simulation-based curricula. Previous reviews have noted that very few pediatric surgical simulators are readily available for purchase, but some literature examples enable departments and hospitals to develop their own ^[3][35]. Now that 3D printers have become more commercialized, some hospitals have 3D printing programs or institutes for clinical and research purposes. It is possible to print anatomic structures—like bones to internal organs—that can be handled during surgical procedures. Engineers and trained technicians can therefore develop products to meet the haptic and tactile needs of surgeons (Figure 1). A hybrid of 3D printing and cadaver tissue has even been used ^[4][30].

2.1. Technology Expansion

The expansion of video gaming technology also enables training in areas of limited exposure for pediatric surgery trainees. These are low-frequency, high-stakes events. One such area is pediatric trauma education. Pediatric trauma is the leading cause of mortality in children ^[5][51]. It is essential to prepare providers, surgeons, and non-surgeons to take care of this special population to improve outcomes. However, specific simulators for trauma are very limited, especially for pediatric and infant patients. Moulage, special makeup, is often used to simulate critical injuries on non-trauma-designated manikins (Figure 2a,b). Trauma simulators can range from USD 14,000 to USD 200,000 depending on the size of the manikin and the level of desired fidelity ^[6][7][8][52,53,54]. A lower-cost simulation solution is digital. Several companies are creating simulation training through VR to train providers with minimal exposure to pediatric trauma ^[9][55]. Specialized topics include mass casualty situations in both the military and civilian populations. It provides a psychologically safe environment to practice making life-saving decisions in preparation for actual events. Taking it a step further, augmented reality (AR) decision-making systems with algorithms for trauma activations have been designed in New Zealand, with expanded use in Asia and the Middle East ^[10][56]. Collaboration among adult and pediatric surgeons can expand this further and help reduce morbidity and mortality outcomes in children around the world. The surgical field is shifting to implementing artificial intelligence (AI) which encompasses machine learning, to offer feedback on trainee surgical performance after video review ^[11][57]. As surgical fields such as neurosurgery, urology, and some general surgery subspecialties look to artificial intelligence, the question remains if pediatric surgery will follow suit ^[12][13][14][58,59,60]. Similar to 3D VR, AI has been proposed for pre-operative planning with a focus on visualization ^[15][61]. However, there is still work that needs to be done as far as reducing implementation and production costs, providing clear evidence that this technology is superior to the current standard, and addressing intrinsic technology limitations (i.e., cybersickness, head-mounted devices, and power for graphic processors) ^[10][56]. Future technologies are likely to improve haptic sensations in VR and digital simulations, building on hybrid models that combine tactile sensations with digital solutions to achieve learning objectives. Haptics are not optimized for current digital simulations, despite the importance of haptic feedback in pediatric surgical procedures. The researchers predict that haptic technology will enhance future training, which will fully enable digital and distance-based simulations for pediatric surgeons ^[16][62]. In addition, as the future becomes even more technology-driven, we must not forget the importance of pediatric surgery training in countries with limited resources or technological access (Figure 3).

2.2. The Widespread Implementation of Simulation-Based Curricula

The idea of simulation-based training was to build on technical skills that will be transferred to improve performance in the operating room and/or to fill in the education gaps for limited exposure to certain pediatric surgical cases. In addition to evaluating technical skills, simulation has been shown to be superior to didactic training courses for non-technical skills such as leadership, communication, situational awareness, and decision-making ^[17][63]. This is important as up to 35% of total adverse events in children are reported during the perioperative period, and communication is thought to be a factor in 43% of errors made in surgery ^[18][19][64,65]. A survey of pediatric surgical trainees as part of a simulation program in France reported inadequate training in the area of non-technical skills ^[20][66]. More pediatric surgery programs have used simulation as part of boot camps or developed simulation-based curricula as part of trainee development ^[21][22][23][32,67,68]. With the implementation of minimally invasive surgery three decades ago, MIS procedures have become more integrated into the pediatric surgery training curriculum. From 2004 to 2016, there was a 30% increase in the average number of MIS cases per fellow in Canada and the United States with variation in exposure among trainees ^[24][69]. In contrast, 67% of pediatric surgery trainees from European countries responded to a survey of the challenges in their program performing of MIS procedures, and fewer than 5 out of 25 pediatric MIS procedures were performed by at least 50% of trainees ^[25][22]. Like in Northern America, there was great variability in training and exposure in Europe as years spent in a general surgery department led to a greater number of higher complex procedures performed compared to years in pediatric surgery training ^[25][22]. Some fellowship programs have developed and implemented MIS programs to help mitigate this weakness in training fellows. Recently, Bailez et al. wrote about the development of a minimally invasive surgery training program, onsite and telesimulated, with low-cost models in Argentina that has led to surgical efficiency and an increase in the complexity of cases performed ^[26][70]. In low- to middle-income countries (LMICs), there is a greater need to train more pediatric surgeons, and the method of training varies per country ^[27][28][71,72]. Almost half of the population in LMICs are children under the age of 15 ^[29][73]. Compared to high-income countries (HICs), LMICs do not have enough resources at each site, but substantial improvements have been made ^[30][74]. Education methods include collaborations between countries with different resources. High-income countries have sent visiting teams to teach workshops on complex procedures, acting as mentors to trainees and, through advocacy after returning home, helping bring awareness to the training needs of LMIC ^[31][75]. Other training methods used in the past include international pediatric surgery fellowships and fellow exchange programs in HICs to further improve the availability of diverse pediatric surgery talent ^[28][32][33][72,76,77]. A fellow exchange program between Montreal Children’s Hospital (Canada) and Bethany Kids of Kijabe Hospital (Kenya) resulted in more frequent exposure to neonatal, MIS, and vascular procedures for Kenyan trainees ^[33][77]. Reported difficulties from Kenyan surgical trainees were obtaining a training license and the financial burden of the cost of living in HICs. As of today, some pediatric surgery training centers in Africa still have limited exposure to trauma, burn, and minimally invasive surgery ^[34][78]. A recent survey of surgery residents in 11 Sub-Saharan African countries apart of the College of Surgeons of East, Central, and South Africa (COSECSA) strongly believed that simulation was valuable and should be part of their training program ^[35][79].

2.3. The Metric-Based Evaluation of Surgical Trainees in Simulation Training

Prior to the introduction of anesthesia in the 19th century, the early metric in the assessment of skills for surgeons was operative time length. This type of evaluation gave no indication of the quality of performance or feedback. Metric-based assessment in surgery has evolved with the development of the Objective Structured Assessment of Technical Skills (OSATS) which is similar to the Objective Structured Clinical Examinations (OSCE) commonly used to evaluate healthcare students ^[36][80]. Since its first creation, the OSATS has been modified in different surgical fields such as CT surgery and gynecology ^[37][38][81,82]. Although the OSATS is widely accepted in surgery, the greatest issues are a lack of objectivity, it does not meet the extrapolation criteria for Kane’s validity framework, and the inability to differentiate competencies for more experienced trainees due to the ceiling effect of the rating scale ^[39][40][83,84]. The development of a successful metric might appear to be simple, but more attention needs to be given to breaking down procedure-specific tasks into their essential components, strictly defining what differentiates optimal from suboptimal performance, and including non-technical skills. The combination of an assessment tool with video recordings strengthens the evaluation of trainee performance and enables evaluation for discriminative validity ^[41][85].