# Young pediatric surgeons without endoscopic surgical skill qualification safely perform advanced endoscopic surgery under the supervision of expert qualified surgeons

## TL;DR

Young pediatric surgeons can safely perform complex endoscopic surgeries under the guidance of experienced surgeons, even without formal skill certification.

## Contribution

Demonstrates that supervised practice by non-certified surgeons achieves comparable safety and outcomes to certified surgeons in most cases.

## Key findings

- No significant differences in outcomes for choledochal cyst and lobectomy surgeries between ESSQ and non-ESSQ groups.
- Non-ESSQ surgeons had longer operative times for biliary atresia but similar complication and recovery rates.
- Supervised practice by non-ESSQ surgeons is safe and effective for most advanced endoscopic pediatric surgeries.

## Abstract

Young pediatric surgeons should receive adequate training in various minimally invasive surgeries (MIS). However, it is essential to maintain patient safety and outcomes during the learning process. In Japan, the endoscopic surgical skill qualification (ESSQ) system in pediatric surgery was initiated by the Japan Society for Endoscopic Surgery (JSES) in 2009 to objectively evaluate the skill of endoscopic surgeons. This study compared perioperative outcomes between pediatric surgeons with ESSQ qualifications and those without (non-ESSQ).

We retrospectively reviewed the medical records of children with choledochal cyst (CC), lobectomy, and biliary atresia (BA) who underwent MIS at our hospital from 2013 to 2023. We assessed the performance of nonqualified surgeons assisted by supervisors with ESSQ qualifications.

This study included the records of 101 surgical cases with CC (operated by ESSQ: 36, non-ESSQ: 65), 78 patients with BA (operated by ESSQ: 35, non-ESSQ: 43), and 67 patients with lobectomy (operated by ESSQ: 31, non-ESSQ: 36). For the CC and lobectomy groups, there were no significant differences in operating time, blood loss, and postoperative complications (PO) between the ESSQ and non-ESSQ groups. In BA, the operative times for the ESSQ and non-ESSQ groups were 310 and 377 min, respectively (p = 0.001). Furthermore, no significant differences were observed in blood loss, PO, jaundice-clearance ratio, and jaundice-free survival rate with the native liver between the two groups.

The results indicate that young pediatric surgeons can safely perform MIS while practicing under the supervision of experienced ESSQ-qualified surgeons.