The specialty of pediatric surgery has undergone a significant evolution during the past 50 years. During the career of Robert Gross (19051988), one of the leaders in pediatric surgery in the 20th century, the specialty was practiced mainly in children's hospitals by surgeons trained in a few centers. Routine procedures, such as appendectomy and pyloromyotomy, were performed mainly in community hospitals by general surgeons. More specialized pediatric surgical procedures, such as repair of intestinal atresias and solid organ tumors, were performed at children's hospitals more often than they are today.
Pediatric surgical care has steadily become decentralized as the number of trained pediatric surgeons has increased and the quality of pediatric care in community hospitals has improved. Today, more newly trained pediatric surgeons begin their careers in practices based at large general hospitals man at children's hospitals. In addition, pediatric surgical groups increasingly provide coverage at more man one hospital.1 The effect of these changes is that the services of our specialty are available to more children in their own communities than ever before. In many communities, it is no longer necessary to transfer infants and children with problems requiring the specialized training of a pediatric surgeon, such as esophageal atresia. In addition, children with common problems, such as appendicitis and pyloric stenosis, can benefit from the specialized care of a pediatric surgeon without having to travel to a large, urban children's hospital.
The success of decentralized pediatric surgical care depends on support from the local medical community. The pediatric surgeon cannot work in isolation, but instead must work closely with pediatricians and other pediatric specialists in anesthesia, critical care, oncology, gastroenterology, pulmonary medicine, and cardiology, just to mention a few.
However, the ability of pediatric surgeons to perform specialized care at a community hospital depends more often on the quality of the hospital's specialty and nursing support man on their surgical skills. The limitations of decentralizing pediatric surgical care should be recognized. Because the depth and the breadth of services at a large children's hospital cannot easily be duplicated at every community hospital, the children's hospital will continue to have an essential leadership role in advancing care in highly specialized areas, such as fetal surgery and intestinal transplantation.
The range of services that the well-trained pediatric surgeon can provide remains wide, whereas the scope of many surgical specialties has narrowed. For this reason, pediatric surgery has been called the last bastion of the "general" surgeon. The scope of pediatric surgery still includes antenatal diagnosis and counseling, neonatal surgery, thoracic surgery, basic urologie surgery, oncologic surgery, and trauma. In contrast to the adult surgeon who may have occasional experience with children, the pediatric surgeon brings a "child's surgeon" perspective to each of these areas and should be used as a resource for the evaluation and treatment of childhood surgical diseases.
For this issue of Pediatric Annals, I have selected several pediatric surgical topics of interest to the pediatrician. I have asked each author to present "what his or her referring pediatrician would like to know" about each topic. Although each problem is common in children, important improvements in the diagnosis and treatment for each have been made during the past decade. I hope that you find the information contained in this issue to be an important update, and to be useful in your practice.
1. Parkerton PH Geiger JD, Mide SS, O'Neill JA Jr. The market for pediatric surgeons: a survey of recent graduates. J Pediatr Surg. 1999;34: 931-939.