title: Laparoscopy in pediatric surgery: Implementation in Canada and supporting evidence.
abstract: OBJECTIVE
  The purpose of this study was to assess the diffusion of laparoscopy usage in Canadian pediatric centers and the relationship between uptake of laparoscopic surgery and the level of evidence supporting its use.
  
  
  METHODS
  National data on four pediatric laparoscopic operations (appendectomy, pyloromyotomy, cholecystectomy, splenectomy) were analyzed using the Canadian Institute for Health Information Discharge Database (2002-2013). The highest level of evidence to support the use of each procedure was identified from Cochrane, Embase, and Pubmed databases. Chi-square test for trend was used to determine significance and time to plateau.
  
  
  RESULTS
  There were 28,843 operations (open: 12,048; laparoscopic: 16,795). Use of laparoscopic procedures increased over time (p<0.0001). A plateau was reached for cholecystectomy (2006), splenectomy (2007), and appendectomy (2012), but not for pyloromyotomy. Laparoscopic pyloromyotomy in 2013 remains less diffused than the other procedures (p<0.0001). Laparoscopic appendectomy and pyloromyotomy are supported by level-1a evidence in children, whereas cholecystectomy and splenectomy are supported by level-1a evidence in adults but level-3 in children.
  
  
  CONCLUSIONS
  In Canada, it has taken a long time to reach high-level implementation of laparoscopic surgery in children. Laparoscopic cholecystectomy first reached plateau, whereas laparoscopic pyloromyotomy continues to increase but remains low despite high level of evidence in support of its usage compared to open surgery.
authors.affiliation: Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Victoria
authors.initials: V
authors.lastname: Sattarova
authors.affiliation: UCL Institute of Child Health, London, United Kingdom.
authors.forename: Simon
authors.initials: S
authors.lastname: Eaton
authors.affiliation: Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
authors.forename: Nigel J
authors.initials: NJ
authors.lastname: Hall
authors.affiliation: Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Eveline
authors.initials: E
authors.lastname: Lapidus-Krol
authors.affiliation: Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Augusto
authors.initials: A
authors.lastname: Zani
authors.affiliation: Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. Electronic address: agostino.pierro@sickkids.ca.
authors.forename: Agostino
authors.initials: A
authors.lastname: Pierro
mesh_terms: D001062:Appendectomy / Q000379:methods / Q000706:statistics & numerical data; D002170:Canada; D002648:Child; D017081:Cholecystectomy, Laparoscopic / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data*; D011708:Pylorus / Q000601:surgery; D012189:Retrospective Studies; D013156:Splenectomy / Q000379:methods / Q000706:statistics & numerical data
keywords: Appendicitis; Children; Cholecystectomy; Laparoscopy; Minimally invasive surgery; Pediatric surgery; Pyloromyotomy; Splenectomy; Surgery