Reconceptualizing Pediatric Surgery for the Adult Surgeon: A New Era of Integrated Surgical Care

BACKGROUND: Despite major advances in global surgery, children remain insufficiently represented within surgical system strengthening efforts, particularly in low- and middle-income countries where specialist pediatric surgical capacity is limited. This article reflects on a decade of work by the Global Initiative for Children's Surgery and its academic partners, highlighting approaches to addressing unmet pediatric surgical needs and considering how these lessons can inform closer integration of children's surgical care within broader global surgery systems. METHODS: We synthesized published literature on global pediatric surgical need, barriers to access, workforce limitations, surgical outcomes and health-system responses, alongside examples of initiatives developed through the Global Initiative for Children's Surgery (GICS) and its academic partners. Findings were interpreted through the three-delay framework and emerging integrated emergency, critical and operative care approaches. RESULTS: Pediatric surgical access is constrained by delays in seeking, reaching and receiving appropriate care, compounded by shortages of specialist personnel and concentration of pediatric surgical services in urban tertiary centers. GICS-supported initiatives have addressed different points along this pathway through service standards, outreach, decentralized care, multidisciplinary training and hub-and-spoke models. Training adult surgical, anesthesia and nursing teams to provide essential pediatric care represents a pragmatic strategy where specialist pediatric surgeons are unavailable. However, improving access alone is insufficient without parallel attention to quality, resuscitation, perioperative care and recognition of deterioration. CONCLUSIONS: Pediatric surgery should not develop as a parallel system to broader global surgery efforts. Children's surgical care should be deliberately incorporated into national surgical planning and workforce development and integrated emergency, critical and operative care systems. Strengthening adult teams to safely manage essential pediatric surgical conditions offers a scalable approach to improving both access and quality in resource-constrained settings.