Download - George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri
![Page 1: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/1.jpg)
Laparoscopy for Acute Abdominal Conditions
50th Meeting of the Brazilian Association of Pediatric Surgeons
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, Missouri
![Page 2: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/2.jpg)
Acute Abdominal Conditions• Abdominal trauma
• Small bowel obstruction
• Intestinal perforation – free air
• Ovarian torsion
• Volvulus
• Intussusception
and . . . .
![Page 3: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/3.jpg)
Acute Appendicitis
![Page 4: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/4.jpg)
Laparoscopy -TraumaBackground
• Most intra-abdominal (and intra-thoracic) injuries can be managed non-operatively
• Absolute indications for operation: Shock from intra-abdominal bleeding Pneumoperitoneum Contrast extravasation
• Selective indications for operation Thickened bowel loops Mesenteric infiltration Unexplained free fluid Violation peritoneum on local exploration for penetrating trauma
![Page 5: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/5.jpg)
Laparoscopy - TraumaBackground
• FAST & DPL not as helpful in deciding management in children
• Equivocal findings for an injury are sometimes found on CT scan
![Page 6: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/6.jpg)
When To Use Laparoscopy in Trauma
• Hemodynamically stable patient
• Blunt trauma Free fluid not from solid
organ injury Persistent abdominal
pain/tenderness
• Penetrating trauma Peritoneal violation?
![Page 7: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/7.jpg)
Algorithm
Gaines BA, et al: The role of laparoscopy in pediatric trauma. Sem Pediatr Surg 19:300-303, 2010
![Page 8: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/8.jpg)
Minimally Invasive Surgery for Pediatric Trauma – A Multi-Center Review
1. The Children’s Mercy Hospital, Kansas City, MO2. Emory University, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA
3. Children’s Medical Center, Dallas, TX4. Children’s National Medical Center, Washington, DC
5. Children’s Hospital of Wisconsin, Milwaukee, WI6. Akron Children’s Hospital, Akron, OH
2014 IPEG/BAPS Meeting
Hanna Alemayehu, MD1 Matthew Clifton, MD2; Matthew Santore, MD2; Diana Diesen, MD3; Timothy Kane, MD4; Mikael Petrosyan, MD4; Ashanti Franklin, MD4; Dave Lal, MD, MPH5; Todd Ponsky, MD6; Margaret Nalugo, MPH6; George W. Holcomb III, MD, MBA1; Shawn D. St. Peter, MD1
![Page 9: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/9.jpg)
Operative Interventions
• 205 total MIS procedures 187 patients (94%) – laparoscopy 8 patients (4%) – thoracoscopy 5 patients (2%) – both
• 36% converted to open
![Page 10: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/10.jpg)
Indications for LaparoscopyIndication for Operation Number Completed
LaparoscopicallyNumber
Converted to Laparotomy
Total Number
Conversion Rate
Penetrating Injury 45 17 62 27%
Peritonitis 7 24 31 77%
Free fluid with abdominal pain 17 10 27 37%
Pneumoperitoneum 9 9 18 50%
Other 15 3 18 16%
Worsening abdominal pain with seatbelt sign
8 3 11 27%
Imaging suspicious for hollow viscus injury
5 6 11 55%
Imaging suspicious for pancreatic duct injury
7 0 7 0%
Equivocal wound exploration 6 0 6 0%
Continued transfusion requirement
1 0 1 0%
![Page 11: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/11.jpg)
Conclusion
• Overall MIS was successful in excluding or diagnosing injury, and completing therapeutic intervention in 65% of cases
• Laparoscopy and thoracoscopy can be performed safely and effectively for both diagnostic and therapeutic purposes in stable pediatric trauma patients
![Page 12: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/12.jpg)
Pediatr Surg Int. 2014 Sep 21(epub ahead of print)
![Page 13: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/13.jpg)
Laparoscopic Pancreatic Resection forTrauma
• 2000 – 2012• 13 US pediatric trauma centers• 167 patients
95 managed nonoperatively 57 underwent resection
80% laparoscopically since 2008
Pediatr Surg Int. 2014 Sep 21(epub ahead of print)
![Page 14: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/14.jpg)
Laparoscopic TraumaticDiaphragmatic Hernia Repair
![Page 15: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/15.jpg)
Laparoscopic TraumaticDiaphragmatic Hernia Repair
![Page 16: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/16.jpg)
Laparoscopy forPossible Traumatic Bowel Injury
![Page 17: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/17.jpg)
Laparoscopy for Possible Traumatic Bowel Injury
![Page 18: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/18.jpg)
Laparoscopy forPenetrating Traumatic Injury
![Page 19: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/19.jpg)
Conclusions
• Laparoscopy can be a useful tool for diagnosis of a traumatic injury when the diagnosis is not clear
• Some traumatic injuries can be managed entirely laparoscopically or with the use of a small umbilical incision
• Patient must be hemodynamically stable if the laparoscopic approach is utilized
![Page 20: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/20.jpg)
![Page 21: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/21.jpg)
Laparoscopy for Small Bowel Obstruction
• Jan 01 – Dec 08• 34 patients
Mean age 8.1 yrs ± 5.9 Adhesions – 74% Conversion – 11 pts
Inadeq working space Volvulus Could not identify source Enterotomy
Our protocol: Initial laparoscopic management unless contraindications present
![Page 22: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/22.jpg)
Laparoscopy for Small Bowel Obstruction
![Page 23: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/23.jpg)
Intestinal Perforation – Free Air
• Patient hemodynamically stable• Reason for perforation unclear• Allows directed open incision (if necessary)
![Page 24: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/24.jpg)
Laparoscopy for Ovarian Torsion
![Page 25: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/25.jpg)
Emphasis Now On Conservation Of Ovarian Tissue
• Long-term results of conservative management of adnexal torsion in children J. Pediatric Surgery (2005) 40: 704– 708
• Ovarian torsion in children: Management and outcomes J. Pediatric Surgery (2013) 48: 1946–1953
• Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls Eur. J. Pediatric Surgery (2010) 20: 298 – 301
![Page 26: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/26.jpg)
Laparoscopy for Malrotation - Volvulus
• Hemodynamically stable patient
• Difficult to reduce volvulus in an infant (not enough working space)
• Laparoscopy very good for pt with malrotation but no volvulus
![Page 27: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/27.jpg)
• 1996 – 2009
• 284 Ladd procedures Open – 241 Laparoscopic - 43
• Laparoscopic – 33% conversion – almost all
due to volvulus
• Recurrent volvulus – 6 pts (2.4%) - all s/p open Ladd procedure
![Page 28: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/28.jpg)
Laparoscopy for Intussusception
• Hemodynamically stable infant
• Our usual initial approach
• Convert if unsuccessful
• 5 mm atraumatic clamps position across width of bowel
![Page 29: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/29.jpg)
• 1998 – 2008
• 22 pts (2.9 yrs, mean) 19 ileocolic 3 small bowel
• 20 pts successfully managed laparoscopically or via extending umbilical incision ( 9 pts 7 bowel resections)
• 2 required RLQ laparotomy
![Page 30: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/30.jpg)
Acute Appendicitis
1. When do we operate?
2. How do we define perforation?
3. What is the incidence of a postoperative abscess?
4. Should we irrigate the abdomen?
5. Is there an advantage to a single umbilical laparoscopic approach?
![Page 31: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/31.jpg)
1. When to operate?Current Practice at CMH
• Patients identified with appendicitis are booked for laparoscopic appendectomy• All receive a dose of rocephin (50mg/kg) and flagyl
(30mg/kg)
• This antibiotic regimen was shown to be most cost effective in PRT
• If patients present at night, the operations are scheduled for the ‘surgeon of the week’ the next day (8 am or 1 pm start)
• Appendectomies rarely occur after 10 PM at night
![Page 32: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/32.jpg)
Non-Operative Mgmt• Non-operative management with antibiotics for
both acute and perforated appendicitis in adults is successful as primary, definitive therapy in up to 70% of patients.
• About 20-30% will fail antibiotic management and will need an operation
• Appendectomy is now probably considered the gold standard of treatment options, but unclear if this will change in the next 10 years.
![Page 33: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/33.jpg)
Operation At Presentation Versus The Following Day
Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 39:464–469, 2004.
• Retrospective comparison in children (Level 3 study) between operation < 6 hrs after presentation or the following day
• 126 patients (38 early vs 88 late)
• No differences in operating time, perforation rate, or complications
![Page 34: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/34.jpg)
• The literature is replete with retrospective studies regarding perforated appendicitis
• All of these studies fail to strictly define perforation
Dependent on surgeon’s definition
“Gangrenous”, “suppurative”, “perforated”
• Therefore, the conclusions from these retrospective reports must be approached cautiously
2. How do we define perforated appendicitis?
![Page 35: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/35.jpg)
J Pediatr Surg 43:2242-2245, 2008
![Page 36: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/36.jpg)
Visible appendicolithHole in appendix
Definition of Perforation Used in Prospective Randomized Trial
![Page 37: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/37.jpg)
3. What is the incidence of postoperative abscess?
• Acute, non-perforated appendicitis 609 pts (Apr 03 – Nov 06) 3 postop abscesses (0.49%)
• Perforated appendictis 20%
![Page 38: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/38.jpg)
4. Should we irrigate and suction the abdominal cavity for perforated appendicitis?
![Page 39: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/39.jpg)
• Perforated appendicitis: hole in appendix or fecalith in abdomen
• Minimum irrigation 500 cc saline
![Page 40: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/40.jpg)
ResultsPatient Demographics
No Irrigation (n = 110) P Value
Age (years)
Weight (kg)
BMI (%tile)
Gender (% male)
9.7 +/- 3.6
41.2 +/- 19.8
65.0 +/- 32.3
59.1%
10.4 +/- 3.8
41.5 +/- 18.8
60.7 +/- 31.9
52.7%
0.17
0.92
0.36
0.89
Irrigation (n = 110)
ASA 2012Ann Surg 256:581-585, 2012
![Page 41: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/41.jpg)
ResultsOutcomes
No Irrigation (n = 110)
Abscess (%)
Op Time (mins)
Initial PO’s (days)
Reg Diet (hrs)
Narcotic Doses
Days of Stay
Charges ($K)
P Value
19.1%
38.7 +/- 14.9
2.6 +/- 1.5
3.4 +/- 1.7
11.4 +/- 5.4
5.5 +/- 3.0
48.1 +/- 20.1
18.3%
42.8 +/- 16.7
2.5 +/- 1.3
3.5 +/- 1.5
11.6 +/- 6.3
5.4 +/- 2.7
48.1 +/- 18.2
1.0
0.06
0.70
0.63
0.76
0.93
0.97
Irrigation (n = 110)
ASA 2012Ann Surg 256:581-585, 2012
![Page 42: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/42.jpg)
Conclusions
There is no advantage to irrigation of the
peritoneal cavity over suction alone during
laparoscopic appendectomy for perforated
appendicitis
ASA 2012Ann Surg 256:581-585, 2012
![Page 43: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/43.jpg)
5. Is a single umbilical laparoscopic approach advantageous?
![Page 44: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/44.jpg)
Prospective Randomized Trial
• 360 total patients• Acute non-perforated appendicitis• August 09 – November 10• Primary outcome variable – postoperative wound
infection• Standardized pre and postoperative management• Quality of life surveys at 6 weeks and 6 months
Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy
ASA 2011Ann Surg 254:586-590, 2012
![Page 45: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/45.jpg)
Patient Characteristics at Operation
Single Incision (N=180)
3-Port (N=180)
P-value
Age (yrs) 11.05 ± 3.47 11.04 ± 3.41 0.98
Weight (kg) 42.7 ± 18.5 42.5 ± 17.4 0.90
Gender (% male) 54.4% 51.1% 0.53
Leukocyte count 14.7 ± 5.2 14.6 ± 5.4 0.89
ASA 2011Ann Surg 254:586-590, 2012
![Page 46: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/46.jpg)
Outcome Data
Single Incision (N=180)
3-Port (N=180)
P-value
Wound Infection 3.3% 1.7% 0.50
Operative Time (mins) 35.2 ± 14.5 29.8 ± 11.6 <0.001
Postoperative Length of Stay (hours) 22.7 ± 6.2 22.2 ± 6.8 0.44
Hospital Charges ($) 17.6K ± 4.0K 16.5 ± 3.8K 0.005
ASA 2011Ann Surg 254:586-590, 2012
![Page 47: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/47.jpg)
Other OutcomesSingle Site (N=180)
3-Port (N=180) P-
ValueSurgical Difficulty (1 – Easy to 5 – Difficult)
2.3 +/- 1.4 1.7 +/- 1.0 < 0.001
Abscess 0.0% 0.6% 0.99Time to Liquid Diet (Hours)
4.1 +/- 3.7 3.7 +/- 3.1 0.25
Time to Regular Diet (Hours)
7.2 +/- 5.1 6.9 +/- 5.2 0.48
Total Doses of Analgesics
9.6 +/- 4.9 8.5 +/- 4.3 0.04
ASA 2011Ann Surg 254:586-590, 2012
![Page 48: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/48.jpg)
![Page 49: George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri](https://reader036.vdocument.in/reader036/viewer/2022062407/56812c1b550346895d9082e5/html5/thumbnails/49.jpg)
QUESTIONS
www.cmhclinicaltrials.com
www.cmhmis.com