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BACKGROUND: In Pediatric Urology, minimally invasive surgical (MIS) techniques are increasingly utilized with various advantages noted including improved cosmesis. Some advocate that the same surgery can be performed open with a single incision that competes in length with the sum of trocar incisions in a MIS procedure. While the total length may be comparable, the tension of the incision(s) must be taken into account; since it might impact wound healing and could lead to pathologic scarring. It has been demonstrated that open incisions are subject to considerably more tension than the sum of MIS incisions of equal total length (1). We sought to prospectively evaluate the wound characteristics of MIS and open surgical incisions in a pediatric cohort using Crowdsourcing. Crowdsourcing is a novel method for data processing that employs the collective intelligence of networked communities.
METHODS: Between July 2012 and December 2015, we prospectively evaluated the incisions of children who underwent MIS and those who underwent open inguinal procedures. All surgeries were performed by a single surgeon. The incision was measured intraoperativey and then compared to de-identified photos of the incision with a ruler in the field that underwent measurement by Crowdsourcing. In-person and Crowdsourcing measurements were also completed at one month and one year postoperatively. The Crowdsourcing measurement was used for the below analysis. IRB approval and informed consent for photography was obtained.
RESULTS: There were 210 MIS patients and 242 open surgical patients, of which 6.7% and 16.1% were lost to follow up, respectively. In the final analysis, a total of 610 MIS incisions from 196 patients were compared to 278 inguinal incisions in 203 patients (128 unilateral, 75 bilateral cases) from the open cohort. For MIS procedures, the wounds consisted of incisions from 156 3mm ports, 242 5mm ports, 201 8mm ports, and 11 12mm ports. The mean age of children for the MIS procedures was 19.8 months (range 6-87) and 22.1 months (range 3-98) for open surgery. There were 131 boys and 65 girls who underwent MIS, and 199 boys and 4 girls in the open cohort. See Table 1 for results. Upon further evaluation, all incisions larger than 15.77mm increased in length by 22.3% by one year postoperatively, whereas incisions between 14.11-15.77mm remained relatively stable and those smaller than 14.11mm had a 28.8% reduction in length by one year follow up. The difference between the in-person and Crowdsourced incision measurement was insignificant, as the in-person measurement fell within one standard deviation of the Crowdsourced mean.
CONCLUSIONS: We observed that in pediatric urology MIS incisions and open incisions measuring less than 14.11mm in length will contract over time. Future investigation is warranted to explore this phenomenon so that wound healing can be better characterized. In this analysis, Crowdsourcing proved to be an effective instrument for blinded assessment.
(1) Blinman T (2010) Incisions do not simply sum, Surg Endosc 24: 1746-51

Table 1: Wound characteristics measured in millimeters(mm) with percentage change by one year postop

Type of Incision	Number	Intra-op (mm)	1 mo post-op (mm)	1 yr post-op (mm)	% Change
3mm Ports	156	3.72 (3.33-3.89)	3.85 (3.51-4.13)	2.42 (2.24-3.05)	-35.1
5mm Ports	242	6.11 (5.65-6.57)	6.34 (5.89-6.97)	4.46 (3.89-5.41)	-27.7
8mm Ports	201	9.25 (8.72-10.10)	9.54 (8.53-11.22)	6.65 (5.86- 8.18)	-28.1
12mm Ports	11	13.97 (13.22-15.37)	13.85 (13.35-15.79)	10.80 (9.75-12.85)	-23.5
Inguinal	278	17.42 (13.33-21.25)	19.10 (13.52- 22.28)	20.03 (12.29- 24.12)	+15.8