Available online 11 February 2026, 151590

Author links open overlay panelLuis G. QuinonezShow moreAbstract

What begins as a surgical improvisation needed during one specific case could later be considered an innovation that warrants widespread adoption. An improvisation only becomes an innovation if it is carefully refined and developed to the point at which it becomes a reliable, reproducible, standardized procedure. This process can take years. This article draws on a case to walk a reader through key ethically and clinically important questions along the path of developing what might eventually come to be called an important surgical innovation.

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Dr C is a pediatric cardiac surgeon scrubbing for a tetralogy of Fallot (TOF) repair, which they have performed many of times. Preoperatively, the anatomy of the 4-month-old patient, JJ, is known to be complex. When JJ’s chest is opened, a previously unrecognized coronary artery anomaly is also revealed, which necessitates an urgent and creative response from Dr C. Dr C modifies their surgical approach to avoid JJ’s coronary artery. JJ recovers from surgery and does well postoperatively.

Dr C

Commentary

Surgeons have developed techniques, tools, and instruments to give them access to the body’s spaces and the ability to operate in them. Surgery during time of war, surgical treatment of infections prior to antibiotics, and oncologic resection prior to chemotherapy (before the understanding of cancer as a systemic disease) have all been drivers of surgical innovation. The nature of pediatric surgery is particularly suited to innovation because of the variability in children’s anatomy, especially

Concluding remarks

Dr C has improvised a surgical technique on one patient and wonders if it could be applied to others. In order to ethically navigate this pathway from innovation to widespread adoption, Dr C should reflect on and discuss this specific improvisation with colleagues. The improvisation must be judged against the standard of care and thought given to risks of harms posed by the new technique. Dr C needs to decide whether similar improvisation in the care of other patients requires consent. Based on

Author information

Luis G. Quinonez, MD is an attending cardiac surgeon at Boston Children’s Hospital affiliated with Harvard Medical School in Massachusetts. He is a Fellow of the Royal College of Surgeons of Canada and a member of the Surgical Ethics Working Group at the Harvard Medical School Center for Bioethics.

Declaration of Interest Seminars in Pediatric Surgery

To the Editorial Board of Seminars in Pediatric Surgery,

I would like to submit my Case Commentary for the upcoming edition of Ethics of Pediatric

Declaration of competing interest

Author disclosed no conflicts of interest relevant to the content.

References (4)

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