An interview with William Middlesworth, MD, Interim Chief of the Division of Pediatric Surgery.
What excites you the most about where pediatric surgery is headed right now?
One of the truly remarkable things about pediatric surgery is how many exciting aspects there are—from the doctoring and educating to the technological and operative advances. Right now, I'm particularly excited about the potential for miniaturization of robotic instrumentation.
Currently, robotic tools aren't quite small enough for infants, but that's starting to change. Our specialty often treats rare diseases, which means there's not always a strong financial case for companies to invest in scaling down instruments for such a small market. But that’s where passion projects come in. People like Steve Rothenberg partnered with engineers to develop three-millimeter instruments, allowing us to perform thoracoscopic procedures, like lung resections, on infants. I think the next major leap will be adapting robotic instrumentation to a size that’s appropriate for babies.
So, would the arms and everything need to shrink as well? Not just the instruments themselves?
Absolutely. It’s not just about modifying the instruments; it’s about reconfiguring the entire platform to operate in tiny spaces. That added precision and improved optics robotics can offer would be even more significant for surgical care in infants.
Wow, that’s exciting.
The other aspect of pediatric surgical care that is so wonderful and amazing is just the gratification that comes from taking care of somebody's child. I really embrace the idea of working with a family, with parents and maybe extended family members, grandparents.
That can be off-putting to some physicians and surgeons because it is another layer of complexity. It's another whole group of people. But I realize whenever I have interactions with adults now or older patients that come on their own, it feels to me like there's something missing, and that everybody should have their family there with them at a doctor visit. Pediatric surgical care is really special and affirming.
Embracing the Future: Tissue Engineering and Magnetics
We ask this question in every interview as part of our Future, Today series, and I’d love to hear your thoughts: what would you say is the most futuristic thing happening in surgery today?
I think tissue engineering is incredibly exciting. One area I’m deeply interested in is esophageal atresia. It's a challenging condition where the esophagus isn't properly connected, and sometimes the gap is too large to bridge. Traditionally, we’ve used methods like pulling the stomach up into the chest or even transposing parts of the intestine to fill the gap. But the future is in tissue engineering—using a scaffolding populated with stem cells to grow a segment of the esophagus that’s genetically native to the patient. This eliminates the need for immunosuppression and, if we can solve vascularization challenges, would be a game-changer.
We’re also experimenting with magnets for esophageal lengthening. The idea is to use magnets to gradually stretch the two ends of the esophagus until they meet. It’s tricky—too far apart, and there’s no attraction; too close, and the force is too strong. But these are hurdles we’re getting closer to overcoming.
We recently talked to Dr. Duron about the latest in vitro surgery. What about fetal surgery?
There's a condition called gastroschisis, which involves a defect in the fetus's abdominal wall, where the intestine is exposed to the amniotic fluid during gestation. We used to treat these babies operatively after birth by reducing the bowel back into the abdomen and suturing or physically opposing the edges of the defect to close it.
And it’s fascinating to me that we've learned this defect can close spontaneously. Our approach has completely shifted. Now, we contain the bowel in a little see-through silo right after birth. Over the course of several days, we gradually reduce it back into the abdomen. Then we wrap the area with the umbilical cord and stabilize it with a dressing for about a week. Incredibly, that abdominal wall defect will actually spontaneously close and heal. The idea that a baby can be born with a significant hole in the abdominal wall and it heals itself without surgical closure is just remarkable to me.
That reminds me of something Dr. Charlie Stolar once said to me: “Too often we’re looking for a surgical answer to a medical problem.”
Right! I think our understanding of what the body can do spontaneously has a lot of room to grow. Pediatric surgery, I believe, has always been about knowing when to jump in and when to try to stay out of the way and let the baby get better, to let a child heal. Especially in children with complex sets of birth defects, it’s about pacing interventions thoughtfully, addressing each condition in a way that doesn’t overwhelm the child but allows for steady, forward progress. Sometimes, doing less is the right choice.
Through having these conversations over the years, that’s been the spirit of the pediatric surgery division for a long time, too.
I look back with a lot of gratitude at the division chiefs that I've had the privilege to work with. Things like professional culture and intellectual honesty, candor, all those things I think come from the top of a smaller organization like an academic surgical division. I feel really lucky in the leadership that I've worked with so far, both for the example that they've set and for having a fertile ground for my own professional growth.
Elevating Outcomes Through Collaboration
Are there any new integrations across specialties or condition-specific collaborations that have evolved in recent years?
Absolutely, and this is the crux of what distinguishes a top-tier children's hospital. It's not just about the talent of individual physicians, but how those talents come together to provide truly synergistic care. At Columbia, we have incredible multidisciplinary teams—our trauma program is a prime example. It brings together pediatric emergency medicine, surgery, orthopedics, and more. It’s a model that really cuts across disciplines.
It's really apparent through the evolution of care for congenital diaphragmatic hernia (CDH) too.
Absolutely. Our diaphragmatic hernia program, where pulmonary hypertension cardiologists work alongside GI physicians and surgeons. Dr. Julie Khlevner, my partner in our Esophageal Atresia Center, has been phenomenal in leading that initiative. We collaborate with ENT, pediatric GI, and pulmonology to manage complex cases, offering not just treatment but a coordinated experience. That makes a real difference for families. I always think about a family with multiple children, where one child has significant medical needs. To be able to consolidate care into fewer visits, even small adjustments like that can be transformative.
Across specialties, that kind of convenience can have massive impact.
The ability to make things a little more convenient for them is important and impactful. That’s one of the promises of the Children's Health Center of Excellence at the 1111 Westchester facility—bringing specialists into proximity so they're actually working side by side and lowering the barriers for collaboration. Being able to chat about tough problems and get other people's perspectives.
How do you hope to evolve this type of close collaboration in the future?
There are so many areas for potentially improving the way we do things. It's so rare now that a hospitalized patient has just one physician team. They almost all have consulting teams, and I think we could improve the way we structure our rounds and our workflow so that it facilitates us communicating with each other and then bringing one voice to the family.
We have a lot of room to grow in that regard because our current model is sort of that each clinical team rounds and sees the patient and the family every day. Often, we're even using the family as a conduit of information from one specialist to another, and that's not really optimal. If I go into a room and say, ‘Oh, what did the infectious disease team say about this infection that we're treating?’ That's not the best. It would be much better if we all could round together.
I haven't figured out logistically how we would do that because surgeons are always rounding obscenely early in the morning and waking everyone up. No one else is even at work yet because we're trying to figure out who might need an operation that day—lots of logistical challenges. There are good models, though, the intensive care units (ICUs) are really setting the standard in rounding, doing a family-centered model, and often having multiple clinical teams together at the bedside at the same time, which really would be the gold standard.
Minimally Invasive Techniques and Surgical Innovation
Have there been any changes to diagnostics, imaging, or genetic testing that are changing the cadence of care or surgery?
Increasingly, genetics is playing a role in identifying specific targets for anti-neoplastic therapies based on a very specific molecular profile of a particular cancer. With imaging, I think for a long time we've tried to steer away from anything that involves ionizing radiation. So, for many years, we've used MRI rather than CT scanning as a way to help diagnose appendicitis. When you think about every kid with a tummy ache who goes to the ER, if they get a CT scan, that's going to be a meaningful increase in the number of cancers in the population as a result.
Ultrasound is ever more accurate and sophisticated, and we’re using it more and more frequently—in the operating room to guide biopsies and tube placements and things like that. So it's not just interventional radiology, which has sort of been the leader in that sort of image-guided therapies, but the use is spreading across lots of other disciplines.
Are there any new minimally invasive tools, techniques, or indications that you're particularly excited about?
Absolutely. One thing that's gaining a lot of attention is the use of indocyanine green (ICG) for enhanced imaging during laparoscopic cases. It's administered intravenously and illuminated with a special light, allowing surgeons to see structures that aren't typically visible to the naked eye. For instance, it can help us clearly identify the common bile duct during gallbladder removal, significantly reducing the risk of injury.
We’re also using ICG in intestinal anastomosis to confirm that there’s adequate blood supply to the ends we are hoping to heal together. This technology makes it much safer and more precise. There’s also been progress in microvascular techniques, particularly in cases like long-gap esophageal atresia, where moving a piece of intestine into that space requires careful preservation of its blood supply. These techniques are allowing us to push the boundaries of what minimally invasive surgery can achieve.
I’m sure clinical trials play a role in all this advancement. Anything to know from the world of research?
Yes, absolutely. Trials are underway to determine the timing of inguinal hernia repair in the very smallest babies. Operating on extremely premature infants carries a higher risk of injury to adjacent structures and a higher risk of hernia recurrence. A lot of what surgeons learn comes from practice that’s been passed down—things we've been taught rather than what would be considered truly rigorous scientific evidence. So now, we have trials investigating not just the optimal timing for repair of inguinal hernias, but also the best techniques.
One of the newer approaches includes minimally invasive methods—needle-scopic techniques, where we introduce a suture through a needle with laparoscopic guidance. We’re also now performing percutaneous tracheostomies safely at the bedside, something that used to require an OR.
Advances in intravenous nutrition enable us to support patients for much longer using lipids that limit adverse effects on the liver. There are also promising models for stimulating intestinal growth, which is critical for babies with intestinal failure caused by conditions like necrotizing enterocolitis. I’ll be the first to admit that my understanding of some of these areas is superficial, but it’s clear that research is pushing boundaries in ways we couldn’t have imagined a decade ago.
Future Directions and Vision for Pediatric Surgery
With all these innovations, what goals are at the top of your mind for you and the team over the next year?
One of the most exciting opportunities in divisional leadership is the impact you can have on the careers of the faculty in your division. Being a good leader and mentor means providing opportunities across clinical practice, education, and research. For me, it’s about helping our faculty grow as surgeons, educators, and researchers—advancing our academic mission and driving new knowledge in the field.
It’s not just about impacting one family or one patient. It's about empowering those who will treat those children and families in the future. At this stage in my career, I’m incredibly passionate about that mentorship aspect and ensuring our division continues to innovate and thrive in pediatric surgery.
What challenges do you foresee for pediatric surgery in the years to come?
The biggest challenge remains access, both in terms of technology and availability of care. Pediatric surgery isn't always profitable, and in this society, that means we have to rely on passion projects and institutional support to drive innovation. But I’m confident that we'll overcome those barriers if we keep focusing on patient-centered care and multidisciplinary collaboration. I hope that we continue to push forward, not just technologically, but also in how we deliver care holistically.
Absolutely. Before we go, what’s your favorite part of your job?
I love so many things about it, but I think one of the really special parts—and this might sound shallow, I don’t know—is the amount of affirmation you get from the people you treat. It’s genuinely wonderful. There just aren’t that many jobs where every single day, somebody thanks you or expresses their gratitude. Most people don’t have that kind of affirmation in their work life, certainly not on such a meaningful level.
And for me, that’s huge. To know in such a tangible way that you’ve impacted someone’s life for the better—there’s just nothing like it. It’s incredibly meaningful, and I’m grateful to experience that every day.
Related:
- Tiny Patients, Big Solutions: A Closer Look at Fetal Surgery Innovations
- On Changing the Standard of Care for Children: What the Evolution of ECMO Can Teach Us
- Teach Them Young: Lemonade Stand Raises Money for Sick Kids at NYP/Columbia