Peer-reviewed article

NEC-In-A-Box: Simulating Intraoperative Decision Making for Necrotizing Enterocolitis.

Devin J Shah, Branae Rollins, Todd P Chang, Arash Safavi, Ryan G Spurrier · 11 Sept 2026

Abstract

OBJECTIVES: The purpose of this study was to evaluate the efficacy of a novel, low-fidelity simulation activity in improving intraoperative decision-making and confidence among surgical trainees managing necrotizing enterocolitis (NEC). DESIGN: This was a prospective educational pilot study utilizing a pre-test/post-test design. The intervention was developed using Kern's Six-Step Framework and designed to address American Board of Surgery (ABS) Entrustable Professional Activities (EPAs). The activity followed a structured five-phase progression including a pre-survey, a pre-brief orientation, independent model evaluation of four distinct NEC pathologies with real-time hemodynamic data, an expert-led didactic debriefing session, and a post-survey. SETTING: The study was conducted at a single quaternary academic children's hospital during a protected surgical education block. PARTICIPANTS: A convenience sample of nine participants completed the study, including six general surgery residents (PGY-2 to PGY-6), two pediatric surgery fellows, and one medical student. RESULTS: Trainees demonstrated significant shifts in operative strategy as they integrated visual and physiological data. In a multifocal NEC scenario, preference for primary anastomosis decreased from 85.7% (pre-survey) to 11.1% (intra-operative) as trainees responded to disease complexity. For NEC Totalis, documentation of goals-of-care discussions rose from 0% at baseline to 66.7% post-intervention. A Wilcoxon Signed-Rank Test revealed a statistically significant increase in participant confidence regarding their ability to modify surgical plans based on intraoperative findings (p = 0.038). CONCLUSIONS: This low-fidelity simulation effectively bridges the gap between theoretical knowledge and the complex, real-time judgment required for neonatal surgical emergencies. By prioritizing cognitive rehearsal over technical haptics and providing structured didactic debriefing, the activity supports ABS EPA attainment and significantly improves trainee confidence.