From Barriers to Solutions: Establishing an Academic Pediatric Surgical Hub in an Underserved Region of Tunisia

In low- and middle-income countries (LMIC), pediatric surgical care remains concentrated in urban tertiary centers, resulting in delayed access for rural populations. To address this inequity, we established an academic pediatric surgery department within a secondary-level regional hospital in Zaghouan, Tunisia, serving a broad underserved catchment area. Operating without dedicated pediatric infrastructure or pediatric anesthesiology services, we implemented a "service without walls" model by embedding pediatric surgery within an existing adult surgical department. Adult wards and perioperative systems were adapted through close collaboration with anesthesia teams, and a strict triage system was implemented to ensure safe case selection. Since its establishment, the department has demonstrated a significant increase in activity, with an 84% rise in annual surgical volume (361 procedures in 2025) and a tripling of inpatient admissions. The service now manages a wide spectrum of pediatric surgical conditions locally, including emergencies and selected complex cases, while high-risk neonates are stabilized and referred. No perioperative mortality occurred, and postoperative morbidity was limited to 3% consisting of minor wound-related complications. Our experience demonstrates that establishing a regional surgical hub does not require waiting for flawless infrastructure. By embedding pediatric surgery within existing adult surgical infrastructure, implementing collaborative perioperative protocols, and using triage-based risk management, safe pediatric surgical care can be successfully decentralized in resource-constrained settings. This model provides a scalable framework for improving access to pediatric surgical care in similar LMIC settings.