OBJECTIVE : High surgical volume for both surgeons and hospital systems has been linked to improved outcomes for many surgical problems, yet case volumes per pediatric surgeon are diminishing nationally in complex pediatric surgery. We therefore sought to review our experience in a geographically isolated setting where a surgical team approach has been used to improve per-surgeon exposure to index pediatric surgical cases. METHODS : As a surgical group, we incorporated a surgical team approach to complex pediatric surgical cases in 2010. We obtained institutional review board approval to review our pediatric surgeon index case volume experience. We then compared our surgeon experience to published surgical volumes for complex pediatric surgical cases. RESULTS : A surgical team approach (2 or 3 board certified pediatric surgeons/urologists working as co-surgeons or assistant surgeon) was used in the majority of cases for tracheoesophageal fistula/esophageal atresia (77%), congenital pulmonary airway malformation (73.5%), cloaca (75%), anorectal malformation (43.6%) biliary atresia (77.8%), Hirschsprung's disease (51.9%), congenital diaphragmatic hernia (67.6%), robotic choledochal cyst (100%), and complex oncology (adrenal tumors, neuroblastoma, Wilms tumor and Hepatoblastoma surgery) (85-100%). Over the 5-year period, surgeon index case exposure for all index pediatric surgical cases was above the published national median for pediatric surgeons, except for in splenic operations when contrasted to published experience. CONCLUSIONS : A surgical team approach to complex pediatric surgery may help maintain exposure to adequate index case volumes. This model may be useful for maintaining competence in geographically-isolated practice settings and low-volume pediatric hospitals that provide surgical care; the model has implications for systems development and workforce allocation within pediatric surgery. METHODS : 4.