Totally endoscopic Nissen fundoplication with a robotic system in a child

Robotic surgeries in pediatric patients: an early experience in a single center

Purpose

Robotic surgery (RS) has the advantages of 3-dimensional view, optical magnification, motional scaling, and improved ergonomics and degree of freedom. Although RS has widely been performed on pediatric patients lately, there are still numerous restrictions and ambiguous indications. The purpose of this study was to report our early experience with RS on pediatric patients at a single center.

Methods

Electronic medical records of patients who underwent RS with the da Vinci Xi surgical platform (Intuitive Surgical, Inc.) in Seoul National University Children Hospital from November 2019 to August 2021 were reviewed retrospectively. The median follow-up was 21.0 months (range, 12.3-31.8 months). An online survey was conducted to investigate satisfaction with robotic surgical scars.

Results

Fifty-four patients underwent robotic surgeries (median age at operation, 11.1 years [range, 0.1-17.8 years]). In our hospital, patients had 20 different kinds of robotic surgeries, including choledochal cyst excision with hepaticojejunostomy, ovarian mass excision, and others. Median operation time and console time were 157.5 minutes (range, 45-505 minutes) and 40 minutes (range, 11-360 minutes), respectively. All cases were done without conversion into open or laparoscopic methods. Postoperative complications were found in 5 patients. According to an online survey, over half of patients (60.9%) answered that they felt satisfied with scars.

Conclusion

Our early experience demonstrated the safety and feasibility of RS in children with a range of diagnoses and complicated procedures. With more experience, RS could be an alternative to traditional open or laparoscopic operations in pediatric patients. Further studies are needed to clarify indications of pediatric RS.

Exploring the frontier in robotic pediatric cancer surgery: when to move forward and when to stop

PURPOSE

In recent years, the use of robotic-assisted minimally invasive surgery in pediatric oncology has increased. Despite its benefits, its adoption remains limited. This single-center retrospective analysis examines technical nuances, indications, and surgical limitations to prevent complications.

METHODS

Data from cancer patients treated robotically in 2015-2016 (Group A) and 2020-2022 (Group B) were compared. Decision-making considered tumor characteristics and risks, guided by multidisciplinary tumor board discussions. Data collected included demographics, intra/post-operative details, and tumor classifications. Statistical analysis evaluated influencing factors.

RESULTS

Thirty-eight pediatric patients underwent robotic-assisted tumor resection, the median age was 5 years and weight 21.5 kg. Group A had higher median age and weight. Lesions included 23 malignant, 9 borderline, 5 benign cases; neuroblastoma (n = 19) was prevalent procedure and adrenalectomy was the predominant (28.94%). Open conversion occurred in 12 patients (31.58%), mainly due to vascular challenges (23.68%). Intraoperative complications were 10.53%, postoperative 7.9%. About 27% discharged by the third postoperative day; longer stays were needed for complex cases. All resumed post-op chemotherapy as scheduled, and all alive during follow-up.

CONCLUSIONS

Our study confirms the safety and efficacy of robotic-assisted tumor resections in pediatric oncology, even during the learning phase, emphasizing the importance of learning curve, patient selection, and trocar positioning.

Framework for pediatric robotic surgery program development

Pediatric robotic surgery has seen increasing implementation for its many benefits over the past two decades. As more pediatric surgeons gain exposure to robotic surgery, the interest in utilizing this technology is growing. However, there are no guidelines or existing framework for developing pediatric general surgery robotic programs. Programmatic development can be challenging, requiring institutional support, a minimum 12-month multistep process in partnership with the robot manufacturer, and organization of a local dedicated team. A cornerstone to all program building is collaboration and communication with key stakeholders who are committed to establishing a robotic surgery program. In this manuscript, we detail numerous best practices for implementation, followed by three variations of programmatic development, each drawing lessons from one of three practice settings: (i) A children's hospital in a large medical center associated with an adult hospital, (ii) a free-standing children's hospital, and (iii) a community-based practice. We aim for this article to provide a framework that can serve as a guide for those beginning this process, consolidating the key resources and strategies used to develop a robust pediatric robotic surgery program.

Establishment of a successful robotic pediatric general surgery practice

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3 years and 76.4 kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30 days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

Validation and effect of the NASA-TLX score on the assessment of the workload of pediatric robotic operations

OBJECTIVE

The objective of the study was to assess the validity of the NASA-TLX score in rating the workload of pediatric robotic operations.

METHODS

The workload of 230 pediatric gastrointestinal and thoracic robotic operations was rated using the NASA-TLX score. The difference between the high workload group and the low workload group in each subscale of the NASA-TLX score was analyzed. The correlation of each subscale with the total workload score in the high workload group and low workload group was also analyzed. A logistic regression analysis was subsequently conducted to assess the effects of different factors (sex, age, weight, procedure duration, procedure specialties, combined malformation and blood loss) on the workload.

RESULTS

The average NASA-TLX score was 56.5 ± 5.1 for the total group, 56.9 ± 5.0 for the gastrointestinal group and 54.6 ± 4.8 for the thoracic group, p = 0.007. The score of the high workload group was 62.7 ± 3.2, while it was 50.6 ± 2.7 for the low workload group (p < 0.001). The score on each subscale was also significantly different between the high and low workload groups. In the high workload group, a stronger correlation was observed between the total score and TD and Fr and a lower correlation with MD and Pe. In the low workload group, all six subscales showed a moderate correlation with the total score. A multivariate logistic regression analysis revealed that the procedure duration was an independent influencing factor for a higher workload score.

CONCLUSIONS

NASA-TLX is a valid tool to rate the surgeon's workload in pediatric robotic surgery. A longer operative time contributes to a higher workload.

Pediatric colorectal robotic surgery

Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.

Robotic-assisted surgery in the pediatric surgeons' world: Current situation and future prospectives

Robotic-assisted surgery has been fully embraced by surgeons for the adult population; however, its acceptance is too slow in the world of pediatric surgeons. It is largely due to the technical limitations and the inherent high cost associated with it. In the past two decades, indeed, there has been considerable advancement in pediatric robotic surgery. A large number of surgical procedures were performed on children with the assistance of robots, even with comparative success rates to standard laparoscopy. As a newly developing field, it still has many challenges and obstacles. This work is centered on the current status and progression of pediatric robotic surgery as well as the future perspectives in the field of pediatric surgery.

Robotic Surgery: Is There a Possibility of Increasing Its Application in Pediatric Settings? A Single-Center Experience

Introduction: Robotic surgery has shown explicit benefits and advantages in adults, but it is not yet strongly established in the pediatric population, even though its popularity is increasing, especially in the urologic field. Materials and methods: In this article we present our experience with the Da Vinci System (SI first and XI nowadays) at our pediatric institution in order to analyze our progress over the years. We considered all patients from the start of the robotic surgery program in 2016 until the end of 2021, dividing them into general abdominal surgery and genitourinary surgery. Analyzed data were the patient’s demographic, details of surgery, and intra and post-operative complications. Results: The total number of patients (pts) included in this study was 76, of whom 40 (52%) were male and 36 (48%) were female. The mean age at surgery was 90.9 months (range 10–207 months), and the mean weight at surgery was 29.3 kg (range 9.5–68 kg). There were 18 general abdominal robotic surgeries and 58 genitourinary robotic surgeries performed. The most performed surgeries in these two categories were fundoplication for gastro-oesophageal reflux disease (11%) and Anderson–Hynes pyeloureteroplasty. The mean operative time was 224.2 min (range 72–530 min): the mean times in the two groups (general abdominal surgery and genitourinary surgery) were 165 min (range 84–204 min) and 194 min (range 95–360 min), respectively. A total of four (5%) minor complications were reported. The total conversions were two (2.6%) and the mortality rate was 0%. Conclusions: Pediatric robotic surgery is a field of considerable interest and it is rapidly expanding. In our experience, it is evident how the learning curve has increased gradually, but steadily, allowing us to advance from standardized surgery, such as fundoplication and pieloplasty, towards a more technically complex one, achieving the same good results. We believe that robotic surgery is very respectful of tissues and feasible, especially for reconstructive surgery. For these reasons, it could become of common use also in the pediatric population, overcoming impediments such as excessive cost and the lack of pediatric instruments, in order to be able to treat children with a progressively lower age and weight.

Surgical Management of Hirschsprung's Disease: A Comparative Study Between Conventional Laparoscopic Surgery, Transumbilical Single-Site Laparoscopic Surgery, and Robotic Surgery

Background

Hirschsprung's disease (HD) is a commonly digestive malformation in children that usually requires surgery. This study aims to evaluate the short-term efficacy of conventional laparoscopic surgery (CLS), transumbilical single-hole laparoscopic surgery (TU-LESS), and robotic surgery (RS) in the treatment of Hirschsprung's disease.

Methods

90 patients with Hirschsprung's disease undergone laparoscopic surgery at our center between 2015 and 2019, divided into three groups (group CLS, TU-LESS and RS), were retrospectively analysed.

Results

CLS and TU-LESS group showed no significant difference in operation duration (P &gt; 0.05) but shorter operation duration than the RS group (P &lt; 0.05). RS group had highest overall SCAR scores, while TU-LESS group had the lowest one (P &lt; 0.05). Other parameters such as operative blood loss, hospital stays, recovery time of digestive function, postoperative complications had no significant difference among the three groups (P &gt; 0.05).

Conclusion

The three surgical methods for HD revealed similar efficacy, where TU-LESS and CLS spent less time than RS; TU-LESS led to the most aesthetic effect, followed by CLS and RS.

The Role of the Versius Surgical Robotic System in the Paediatric Population

The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, dexterity, and ergonomics, could make it a superior choice over the traditional laparoscopic approach. However, its implementation in the paediatric surgery arena has been limited primarily due to the unavailability of appropriately sized instruments as per paediatric body habitus, therefore, requiring more technologically advanced systems. The Versius surgical robotic system is a new modular platform that offers several benefits such as articulated instruments which pass through conventional 5 mm ports, compact arms for easier manoeuvrability and patient access, the ability to mimic conventional port placements, and adaptive machine learning concepts. Prior to its introduction to paediatric surgery, it needs to go through a careful pre-clinical and clinical research program.

Robotic Anxiety—Parents’ Perception of Robot-Assisted Pediatric Surgery

In contrast to many other countries, robot-assisted (RA) pediatric surgery is not yet very common in Germany. Although the first pediatric RA intervention was published in 2001, RA pediatric surgery is still perceived as a “new technology”. As a consequence, little is known about parents’ perception of this operation method. In this study, we analyzed parents‘ intention to let their child undergo RA and laparoscopic (LA) surgery. Two subsamples (online and at the University Medical Center Goettingen) received a questionnaire addressing attitude towards RA and LA pediatric surgery with the help of a case example. Results showed that parents had a higher intention to consent to LA surgery. Perceiving more benefits, assuming a positive attitude of the social environment, and feeling less anxiety increased intention. A mediation analysis indicated that the type of surgery affected intentions through assumed attitude of the social environment. Exploratory analyses showed that the perception of risks and anxiety reduced intention for only RA surgery. These findings should be considered in preoperational discussions with parents. Anxiety and perceived risks should especially be addressed in order to encounter hesitancy.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

An Audit of Robot-Assisted Minimally Invasive Surgeries in Children: Early Experience from a Tertiary Care Center in India

Background: Over the last decade, a significant rise in pediatric robot-assisted minimally invasive surgeries has been observed. Apart from the urological surgeries in children, robot assistance for complex nonurological reconstructions is being explored increasingly. This study highlights our preliminary experience of robot-assisted minimally invasive surgeries in children. Materials and Methods: An ethical waiver was given by the Institute's Ethics Committee in view of the retrospective nature of the study and all procedures being performed as a part of the routine care. A retrospective analysis was done to include all the pediatric robot-assisted surgeries performed at our hospital over a 4-year period (January 2017-January 2021). The surgeries were categorized based on the involved organ system and the total study duration was divided into four 12-month time periods. A comparison of the total number of surgeries done in each time period was also done. A log of the surgeon's console duration for each surgery was also kept. Results: A total of 65 patients, with the majority (50/65; 77%) undergoing reconstructive surgeries for anomalies within the genitourinary system, were included. Almost two-thirds of the total surgeries were technically complex. The number of procedures performed during the four 12-month time periods was 18, 18, 15, and 14. The average (range) surgeon's console time was 95 minutes (45-327 minutes) and showed a progressive improvement with the passage of time. Only 1 patient required conversion to an open approach, and none had major complications during the postoperative period. Conclusion: Our early experience of robot-assisted minimally invasive surgeries in children reaffirms its safety and feasibility in complex reconstructive surgeries. It also highlights the advantages of robot assistance in smaller children with nonurological anomalies.

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

Robotic surgery in paediatric patients: Our initial experience and roadmap for successful implementation of robotic surgery programme

Introduction:

The popularity of robot-assisted surgeries has accelerated since its advent in 1990s. Recently, we procured da Vinci surgical system in our institution; and here, we present our initial experience of robot-assisted surgeries at our hospital. We also discuss the stepwise approach for successful implementation of the robotic surgical programme at our institute. Moreover, the importance of efficient use of this advanced but expensive technology has been highlighted.

Materials and Methods:

Retrospective analysis of the medical record of all the paediatric patients between the age ranges of 1–18 years who had undergone robotic-assisted laparoscopic surgery during April 2019–April 2019 was done. Medical record was reviewed for descriptive data, clinical presentation, investigations, operative details and follow-up. Statistical data were also obtained from medical superintendent office.

Results:

During April 2018–April 2019, total of 111 cases were operated across six specialities. Approximately 73% of cases (81/111) belonged to adult urology and gynaecology speciality. Less than 5% (5/111) of patients were in paediatric age group. The department of paediatric surgery performed one pyeloplasty, 3 ureteric reimplantation and 1 bladder diverticulum excision with robot assistance. The operative duration of the cases was comparable to the standard laparoscopic techniques. All patients are asymptomatic on follow-up visits.

Conclusion:

The robotic surgery is feasible in paediatric population and has favourable post-operative outcomes. Detailed planning and stepwise approach is key to the establishment of new robotic surgery programme in any institute.

Thoracic surgery by minimally invasion robot-assisted in children: “experience and current status”

Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic.

Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the “da Vinci surgical system” (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery.

Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing’s tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases.

Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.

Totally robotic soave pull-through procedure for Hirschsprung's disease: lessons learned from 11 consecutive pediatric patients

INTRODUCTION

Since Hirschsprung's disease (HSCR) already proved to benefit from robotic surgery, we aimed at describing a wider series of patients with this rare disease who were operated on with a robotic approach.

PATIENTS AND METHODS

All consecutive HSCR patients who underwent totally robotic soave pull-through (TRSPT), between October 2015 and June 2019, have been included. Ethical Committee approval was obtained. Data regarding clinical features, technical details, complications, hospital stay, and functional outcome have been prospectively collected for each patient.

RESULTS

Eleven patients have been included. Mean age at surgery was 29 months. Median length of surgery was 420 min. Median console time was 180 min. Six patients suffered from rectosigmoid aganglionosis, three from long HSCR (extending up to the hepatic flexure), two from total colonic aganglionosis. No major intraoperative complications occurred. Four patients (three of whom carrying a stoma) experienced minor mucosal tearing during dissection. One anastomotic stricture required dilatation under general anesthesia and two cuff strictures required cuff release (both occurring in patients who experienced intraoperative mucosal tearing). Follow-up lasted a median of 12 months. One patient experienced mild postoperative enterocolitis. Continence scored excellent-to-good in all patients who could be assessed on that regard (7 out of 11).

CONCLUSIONS

Provided a number of technical key points are respected, the outcome of TRSPT for HSCR is promising. Younger patients, particularly those carrying a stoma, proved to be technically demanding and deserve a longer learning curve. Accurate preoperative bowel preparation, correct trocar placement and patient positioning proved to be crucial aspects of treatment. To conclude, TRSPT is particularly suitable for older HSCR patients, even those requiring a redo, and represents a valid alternative to available surgical option for this delicate subgroup of HSCR patients.

Conversion Rate in Pediatric Robotic-Assisted Surgery: Looking for the Culprit

Introduction: Robotic-assisted surgery (RAS) is increasingly used in adulthood but its application in pediatric population is limited. We report our initial experience in pediatric RAS, focusing on conversions to analyze their causes. Methods: All pediatric patients who underwent RAS between June 2015 and April 2019 were included, analyzing demographics, comorbidities, previous surgery, and intraoperative surgical and anesthetic parameters. A three-arms robotic technique was used in all cases. Additional laparoscopic ports were added, when needed. The surgical team did not change during the program, whereas the anesthesiology team varied. Results: Thirty-nine patients (23 females, 16 males; mean age ± SD = 9.33 ± 4.73 years [range = 1-16]; mean weight ± SD = 35.2 ± 20.0 kg [range = 9-85]) underwent 40 different procedures (18 gastrointestinal, 15 urogynecological, 5 oncological, and 2 miscellaneous). Three procedures (7.5%) were converted to open surgery for inadequate working space (two marked bowel distension and one insufficient hepatic retraction). Converted patients were of significant lower age (mean ± standard error of mean [SEM] = 2.97 ± 1.03 versus 9.83 ± 0.77 years, P = .01) and lower weight (mean ± SEM = 11.83 ± 1.74 versus 35.47 ± 3.16 kg, P = .03). The two groups did not differ statistically for duration of facial mask ventilation before intubation (mean ± SEM = converted 10.67 ± 2.33 versus completed 10.31 ± 0.91 minutes), neuromuscular block dosage (rocuronium; mean ± SEM = converted 0.46 ± 0.06 mg/kg versus completed 0.62 ± 0.03 mg/kg) and in the type of bowel preparation (mechanical and/or pharmacological). Discussion: Conversion rate in initial pediatric RAS program is acceptable. In children, the need for conversion is mainly because of inadequate working space, particularly in smaller children, but it seems not to be influenced by measurable anesthetic factors or different regimen for bowel preparation.

Robotics in Cleft Surgery: Origins, Current Status and Future Directions

The field of robotic surgery is an exciting and growing field that has bolstered its way to become a mainstream application in a number of surgical disciplines. The application of robotic surgery in cleft surgery is novel and has captivated many with the benefit it provides: the slender and small arms with wrist articulation at the instrument tip; motion scaling; tremor elimination; and high fidelity, three-dimensional visualization make the robot a very attractive platform for use in confined spaces with small surgical targets. The story of the origin of robotic surgery in cleft surgery is an interesting one, and one that has arisen from other allied surgical specialities to render robotic cleft surgery as its own specialised field. A field that has coined its own terms and has demonstrated a number of applications for its use. This review details the origins of robotic cleft surgery, its evolution and its current status and elaborates on future directions to enhance its application.

Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries

Objective: We present the applications and experiences of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery. Materials and Methods: A prospective, observational, and longitudinal study was conducted from March 2015 to March 2018 that involved a non-random sample of a pediatric population that was treated with RALTS. The parameters examined were: gender, age, weight, height, diagnoses, surgical technique, elapsed time of console surgery, estimated bleeding, need for hemotransfusion, complications, surgical conversions, postoperative hospital stay, and follow-up. The Clavien-Dindo classification of complications was used. The surgical system used was the da Vinci model, Si version (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A), with measures of central tendency. Results: In a 36-months period, 186 RALTS cases were performed, in 147 pediatric patients and an adult; 53.23% were male, and the remaining were female. The average age was 83 months, ranging from 3.5 to 204 months, plus one adult patient of 63 years. The stature was an average of 116.6 cm, with a range of 55-185 cm; the average weight was 26.9 kg, with a range of 5-102 kg; the smallest patient at 3.5 months was 55 cm in stature and weighed 5.5 kg. We performed 41 different surgical techniques, grouped in 4 areas: urological 91, gastrointestinal and hepatobiliary (GI-HB) 84, thoracic 6, and oncological 5. The console surgery time was 137.2 min on average, ranging from 10 to 780 min. Surgeon 1 performed 154 operations (82.8%), and the remainder were performed by Surgeon 2, with a conversion rate of 3.76%. The most commonly performed surgeries were: pyeloplasty, fundoplication, diaphragmatic plication, and removal of benign tumors, by area. Hemotransfusion was performed for 4.83%, and complications occurred in 2.68%. The average postoperative stay was 2.58 days, and the average follow-up was 23.5 months. The results of the 4 areas were analyzed in detail. Conclusion: RALTS is safe and effective in children. An enormous variety of surgeries can be safely performed, including complex hepatobiliary, and thoracic surgery in small children. There are few published prospective series describing RALTS in the pediatric population, and most only describe urological surgery. It is important to offer children the advantages and safety of minimal invasion with robotic assistance; however, this procedure has only been slowly accepted and utilized for children. It is possible to implement a robust program of pediatric robotic surgery where multiple procedures are performed.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty

The laparoscopic approach to the pyeloplasty procedure has proven to be safe and effective in the pediatric population. Multiple studies have revealed outcomes comparable to the open approach. However, a major drawback to laparoscopy is the technical challenge of precise suturing in the small working space in children. The advantages of robotic surgery when compared to conventional laparoscopy have been well established and include motion scaling, enhanced magnification, 3-dimensional stereoscopic vision, and improved instrument dexterity. As a result, surgeons with limited laparoscopic experience are able to more readily acquire robotic surgical skills. Limitations of the robotic platform include its high costs for acquisition and maintenance, as well as the need for additional robotic surgical training. In this article, we review the current status of the robot-assisted laparoscopic pyeloplasty, including a brief history, comparative outcomes, cost considerations, and training.

Robotic Surgery may Not "Make the Cut" in Pediatrics

Since the introduction of robotic surgery in children in 2001, it has been employed by select pediatric laparoscopic surgeons, but not to the degree of adult surgical specialists. It has been suggested that the technical capabilities of the robot may be ideal for complex pediatric surgical cases that require intricate dissection. However, due to the size constraints of the robot for small pediatric patients, the tight financial margins that pediatric hospitals face, and the lack of high level data displaying patient benefit when compared to conventional laparoscopic surgery, it may be some time before the robotic surgical platform is widely embraced in pediatric surgical practice.

Current status of robot-assisted laparoscopic surgery in pediatric urology

Laparoscopic procedures for urological diseases in children have been proven to be safe and effective. However, the availability of laparoscopic procedures is still partly limited to experienced, high-volume centers because the procedures are technically demanding. The da Vinci robot system is being used for an increasing variety of reconstructive procedures because of the advantages of this approach, such as motion scaling, greater optical magnification, stereoscopic vision, increased instrument tip dexterity, and tremor filtration. Particularly in pediatric urologic surgery, where the operational field is limited owing to the small abdominal cavity of children, robotic surgical technology has its own strengths. Currently, robots are used to perform most surgeries in children that can be performed laparoscopically. In this review, we aimed to provide a comprehensive overview of the current role of robot-assisted laparoscopic surgery in Pediatric Urology by analyzing the published data in this field. A growing body of evidence supports the view that robotic technology is technically feasible and safe in pediatric urological surgery. Robotic technology provides additional benefits for performing reconstructive urologic surgery, such as in pyeloplasty, ureteral reimplantation, and enterocystoplasty procedures. The main limitations to robotic surgery are its high purchase and maintenance costs and that the cost-effectiveness of this technology remains to be validated.

Robotic lobectomy for lung cancer: evolution in technique and technology

OBJECTIVES

The aim of this study was to analyse the results of robotic lobectomy for lung cancer. The evolution of technique and technology was evaluated.

METHODS

During the period 2004-12, all patients who underwent robotic lobectomy for clinical early-stage lung cancer were retrospectively reviewed. The patients were divided into two groups. Group 1 included 69 patients operated by the first generation of surgical robotic system. Group 2 included 160 patients treated with the latest generation of surgical robotic system. Age, gender, comorbidities, operative time, docking time, conversion rate, morbidity, mortality and length of postoperative stay were compared in both groups.

RESULTS

The two groups were homogeneous in terms of age, gender and comorbidities. Histopathological analysis showed 41 and 107 adenocarcinomas, 27 and 37 squamous cell carcinomas, 1 and 7 large cell carcinomas, in Groups 1 and 2, respectively, and 5 sarcomatoid carcinomas and 4 carcinoids in Group 2. The pathological stage for Group 1 was Stage I (48 cases), Stage II (17 cases) and Stage III (4 cases). For Group 2, Stage I was found in 115 cases, Stage II in 30 cases and Stage III in 15 cases. The mean operative time was 237 (standard deviation (SD) + 66.9) and 172 (SD ± 39.6) min for Groups 1 and 2 (P = 0.002), respectively. The conversion rates were, respectively, 10.1 and 5.6% (P = 0.21), mortality rates 1.4 and 0% (P = 0.30) and morbidity rates 22 and 15% (P = 0.12). The mean length of postoperative stay was 4.4 (SD ± 3.1) and 3.8 days (SD ± 2.2) (P = 0.26), respectively.

CONCLUSIONS

This study suggests a positive trend in the outcomes for patients who underwent the upgraded robotic system surgery compared with those treated by the standard system.

A literature review of the outcomes after robot-assisted laparoscopic and conventional laparoscopic Nissen fundoplication for gastro-esophageal reflux disease in children

BACKGROUND

Robot-assisted surgery is a promising technical innovation. Given the similarities between laparoscopic and robot-assisted surgery it is unlikely that randomized controlled trials would be conducted to disclose any differences between these two technical instruments. Thus, skepticism remains due to lack of any definitive conclusions in the literature.

AIMS

The aim of the study was to disclose any difference in outcome after robot-assisted (RNF) versus conventional laparoscopic (LNF) Nissen fundoplication for gastro-esophageal reflux disease in children.

MATERIALS AND METHODS

A literature review was carried out. Only studies comparing the two modalities were included. Operative time, duration of hospital stay, 30 days morbidity, mortality, conversion, recurrence and complication rates were analyzed. Review Manager 5.1.6 software, from the Cochrane library, was used for statistical analysis.

RESULTS

Three case series fulfilled the criteria for inclusion in this review. Data on 174 children were identified; 89 were operated on using the computer-assisted technology and 85 controls were operated on using the conventional laparoscopic technique. Data showed no significant difference between these two modalities.

DISCUSSION

This literature review demonstrates no significant difference between patients operated on with robot-assisted surgery and those undergoing conventional laparoscopic surgery regarding the parameters studied.

CONCLUSION

The robot-assisted Nissen fundoplication in children is a safe alternative to conventional laparoscopic surgery. No data support the need for case selection to one of these two minimally invasive procedures.

The first decade of robotic surgery in children

BACKGROUND

Robotic surgery offers technological solutions to current challenges of minimal access surgery, particularly for delicate and dexterous procedures within spatially constrained operative workspaces in children. The first robotic surgical procedure in a child was reported in April 2001. This review aims to examine the literature for global case volumes, trends, and quality of evidence for the first decade of robotic surgery in children.

METHODS

A systematic literature search was performed for all reported cases of robotic surgery in children during the period of April 2001 to March 2012.

RESULTS

Following identification of 220 relevant articles, 137 articles were included, reporting 2393 procedures in 1840 patients. The most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively. There was a progressive trend of increasing number of publications and case volumes over time. The net overall reported conversion rate was 2.5%. The rate of reported robot malfunctions or failures was 0.5%.

CONCLUSIONS

Robotic surgery is an expanding and diffusing innovation in pediatric surgery. Future evolution and evaluation should occur simultaneously, such that wider clinical uptake may be led by higher quality and level of evidence literature.

Laparoscopic versus robot-assisted Nissen fundoplication in an infant pig model

PURPOSE

Surgical robots are designed to facilitate dissection and suturing, although objective data on their superiority are lacking. This study compares conventional laparoscopic Nissen fundoplication (CLNF) to robot-assisted Nissen fundoplication (RANF) using computer-based workflow analysis in an infant pig model.

METHODS

CLNF and RANF were performed in 12 pigs. Surgical workflow was segmented into phases. Time required to perform specific actions was compared by t test. The quality of knot-tying was evaluated by a skill scoring system. Cardia yield pressure (CYP) was determined to test the efficacy of the fundoplications, and the incidence of complications was compared.

RESULTS

There was no difference in average times to complete the various phases, despite faster robotic knot-tying (p = 0.001). Suturing quality was superior in CLNF (p = 0.02). CYP increased similarly in both groups. Workflow-interrupting hemorrhage and pneumothorax occurred more frequently during CLNF (p = 0.040 and 0.044, respectively), while more sutures broke during RANF (p = 0.001).

CONCLUSION

The robot provides no clear temporal advantage compared to conventional laparoscopy for fundoplication, although suturing was faster in RANF. Fewer complications were noted using the robot. RANF and CLNF were equally efficient anti-reflux procedures. For robotic surgery to manifest its full potential, more complex operations may have to be evaluated.

Robotic Swenson Pull-Through for Hirschsprung's Disease in Infants

It has been demonstrated that infants with Hirschsprung's disease can be treated with a one-stage laparoscopic resection and coloanal pull-through. However, the feasibility and benefits of performing this operation using robotic technology have not yet been evaluated. We reviewed our experience with 12 infants diagnosed with Hirschsprung's disease and treated with laparoscopic-robotic assisted colonic resection with proctectomy and pull-through using the da Vinci robotic system. Patients were treated at a mean age/weight of 16 weeks/5.5 kg. The average operative time for the robotic procedure was 230 minutes, and average length of stay was 3 days. At discharge, all patients were having regular bowel movements and tolerating a completely oral diet. All patients received early postoperative anorectal dilation and six patients required dilations for an average of 12 weeks after surgery for management of minor rectal strictures. Only two patients developed postoperative enterocolitis with a mean follow-up of 36 months. A robotic approach for performing a Swenson-type resection and pull-through procedure can be performed safely and successfully in young infants. Robotic technology provided superior dexterity and visualization, essential in performing a more complete rectal dissection, thus allowing for a complete proctectomy and eliminating the risk of leaving a segment of aganglionic rectum behind.

Pediatric robotic surgery: early assessment

OBJECTIVES

This article reviews the evidence regarding the feasibility, safety, benefits, limitations, and costs of robotically assisted surgery in children, evaluates how the technology compares with other pediatric surgical techniques, and provides insights about the near and more-distant future of the technology.

METHODS

The peer-reviewed medical pediatric literature was searched for studies that provided evidence of the feasibility and safety of robotic surgery in children and for studies that compared pediatric robotic surgery with conventional laparoscopic surgery or open surgery.

RESULTS

A total of 8 case series and 5 studies comparing robotic surgery with open or conventional laparoscopic surgery met the selection criteria for review. A few small studies that focused on rare complex surgical procedures also were reviewed. All studies were designed to evaluate the feasibility and safety of robotic surgery in children. None of the studies was randomized, and some studies had a retrospective design. These studies demonstrated that a number of routine, robotically assisted, laparoscopic and thoracic procedures were feasible and safe when performed by surgeons experienced in the technique, although robotic surgery did not provide superior outcomes, compared with traditional laparoscopic and open surgery. The advantages of the robotic system were best seen in complex procedures that involved areas that were difficult to access and in procedures in which dissection of delicate, anatomic structures was required.

CONCLUSIONS

Robotic surgery is feasible and safe for a number of pediatric surgical procedures, but evidence that it offers better clinical outcomes than conventional open or laparoscopic techniques is lacking.

[Special features of laparoscopic operations from an anesthesiologic viewpoint: a review]

The value of laparoscopic procedures has increased over the last decade. Many patients undergoing laparoscopic surgery also have coexisting diseases. The hemodynamic effects of intraperitoneal carbon dioxide insufflation depend on the extent of intraperitoneal pressure, severity of preexisting cardiopulmonary diseases, volume state of the patient and alterations of acid-base balance due to a capnoperitoneum. In addition to endocrinologic reactions, patient positioning also affects hemodynamic parameters. In high risk patients extended cardiopulmonary monitoring with an arterial line and repeated blood gas analysis is recommended intraoperatively, in addition to assessment of end-expiratory CO(2). In this patient group the intra-abdominal pressure should be maintained in the range of 5-7 mmHg.

Robotic Cholecystectomy: Learning Curve, Advantages, and Limitations

BACKGROUND

Robotic cholecystectomy is safe, feasible procedure. Initial studies showed significant set up time and operating time but no clear clinical advantage of the robotic involvement. We have investigated the learning curve, advantages and limitation of the procedure.

MATERIAL AND METHODS

We reviewed all (n = 51) robotic cholecystectomies performed between July 2004 and December 2005. The surgery was performed using the da Vinci system. We recorded operative time, setup time of robotics instrumentation, conversion to laparoscopic or open cholecystectomy and complication of the procedure.

RESULTS

Forty-eight of the 51 procedures (94%) were completed robotically. We did not experience any significant complications directly related to robotics surgery. The mean +/- SD operating time was 77 +/- 22.3 min. The mean setup time for robotics (from incision until robot was in place, including draping the robot) was 24 +/- 8.8 min. However, the setup time significantly improved as we gained more experience: from 30.6 +/- 10.7 min (first 16 cases) to 18.3 +/- 4.0 min (cases 33-48). The mean robotic time was 34 +/- 16.1 min. We observed no significant improvement in robotic procedure time.

CONCLUSIONS

Robotic cholecystectomy offers significant advantages such as three-dimensional view, easier instrument manipulations and possibility of remote site surgery. We observed some shortcomings of robotic surgery such as need for larger and additional ports, and need for undocking the machine in case of cholangiography or change of patient position. Our data shows that the learning curve is between 16 to 32 procedures to significantly decrease the setup time and total operating time.

Evolution of Telemedicine from an Applied Communication Perspective in the United States

Telemedicine, the use of telecommunication technologies to provide health services over some distance, has a history that spans more than five decades. Technological development and deployment have been interrelated with shifting paradigmatic views. This paper proposes that telemedicine has evolved through three generations that began with telemedicine as a communication medium to complement traditional services to a technology of automation and decision tools that expands the scope and range of health services and creates a unique health communication context. This paper provides a literature review and overviews three proposed evolutionary stages for telemedicine to date, namely synchronous versus asynchronous modalities, data transfer and storage, and automating decision making and robotics. Finally, we conclude with a discussion of the barriers for telemedicine and a call for engineers to join with social scientists and medical professionals to set an agenda for future telemedicine development.

Robotics in thoracic surgery

Surgical use of robotics, or computer-assisted surgical systems (CAS), has evolved over the last 10 years; for the treatment of chest diseases, however, the development has really occurred in the last 3 to 4 years. This brief history means that there have been few publications in the medical literature, and those that exist are mostly case reports. Moreover, because of this modest experience, robotic thoracic procedures currently take more time than nonrobotic cases and, thus, are more expensive. The surgical learning curve appears to be steep, especially for the more complex procedures. As surgeons gain greater experience and the complexity and cost of the equipment are reduced, we should expect to see greater utility of CAS in thoracic surgery.

Telemedicine in surgery

BACKGROUND

Telemedicine is influencing surgical training, allows mentoring, proctoring and teleconferencing, and is increasingly being applied to carry out remote surgical procedures. A systematic review of the telemedicine systems available, along with a critical appraisal of their application, potential and limitations in the surgical field, has been undertaken.

METHOD

Medline, Ovid and internet searches were carried out using the keywords 'telesurgery', 'telepresence surgery' and 'telemedicine and surgery', along with hand searches of the two peer-reviewed telesurgery journals.

RESULTS

Telementoring and teleconferencing have been used widely for surgical teaching and training. Two clinical telesurgery systems are currently available and have been a trial in patients undergoing a variety of operations including cholecystectomy, coronary artery bypass, prostatectomy and gastroplasty. Most studies have reported successful outcomes but with prolonged operating times. In 2002 the first long-distance telesurgery procedure was successfully performed.

CONCLUSION

Telemedicine has huge potential to alter surgical practice but improvements are required in telesurgical technology with respect to tactile feedback, instrumentation, telecommunication speed and availability. Issues of liability, legislation, cost and benefit require clarification. The future of telemedicine in surgery may lie in facilitating complex minimally invasive techniques.

What is the value of telerobotic technology in gastrointestinal surgery?

BACKGROUND

Although telerobotic technology has entered clinical application, its value for gastrointestinal surgery is unclear. Our objective was to evaluate the performance characteristics of telerobotically assisted laparoscopic cholecystectomy (TALC).

METHODS

All TALCs performed using the da Vinci Surgical System between January 2000 and September 2001 at a tertiary academic medical center were analyzed.

RESULTS

For this study, 20 patients (80% female) with a mean age of 47 +/- 4 years underwent TALC. All had symptomatic cholelithiasis, and all had successful TALC results without complications or need for conversion to conventional laparoscopic cholecystectomy (CLP). The mean procedure time was 152 +/- 8 min. The procedures were performed by one of three staff surgeons experienced in laparoscopic surgery who had training in telerobotic surgery. The perceived advantages of TALC over CLP included easier tissue dissection, enhanced dexterity, and stimulated interest in biliary surgery. The disadvantages included increased operating time and lack of tactile feedback.

CONCLUSIONS

The TALC procedure is effective and safe when performed by appropriately trained surgeons. Telerobotic technology has the potential to reinvigorate gastrointestinal surgery.

Single cannula technique and robotic telescopic assistance in infants and children who require laparoscopic Nissen fundoplication

BACKGROUND/PURPOSE

Laparoscopic Nissen fundoplication (LNF) is being utilized more extensively in the management of symptomatic gastroesophageal reflux disease in infants and children. The traditional approach utilizes 5 3- to 5-mm cannulas for telescope and instrument access to the peritoneal cavity. The purpose of this study is to report the technique and document the results using a single 5-mm umbilical cannula for LNF, stab incisions for placement of the instruments, and robotic telescope assistance.

METHODS

From November 1999 through March 2002, 154 patients underwent LNF by the senior author for pathologic gastroesophageal reflux disease. All operations were performed with a single 5-mm umbilical cannula through which a 4- or 5-mm telescope was placed for operative visualization. Four stab incisions were made through the upper/lateral abdominal wall under direct visualization avoiding the epigastric vessels. Through these stab incisions, instruments were inserted into the peritoneal cavity. The maximum insufflation pressure was 15 mm Hg in all cases. The ability to perform the procedure in the absence of additional operative cannula placement, complications during instrument insertion, the ability to maintain adequate pneumoperitoneum, the patient's age, weight, operating time, and the addition of a gastrostomy were recorded.

RESULTS

All but one of the 154 LNFs were completed successfully using this technique. The mean age at operation and mean operating time was 23.9 months (range, 3 weeks to 180 months) and 91 minutes (31 to 160 minutes), respectively. Patients weight ranged from 2.4 to 57 kg (mean, 10.4 kg). Gastrostomies were placed in 52 cases. There were no complications associated with the stab incisions or insertion of the operative instruments through the abdominal wall. Pneumoperitoneum was maintained adequately in all cases.

CONCLUSIONS

LNF can be performed safely and effectively with a single umbilical cannula. We recommend its use for pediatric patients who require LNF.