Robotic infant surgery with 3 mm instruments: a study in piglets of less than 10 kg body weight

Robotic-assisted laparoscopy in pediatric surgical oncology: a narrative review

Background and Objective

Robotic surgical oncology in children calls for experienced surgeons in minimally invasive surgery (MIS) and a solid oncological background. The aim of this review was to analyze the current state of robotic-assisted laparoscopy in pediatric tumor resection, assess the necessary framework of minimally invasive surgical oncology and describe future developments of the robotic technology.

Methods

A literature search of the MEDLINE/PubMed database was conducted, using the terms "robotic surgery", "pediatric" or "children" and "oncology" or "tumor". All relevant English-language studies published between 2008 and 2022 were reviewed.

Key Content and Findings

Although concerns have been raised regarding the use of MIS in surgical oncology, current literature reports similar oncological outcome if surgeons comply with the oncologic principles. The benefits of MIS have been established for robotic surgery in adult studies, including a shorter time to adjuvant chemotherapy. Surgical feasibility should be assessed based on tumor characteristics, preoperative imaging focusing on vascular involvement and surgeon's experience until clear guidelines are issued. The difficulties in establishing eligibility criteria for robotic resection of pediatric tumors lie in the great variability of indications, heterogeneity in tumor histology with their own surgical specificities, and wide range of age and weight, as shown by the literature review we performed. Between 2008 and 2022, 31 studies reported 171 cases with three studies including at least ten patients. The most reported procedure was adrenalectomy (41 cases). Current research in pediatric surgical oncology focuses on intraoperative locoregional treatment, improved vision with fluorescence and dyed-loaded specific probes and the many possibilities of enhancement software using the robotic console.

Conclusions

The robotic technology allows the surgeon to push the boundaries of conventional laparoscopy. Specific surgical guidelines are necessary.

Evaluation of the Versius Robotic System for Infant Surgery-A Study in Piglets of Less than 10 kg Body Weight

BACKGROUND

We were able to demonstrate the feasibility of a new robotic system (Versius, CMR Surgical, Cambridge, UK) for procedures in small inanimate cavities. The aim of this consecutive study was to test the Versius^® system for its feasibility, performance, and safety of robotic abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg.

METHODS

A total of 24 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 4 piglets with a mean age of 12 days and a mean body weight of 6.4 (7-7.5) kg. Additional urological procedures were performed after euthanasia of the piglet. The Versius^® robotic system was used with 5 mm wristed instruments and a 10 mm 3D 0° or 30° camera. The setup consisted of the master console and three to four separate arms. The performance of the procedure, the size, position, and the distance between the ports, the external and internal collisions, and complications of the procedures were recorded and analyzed.

RESULTS

We were able to perform all surgical procedures as planned. We encountered neither surgical nor robot-associated complications in the live model. Whereas all abdominal procedures could be performed successfully under general anesthesia, one piglet was euthanized early before the thoracic interventions, likely due to pulmonary inflammatory response. Technical limitations were based on the size of the camera (10 mm) being too large and the minimal insertion depth of the instruments for calibration of the fulcrum point.

CONCLUSIONS

Robotic surgery on newborns and infants appears technically feasible with the Versius^® system. Software adjustments for fulcrum point calibration need to be implemented by the manufacturer as a result of our study. To further evaluate the Versius^® system, prospective trials are needed, comparing it to open and laparoscopic surgery as well as to other robotic systems.

Senhance Robotic Platform in Pediatrics: Early US Experience

INTRODUCTION

Different robotic systems have been used widely in human surgery since 2000, but pediatric patients require some features that are lacking in the most frequently used robotic systems.

HYPOTHESIS

The Senhance^® robotic system is a safe and an effective device for use in infants and children that has some advantages over other robotic systems.

METHODS

All patients between 0 and 18 years of age whose surgery was amenable to laparoscopy were offered enrollment in this IRB-approved study. We assessed the feasibility, ease and safety of using this robotic platform in pediatric patients including: set-up time, operative time, conversions, complications and outcomes.

RESULTS

Eight patients, ranging from 4 months to 17 years of age and weighing between 8 and 130 kg underwent a variety of procedures including: cholecystectomy (3), inguinal herniorrhaphy (3), orchidopexy for undescended testes (1) and exploration for a suspected enteric duplication cyst (1). All robotic procedures were successfully performed. The 4-month-old (mo), 8 kg patient underwent an uneventful robotic exploration in an attempt to locate a cyst that was hidden in the mesentery at the junction of the terminal ileum and cecum, but ultimately the patient required an anticipated laparotomy to palpate the cyst definitively and to excise it completely. There was no blood loss and no complications. Robotic manipulation with the reusable 3 mm instruments proved successful in all cases.

CONCLUSIONS

Our initial experience with the Senhance^® robotic platform suggests that this is a safe and effective device for pediatric surgery that is easy to use, and which warrants continued evaluation. Most importantly, there appears to be no lower age or weight restrictions to its use.

Assessment of the Versius Robotic Surgical System in Minimal Access Surgery: A Systematic Review

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius® surgical robot system was developed with the aim of overcoming some of the challenges associated with existing surgical robots. The present study was designed to investigate the feasibility, clinical safety, and effectiveness of the Versius system in MAS. Materials and Methods: A comprehensive search was carried out in the Medline, Web of Science Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus databases for articles published until February 2022. The keywords used were Versius robot, visceral, colorectal, gynecology, and urologic surgeries. Articles on the use of the Versius robot in minimal access surgery (MAS) were included in the review. Results: Seventeen articles were reviewed for the study. The investigation comprised a total of 328 patients who had been operated on with this robot system, of which 48.3%, 14.2%, and 37.5% underwent colorectal, visceral, and gynecological procedures, respectively. Postoperative and major complications within 30 days varied from 7.4% to 39%. No major complications and no readmissions or reoperations were reported in visceral and gynecological surgeries. Readmission and reoperation rates in colorectal surgeries were 0–9%. Some procedures required conversion to conventional laparoscopic surgery (CLS) or open surgery, and all procedures were completed successfully. Based on the studies reviewed in the present report, we conclude that the Versius robot can be used safely and effectively in MAS. Conclusions: A review of the published literature revealed that the Versius system is safe and effective in minimal access surgery. However, the data should be viewed with caution until randomized controlled trials (RCTs) have been performed. Studies on the use of this robotic system in oncological surgery must include survival as one of the addressed outcomes.

Robotically Assisted Surgery in Children—A Perspective

The introduction of robotically assisted surgery was a milestone for minimally invasive surgery in the 21st century. Currently, there are two CE-approved robotically assisted surgery systems for use and development in pediatrics. Specifically, tremor filtration and optimal visualization are approaches which can have enormous benefits for procedures in small bodies. Robotically assisted surgery in children might have advantages compared to laparoscopic or open approaches. This review focuses on the research literature regarding robotically assisted surgery that has been published within the past decade. A literature search was conducted to identify studies comparing robotically assisted surgery with laparoscopic and open approaches. While reported applications in urology were the most cited, three other fields (gynecology, general surgery, and “others”) were also identified. In total, 36 of the publications reviewed suggested that robotically assisted surgery was a good alternative for pediatric procedures. After several years of experience of this surgery, a strong learning curve was evident in the literature. However, some authors have highlighted limitations, such as high cost and a limited spectrum of small-sized instruments. The recent introduction of reusable 3 mm instruments to the market might help to overcome these limitations. In the future, it can be anticipated that there will be a broader range of applications for robotically assisted surgery in selected pediatric surgeries, especially as surgical skills continue to improve and further system innovations emerge.

First Pediatric Pyeloplasty Using the Senhance® Robotic System—A Case Report

A pediatric robotic pyeloplasty has been performed with the Senhance^® robotic system for the first time in January 2021 on a 1.5-year-old girl with symptomatic ureteropelvic junction stenosis. A Senhance^® robotic system (Asensus Surgical^® Inc., Durham, NC, USA) with three arms and 5 mm instruments was used, providing infrared eye tracking of the 5 mm camera and haptic feedback for the surgeon, facilitating suturing of the anastomosis and double-J stent insertion. The robotic surgery lasted 4.5 h, was uneventful and successful, without recurrence of the ureteropelvic junction obstruction after six months, and with normal development of the patient’s growth and organ function. The use of the robotic system was shown to be safe and feasible; long term follow-up will be conducted subsequently in pediatric surgery.

Evaluation of the Versius Robotic Surgical System for Procedures in Small Cavities

Background: The Versius^® is a recently approved robotic surgical system for general surgery procedures in adults. Before any application in children, data of its feasibility and safety in small cavities has to be compiled, beginning with inanimate models. Therefore, the aim of this preclinical study was to assess the Versius^® system for its performance in small boxes simulating small body cavities. Methods: In total, 8 cardboard boxes of decreasing volumes (15.75 L to 106 mL) were used. The procedures, two single stitches with two square knots each, were performed in every box, starting in the largest and consecutively exchanging the box to the next smaller one. The evaluation included procedure time, port placement and pivot point setup, arrangement of the robotic arms and instrumentation, amount of internal and external instrument–instrument collisions and instrument–box collisions. Results: All procedures could be successfully performed in all boxes. The procedure time decreased due to the learning curve in the first four boxes (15.75 to 1.87 L) and consecutively increased from boxes of 1.22 L up to the smallest box with the dimensions of 4.4 × 4.9 × 4.9 cm³. This may be based on the progress of complexity of the procedures in small cavities, which is also depicted by the synchronous increase of the internal instrument–instrument and instrument–box collisions. Conclusion: With the use of the Versius^® robotic surgical system, we were able to perform robotic reconstructive procedures, such as intracorporal suturing and knot tying, in cavities as small as 106 mL. Whether this system is comparable or even superior to conventional laparoscopic surgery in small cavities, such as in children, has to be evaluated. Furthermore, before any application in newborns or infants, ongoing evaluation of this system should be performed in a live animal model.