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Di Fabrizio D, Alizai NK, Najmaldin AS. Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children. J Pediatr Surg 2023; 58:1832-1837. [PMID: 36997389 DOI: 10.1016/j.jpedsurg.2023.02.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/14/2023] [Accepted: 02/27/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Robotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years. METHODS Between March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed. RESULTS A total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years -/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years -/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications. CONCLUSIONS Complications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late. LEVELS OF EVIDENCE 2B.
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Affiliation(s)
- Donatella Di Fabrizio
- Department of Paediatric Surgery, Leeds Teaching Hospitals, The General Infirmary, Leeds, UK
| | - Naved K Alizai
- Department of Paediatric Surgery, Leeds Teaching Hospitals, The General Infirmary, Leeds, UK
| | - Azad S Najmaldin
- Department of Paediatric Surgery, Leeds Teaching Hospitals, The General Infirmary, Leeds, UK.
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Cundy TP, Fabrizio DD, Alizai NK, Najmaldin AS. Conversions in pediatric robot-assisted laparoscopic surgery. J Pediatr Surg 2022; 57:1637-1641. [PMID: 34924187 DOI: 10.1016/j.jpedsurg.2021.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/10/2021] [Accepted: 10/31/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND New technology attracts necessary concerns regarding safety and effectiveness, including the risk and circumstances of conversions. This study analyses our 11-year experience of conversions from a dedicated pediatric robot-assisted laparoscopic surgery service. METHODS Consecutive patients were evaluated from a prospective database for the period March 2006 to May 2017. Descriptive and quantitative data for conversions were analysed. Variables were investigated including year of surgery, patient age, operation type, surgeon, and experience. RESULTS A total of 539 children underwent 601 procedures. There were 45 different types of procedures. Mean (± SD) age was 7.0 ± 5.2 years, and youngest 4 weeks old. There were 31 conversions (5.8%). Conversion rates were significantly higher in younger children, with rates of 10.0%, 6.1% and 4.2% for age groups 0-2, 2-6, and 6-18 years respectively (p = 0.01). There was a significant difference in conversion rates amongst procedures (p<0.001). Intravesical (9/26, 34.6%), liver cyst (2/8, 25.0%) and choledochal cyst (8/60, 13.3%) procedures were the highest. The most frequent reason for conversion was anesthetic related issues caused by dilated intestine and/or inadequate muscle relaxation (16/31, 52%). Three conversions were attributable to mechanical failures, none attributed to intraoperative complication. CONCLUSIONS Conversion rates are low even in the learning phase and comparable favourably to conventional laparoscopy, supporting the safety and effectiveness of robot-assisted technology for advanced laparoscopy in children. The importance of optimization of surgical conditions cannot be overemphasised.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK
| | | | - Naved K Alizai
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK
| | - Azad S Najmaldin
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK.
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Di Fabrizio D, Lisi G, Lauriti G, Di Renzo D, Lannutti A, Marino N, Lelli Chiesa P. Conversion Rate in Pediatric Robotic-Assisted Surgery: Looking for the Culprit. J Laparoendosc Adv Surg Tech A 2020; 30:315-321. [PMID: 31976805 DOI: 10.1089/lap.2019.0653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Donatella Di Fabrizio
- Pediatric Surgery Unit, Civil Hospital "Santo Spirito" of Pescara-Department of Aging Science, University "G. d'Annunzio" of Chieti-Pescara, Pescara, Italy
| | - Gabriele Lisi
- Pediatric Surgery Unit, Civil Hospital "Santo Spirito" of Pescara-Department of Aging Science, University "G. d'Annunzio" of Chieti-Pescara, Pescara, Italy
| | - Giuseppe Lauriti
- Pediatric Surgery Unit, Civil Hospital "Santo Spirito" of Pescara-Department of Aging Science, University "G. d'Annunzio" of Chieti-Pescara, Pescara, Italy
| | - Dacia Di Renzo
- Pediatric Surgery Unit, Civil Hospital "Santo Spirito" of Chieti-Pescara, Pescara, Italy
| | - Angela Lannutti
- Anesthesia and Intensive Care Unit, Civil Hospital "Santo Spirito" of Pescara, Pescara, Italy
| | - Nino Marino
- Pediatric Surgery Unit, Civil Hospital "Santo Spirito" of Chieti-Pescara, Pescara, Italy
| | - Pierluigi Lelli Chiesa
- Pediatric Surgery Unit, Civil Hospital "Santo Spirito" of Pescara-Department of Aging Science, University "G. d'Annunzio" of Chieti-Pescara, Pescara, Italy
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Complications of Minimally Invasive Surgery in Children: A Prospective Morbidity and Mortality Analysis Using the Clavien-Dindo Classification. Surg Laparosc Endosc Percutan Tech 2018; 27:170-174. [PMID: 28414701 DOI: 10.1097/sle.0000000000000401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
There is a lack of information about evaluation of pediatric minimal access surgery complications; the Clavien-Dindo classification was never used for a large series of laparoscopic and thoracoscopic pediatric procedures. With a prospective Morbidity and Mortality database, all the minimal access surgical procedures carried out between 2012 and 2016 were included in this study. Statistical analyses were used to valuate modification of surgical techniques in to 2 periods (period 1: January 2012 to February 2014; period 2: February 2014 to February 2016). A total of 1374 minimal access procedures were performed on 1371 patients. The overall complication rate was 2.9%. No differences, in terms of complications, were observed between elective and emergency procedures (P=0.3). There was a significant difference between the complication rate of thoracoscopic surgery (P=0.027). These results provide the relevance of adequate recording system and standardized classification for analyses and reduction of complications for pediatric minimal access procedures.
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Oh C, Youn JK, Han JW, Kim HY, Jung SE. Abdominal tumors in children: Comparison between minimally invasive surgery and traditional open surgery. Medicine (Baltimore) 2016; 95:e5181. [PMID: 27861341 PMCID: PMC5120898 DOI: 10.1097/md.0000000000005181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The use of minimally invasive surgery (MIS) in pediatric patients has been steadily increasing in recent years. However, its use for diagnosing and treating abdominal tumors in children is still limited compared with adults, especially when malignancy is a matter of debate. Here, we describe the experience at our center with pediatric abdominal tumors to show the safety and feasibility of MIS.Based on a retrospective review of patient records, we selected for study those pediatric patients who had undergone diagnostic exploration or curative resection for abdominal tumors at a single center from January 2010 through August 2015.Diagnostic exploration for abdominal tumors was performed in 32 cases and curative resection in 173 cases (205 operations). MIS was performed in 11 cases of diagnostic exploration (34.4%) and 38 cases of curative resection (21.9%). The mean age of the children who underwent MIS was 6.09 ± 5.2 years. With regard to diagnostic exploration, patient characteristics and surgical outcomes were found to be similar for MIS and open surgery. With regard to curative resection, however, the mean age was significantly lower among the patients who underwent open surgery (4.21 ± 4.20 vs 6.02 ± 4.99 for MIS, P = 0.047), and the proportion of malignancies was significantly higher (80% vs 39.4% for MIS, P < 0.001). MIS compared favorably with open surgery with respect to the rate of recurrence (6.7% vs 35.1%, P = 0.035), the rate of intraoperative transfusions (34.2% vs 58.5%, P = 0.01), the median amount of blood transfused (14 vs 22 mL/kg, P = 0.001), and the mean number of hospital days (4.66 ± 2.36 vs 7.21 ± 5.09, P < 0.001). Complication rates did not differ significantly between the MIS and open surgery groups. The operation was converted to open surgery in 3 cases (27.2%) of diagnostic MIS and in 5 cases (13.1%) of curative MIS.MIS was found to be both feasible and effective for the diagnosis and curative treatment of pediatric abdominal tumors. However, to determine the surgical role and guidelines for MIS for each specific tumor, a multicenter prospective study with a long-term follow-up is warranted.
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Friedmacher F, Till H. Robotic-Assisted Procedures in Pediatric Surgery: A Critical Appraisal of the Current Best Evidence in Comparison to Conventional Minimally Invasive Surgery. J Laparoendosc Adv Surg Tech A 2015; 25:936-43. [PMID: 26120735 DOI: 10.1089/lap.2015.0119] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION In recent years, the use of robotic-assisted surgery (RAS) has expanded within pediatric surgery. Although increasing numbers of pediatric RAS case-series have been published, the level of evidence remains unclear, with authors mainly focusing on the comparison with open surgery rather than the corresponding laparoscopic approach. The aim of this study was to critically appraise the published literature comparing pediatric RAS with conventional minimally invasive surgery (MIS) in order to evaluate the current best level of evidence. MATERIALS AND METHODS A systematic literature-based search for studies comparing pediatric RAS with corresponding MIS procedures was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. RESULTS A total of 20 studies met defined inclusion criteria, reporting on five different procedures: fundoplication (n=8), pyeloplasty (n=8), nephrectomy (n=2), gastric banding (n=1), and sleeve gastrectomy (n=1). Included publications comprised 5 systematic reviews and 15 cohort/case-control studies (OCEBM Level 3 and 4, respectively). No studies of OCEBM Level 1 or 2 were identified. Limited evidence indicated reduced operative time (pyeloplasty) and shorter hospital stay (fundoplication) for pediatric RAS, whereas disadvantages were longer operative time (fundoplication, nephrectomy, gastric banding, and sleeve gastrectomy) and higher total costs (fundoplication and sleeve gastrectomy). There were no differences reported for complications, success rates, or short-term outcomes between pediatric RAS and conventional MIS in these procedures. Inconsistency was found in study design and follow-up with large clinical heterogeneity. CONCLUSIONS The best available evidence for pediatric RAS is currently OCEBM Level 3, relating only to fundoplication and pyeloplasty. Therefore, higher-quality studies and comparative data for other RAS procedures in pediatric surgery are required.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric and Adolescent Surgery, Medical University Graz , Graz, Austria
| | - Holger Till
- Department of Pediatric and Adolescent Surgery, Medical University Graz , Graz, Austria
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Bruns NE, Soldes OS, Ponsky TA. Robotic Surgery may Not "Make the Cut" in Pediatrics. Front Pediatr 2015; 3:10. [PMID: 25729745 PMCID: PMC4325656 DOI: 10.3389/fped.2015.00010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/29/2015] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas E Bruns
- Department of Pediatric Surgery, Akron Children's Hospital , Akron, OH , USA
| | - Oliver S Soldes
- Department of Pediatric Surgery, Akron Children's Hospital , Akron, OH , USA
| | - Todd A Ponsky
- Department of Pediatric Surgery, Akron Children's Hospital , Akron, OH , USA
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Malkan AD, Loh AHP, Sandoval JA. Minimally invasive surgery in the management of abdominal tumors in children. J Pediatr Surg 2014; 49:1171-6. [PMID: 24952811 DOI: 10.1016/j.jpedsurg.2014.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 04/03/2014] [Accepted: 04/16/2014] [Indexed: 11/26/2022]
Abstract
The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.
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Affiliation(s)
- Alpin D Malkan
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Amos H P Loh
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - John A Sandoval
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN.
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The first decade of robotic surgery in children. J Pediatr Surg 2013; 48:858-65. [PMID: 23583146 DOI: 10.1016/j.jpedsurg.2013.01.031] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 01/03/2013] [Accepted: 01/20/2013] [Indexed: 12/20/2022]
Abstract
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.
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