Pediatric Applications of Robotic Surgery

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.

Robotic endoscopic surgery in a porcine model of the infant neck

Minimally invasive surgery is rapidly becoming the desired surgical standard, especially for pediatric patients. Infants and children are a particular technical challenge, however, because of the small size of target anatomical structures and the small surgical workspace. Computer-assisted robot-enhanced surgical telemanipulators may overcome these challenges by facilitating surgery in a small workspace. We studied the feasibility of performing robotic endoscopic neck surgery on a porcine model of the human infant neck. The study design was a prospective, feasibility pilot study of a small cohort for proof of concept and for a survival model. Sixteen non-survival piglets weighing 4.5–10 kg were used to develop the surgical approach and operative technique. Eight piglets aged 3–6 weeks old and weighing 4.0–9.1 kg underwent survival thyroidectomy by a cervical endoscopic approach using the Zeus surgical robot, which includes the Aesop endoscope holder and “Microwrist” microdissecting instruments. We succeeded in performing endoscopic robotic neck surgery on a piglet as small as 4 kg, in an operative pocket as small as 2 cm³. Total incision length for all three ports was ≤23 mm. There were no major complications, no major robotic instrument malfunctions or breakages, and no procedures required conversion to open surgery. These results support the feasibility of robotic endoscopic neck surgery on a neck the size of a human infant’s.

Robot-assisted pediatric surgery

Computer-enhanced robotic surgical systems have been increasingly used to facilitate complex minimal access surgical procedures. In adult patients, such systems have been used to perform a wide variety of operations including coronary artery bypass grafting, mitral valve repair, Roux-en-Y gastric bypass, colon resection, nephrectomy, and radical prostatectomy. In the field of pediatric surgery, the experience with robotic surgical systems has been more limited. However, with improvements in robotic technology, interest and experience with robotic pediatric surgery have grown rapidly. The purpose of this article is to review the current experimental and clinical literature regarding the use of robotic surgical systems in the pediatric patient population.