Robotically Assisted Minimally Invasive Surgery in a Pediatric Population: Initial Experience, Technical Considerations, and Description of the da Vinci® Surgical System

Robotic repair of pediatric hernias: Current techniques and practices

The use of minimally invasive surgical techniques has gained popularity in pediatric surgery due to decreased length of stay, improved post-operative pain and smaller incisions. Laparoscopic assisted robotic surgical procedures are becoming more common in adults as they carry all of the benefits of traditional MIS but also allow for improved dexterity, visualization and surgeon ergonomics. In adults, hernia repairs are one of the most commonly performed robotic cases but adaption to pediatric repairs has been slower. Case reports and small case series have described a number of various types of pediatric hernia repairs including congenital diaphragmatic hernias, paraesophageal hernias and inguinal hernias. These cases have demonstrated that robotic repair of pediatric hernias is safe and feasible with minimal documented post-operative complications or recurrence. Future directions should focus on larger patient volume in order to assess outcomes between traditional laparoscopic and robotic approaches.

Robot-Assisted Versus Laparoscopic Approach for Splenectomy in Children: Systematic Review and Meta-Analysis

Aim: To compare the outcomes of pediatric splenectomies for hematologic diseases performed by robot-assisted laparoscopic surgery (RALS) and laparoscopic approach. Materials and Methods: Web of Science, Scopus, and PubMed databases were systematically searched for publications in English language from January 2000 to March 2020. All the studies dealing with pediatric elective splenectomies performed by RALS were included. The primary outcomes were the rate of postoperative complications and conversion. The secondary outcomes were the length of hospital stay and the operative time. Results: The search yielded 969 articles. Ten articles were included in the systematic review. Eighty patients underwent RALS splenectomy. Thirteen postoperative complications (16%) were reported and RALS was converted to open surgery in five cases (6.3%). Five of the included articles, three retrospective studies and two case series, were considered relevant for the meta-analysis and dealt with 130 patients. Of them, 71 children (55%) underwent RALS. No difference in the rate of complications was found between the two approaches (P = .235). RALS presented a similar rate of conversion to open surgery (P = .301). The mean operative times and length of hospital stays for RALS, reported in three different studies, were 107.5, 159.6, 140.5 minutes and 4.2, 3.93, 2.1 days, respectively. Conclusion: Even if few studies were included in the review, this meta-analysis reported similar rates of complication and conversion for RALS when compared with laparoscopy. Further studies are required to prove that this innovative technique was as safe and feasible as the current gold standard technique.

A comparative cost analysis of robotic-assisted surgery versus laparoscopic surgery and open surgery: the necessity of investing knowledgeably

BACKGROUND

Robotic surgery has been proposed as a minimally invasive surgical technique with advantages for both surgeons and patients, but is associated with high costs (installation, use and maintenance). The Health Technology Assessment Unit of the Bambino Gesù Children's Hospital sought to investigate the economic sustainability of robotic surgery, having foreseen its impact on the hospital budget METHODS: Break-even and cost-minimization analyses were performed. A deterministic approach for sensitivity analysis was applied by varying the values of parameters between pre-defined ranges in different scenarios to see how the outcomes might differ.

RESULTS

The break-even analysis indicated that at least 349 annual interventions would need to be carried out to reach the break-even point. The cost-minimization analysis showed that robotic surgery was the most expensive procedure among the considered alternatives (in terms of the contribution margin).

CONCLUSIONS

Robotic surgery is a good clinical alternative to laparoscopic and open surgery (for many pediatric operations). However, the costs of robotic procedures are higher than the equivalent laparoscopic and open surgical interventions. Therefore, in the short run, these findings do not seem to support the decision to introduce a robotic system in our hospital.

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.

Robot-assisted surgery in children: current status

The horizon of robotic paediatric surgery has grown in leaps and bounds with advances in technology. The aim of this study was to analyse the extent of robotic involvement in paediatric surgical practice. A systematic database search was performed. Data about children who had undergone robot-assisted procedures were reviewed retrospectively from all published reports up to October 2007. Success rates were defined in term of completion of the procedures, their complications, and the time taken. These results were further studied in comparison with the procedures performed by open and laparoscopic methods. A total of 31 studies were identified describing 566 patients. Of these, four studies were case control, comparing with either laparoscopic or open procedures, one study was a prospective trial, and the rest of the studies were either case reports or series. The most common robotic system used was the da Vinci (23 studies) followed by the Zeus (four studies). The mean age of the children was 8.3 years. The commonest operation was pyeloplasty (141 cases), followed by fundoplication (122 cases) and patent ductus arteriosus ligation (50 cases). The mean operation time for robot-assisted pyeloplasty was 221 min (open pyeloplasty 214 min). The mean operation times for fundoplication were robotic, 170 min, laparoscopic, 158 min, and open, 121 min. The mean operation times for patent ductus arteriosus ligation were 166 min (robotic) and 83 min (open). Overall conversion rate for all paediatric robotic procedures was 4.7% and complications ranged from 0 to 15%. For robotic fundoplications the conversion and complication rates were 0.8 and 3.3%, respectively. For robotic pyeloplasties the conversion and complication rates were 2.1 and 3.5%, respectively. Many other major operations were performed successfully. All studies recommended robotic procedure as safe and feasible. Currently, the most common robotic operations in practice are pyeloplasties and fundoplications. Most of the authors concluded that, despite taking more time, robotic surgery enables more refined hand–eye coordination, superior suturing skills, better dexterity, and precise dissection with minimal conversion and complication rates. The widespread acceptance of this technology largely depends on solving the issues: learning curve; suitable machine size for neonates and infants; ensuring efficacy and safety in all operations; and, most importantly, making this procedure cost effective, so as to cater for the needs of most, if not all, children.

Surgical robotics and image guided therapy in pediatric surgery: emerging and converging minimal access technologies

Minimal access surgery (MAS) is now commonplace in the armamentarium of the pediatric surgeon, and is being applied to a growing list of pediatric surgical diseases. Robot-assisted surgery and image guided therapy (IGT) have evolved as innovative minimal access approaches, and hold the promise of advancing MAS far beyond what is currently possible. The aims of this article are to describe the currently available robotic, and image guided therapy systems, review their present and potential applications, and discuss the future directions of these converging technologies.

Robot-assisted laparoscopic resection of a type I choledochal cyst in a child

Although the laparoscopic approach to the treatment of complex biliary disease is possible, it is technically challenging. In an attempt to overcome these difficulties, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California) was used to facilitate the minimally invasive treatment of a type I choledochal cyst in a 5-year-old, 22 kg, girl. Complete resection of the choledochal cyst and a Roux-en-Y hepaticojejunostomy were performed using the robotic surgical system. Total robotic setup time (preparation, port placement, docking) was 40 minutes. Total procedure time was 440 minutes. Total robotic operative time was 390 minutes. No intraoperative complications or technical problems were encountered. At 6-month follow-up, the child is doing well with no episodes of cholangitis. Robot-assisted laparoscopic type I choledochal cyst resection appears safe and feasible. The three-dimensional visualization and wristed instrumentation greatly aids in the dissection of the cyst and in the biliary reconstruction.

A prospective study comparing operative time in conventional laparoscopic and robotically assisted Thal semifundoplication in children

BACKGROUND

It is not clear if robotically assisted surgery (providing articulating instruments, 3-dimensional vision, intuitive ergonomics) performed in pediatric patients offers the same advantages over conventional surgery as in adult patients. In the laboratory setting, robots require less time to perform certain tasks. Accordingly, we tested the hypothesis that the time required to perform a robotically assisted laparoscopic Thal semifundoplication is different compared with a conventional laparoscopic procedure in children.

METHODS

The time required to perform single operative steps was prospectively recorded in 10 consecutively performed Thal semifundoplications with the use of a robot (da Vinci) and in 10 consecutively performed operations done by conventional laparoscopy.

RESULTS

No conversion to an open operation was necessary, and there were no intraoperative complications throughout the study and no postoperative complications up to 14 months after surgery. Total operative time was similar in both groups. In the robotically assisted group, time for setup was significantly longer (20.8 +/- 7.5 vs 34.6 +/- 9.2 minutes, P < .05), but dissection of the hiatal region as the most challenging operative step was accomplished 34% faster in the robotically assisted group (30.8 +/- 8.7 vs 20.2 +/- 5.3 minutes, P < .05).

CONCLUSION

At the current level of technology, the robotic system is superior compared with established standard laparoscopic techniques requiring tissue preparation; however, the potential benefit in operating time is counterbalanced by the increased complexity of setting up the system.

Laparoscopic Morgagni hernia repair in children using robotic instruments

BACKGROUND

Robotic surgery enhances minimally invasive surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. We report 2 cases of computer- assisted, robot-enhanced, laparoscopic repair of Morgagni hernia in a 23-month-old weighing 10.2 kg and a 5-year-old weighing 21.6 kg.

METHODS

Four 5 mm trocars were used to gain access to the abdomen. In the first case, standard laparoscopic instruments were used to dissect the liver from the rim of the defect and then reduce the hernia. In the second, robotic instruments were used for this dissection. In both cases, the robot- enhanced instruments were used to close the hernia defects with interrupted, nonabsorbable suture, using intracorporeal knot tying.

RESULTS

Both cases were completed laparoscopically without a patch. The robotic system took 9 minutes to set up and drape. The average operative time was 227 minutes. The older child tolerated oral intake the day of surgery and went home the following day. The younger child tolerated oral intake and went home on postoperative day 2.

CONCLUSION

Robot-assisted laparoscopic Morgagni hernia repair is feasible.

Robotically assisted perventricular closure of perimembranous ventricular septal defects: preliminary results in Yucatan pigs

OBJECTIVE

Robotic systems allow surgeons to perform minimally invasive cardiac surgery in adults. Experience in the pediatric population, however, is limited. Perventricular closure of muscular ventricular septal defects has been reported in humans but requires a median sternotomy. The objective of this study was to assess the feasibility of robotically assisted closure of perimembranous ventricular septal defects by using the perventricular approach.

METHODS

The procedure was attempted in 7 pigs with naturally occurring perimembranous ventricular septal defects. Echocardiography was performed to confirm the presence and assess the size of the defect. A 3-armed da Vinci system consisting of two 8-mm instrument ports and a 12-mm endoscopy port was used. A pericardiotomy was performed, and the right ventricular free wall was visualized. A spinal needle was advanced into the right ventricular cavity. By using echocardiographic guidance, a glide wire was advanced through the angiocatheter and manipulated through the defect into the left ventricle or the ascending aorta. A delivery sheath was advanced over the wire. An appropriately sized Amplatzer device was deployed through the sheath.

RESULTS

The procedure was successful in 5 pigs. One device was removed because it was smaller than the defect and an appropriately sized device was not available. The placement failed in the second pig in the series. Four pigs were followed up for 1 to 4 months. Angiograms performed before the pigs were killed documented complete occlusion in 3 and mild-to-moderate shunt in 1.

CONCLUSIONS

Robotically assisted perventricular closure with the Amplatzer Membranous VSD Occluder is feasible. This approach avoids the associated morbidities of cardiopulmonary bypass and median sternotomy. Further investigation and refinements are needed, however, before application of this approach in humans.

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.