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

Abstract

Introduction: Reports of robotically assisted minimal access surgery (RMAS) in the adult patient population have increased over the last several years. Few reports have addressed RMAS in pediatric patients. We present our initial RMAS experience with the da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, California), and discuss technical considerations, advantages, and disadvantages. Methods: From July 2002 to April 2003, the da Vinci surgical system was used in 20 pediatric patients (9 female, 11 male) with a mean age of 8.4 years (range, 4 months to 16 years). The mean weight of our patients was 38.7 kg (range, 6.8-82 kg). Procedures performed were: Nissen fundoplication (10, including 3 with gastrostomy tube placement and 1 with pyloroplasty), cholecystectomy (3), splenectomy (2), urachus resection (1), unilateral iliac and retroperitoneal lymphadenectomy (1), incisional biopsy retroperitoneal presacral mass (1), incisional biopsy hepatic mass (1), Gortex patch repair of a Morgagni diaphragmatic hernia (1), biopsy of a benign infracarinal mediastinal mass (1). Operating times, technical considerations, complications, length of stay, and patient outcomes were recorded. Results: Mean operating room (OR) setup time was 45 minutes (range, 29-80 minutes). Mean patient positioning and preparation time was 17 minutes (range, 5-45 minutes). Mean trocar mapping time was 22 minutes (range, 4-55 minutes). Mean surgical cart docking time was 13 minutes (range 5-40 minutes). Mean console operating time was 93 minutes (range, 10-299 minutes). Mean OR turn-over time was 18 minutes (range, 5-54 minutes). An intraoperative complication rate of 15% was recorded, as each splenectomy required conversion to laparotomy to control bleeding, and the Morgagni hernia repair required intraoperative, percutaneous evacuation of a pneumothorax. All other procedures were completed with the da Vinci surgical system. Mean postoperative length of hospitalization for all patients was 2.7 days (range, 1-16 days). Postoperative complications included limited dysphagia in 2 patients and superficial wound infection from gastrostomy tube leak in 1 patient (10%). Conclusion: RMAS with the da Vinci surgical system can be performed safely in children and offers advantages over conventional minimal access surgery (CMAS), including articulating instruments enabling more precise, intracorporeal tissue manipulation and suturing, three-dimensional vision, and intuitive ergonomics. Currently, disadvantages of RAMS include larger trocar incisions, longer total OR time, and limited tactile sensation and maneuverability in smaller patients.