Robotic Surgery In Children Research Articles

Robotic-assisted choledochal cyst excision with Roux-en-Y hepaticojejunostomy in children: A Chinese expert panel consensus statement

BackgroundThe first robotic surgery in children and adult happened in more or less that same time but the development in children subsequently lagged behind especially for complicated operations such as robotic-assisted hepaticojejunostomy for choledochal cyst (RHCC). In order to achieve a high standard for this operation, expert consensus was developed among Chinese experts with ample experience in RHCC. MethodsThirty experts from twenty-six institutions experts participated in the consensus meeting. A Screening Committee was established to performed a comprehsenive literature review on RHCC. A few specific topics have been proposed based on the review but only topics which were agreed upon were discussed during the meeting using Delphi Rounds. Lastly, formulated recommendations were proposed by the Committee and finalized in the expert consensus meeting. ResultsAfter initial screening and discussion, nine topics were selected for discusssion. Eight recommendation statements were formulated. All recommendations reached more than 80 % consensus among experts at the final Delphi Round. ConclusionsThe consensus statementson RHCC in children were based on available international literatures and experience from Chinese experts. These statements helpto standardize the surgical techniques and prevent surgical complications during RHCC.

Robotic surgeries in pediatric patients: an early experience in a single center.

Robotic surgery (RS) has the advantages of 3-dimensional view, optical magnification, motional scaling, and improved ergonomics and degree of freedom. Although RS has widely been performed on pediatric patients lately, there are still numerous restrictions and ambiguous indications. The purpose of this study was to report our early experience with RS on pediatric patients at a single center. Electronic medical records of patients who underwent RS with the da Vinci Xi surgical platform (Intuitive Surgical, Inc.) in Seoul National University Children Hospital from November 2019 to August 2021 were reviewed retrospectively. The median follow-up was 21.0 months (range, 12.3-31.8 months). An online survey was conducted to investigate satisfaction with robotic surgical scars. Fifty-four patients underwent robotic surgeries (median age at operation, 11.1 years [range, 0.1-17.8 years]). In our hospital, patients had 20 different kinds of robotic surgeries, including choledochal cyst excision with hepaticojejunostomy, ovarian mass excision, and others. Median operation time and console time were 157.5 minutes (range, 45-505 minutes) and 40 minutes (range, 11-360 minutes), respectively. All cases were done without conversion into open or laparoscopic methods. Postoperative complications were found in 5 patients. According to an online survey, over half of patients (60.9%) answered that they felt satisfied with scars. Our early experience demonstrated the safety and feasibility of RS in children with a range of diagnoses and complicated procedures. With more experience, RS could be an alternative to traditional open or laparoscopic operations in pediatric patients. Further studies are needed to clarify indications of pediatric RS.

Robotics and future technical developments in pediatric urology

Minimally invasive surgery (MIS) has represented the main innovation in the field of pediatric surgery and urology over the last 30 years. Pediatric MIS is a wide field, ranging from the standard laparoscopic surgery using 3-mm ports to robotics mainly adopted for pediatric urology indications. The aim of this paper was to summarize the current status of robotic surgery in pediatric urology and to evaluate possible future technical developments for this technique. In pediatric urology, many procedures are challenged by the narrow working space available in smaller children, the difficulty to perform complex and long suture lines to repair complex urinary malformations, and the challenge to remove renal or adrenal tumors. The main characteristic of robotic surgery is that the robotic instruments inserted into the abdominal cavity are remotely controlled by the surgeon, who is sitting at a console next to the patient or even far away, avoiding human tremor during complex suturing. Due to the magnification of the operative field view and the six degrees of freedom of the robotic instruments compared to conventional laparoscopic instruments, providing enhanced 3D vision and improved surgeon ergonomics, robot-assisted surgery appears to be beneficial over conventional MIS, especially in complex reconstructive procedures. Currently, there are two robotic systems available on the market and certified for robotic surgery in children: the DaVinci (Intuitive Surgical, since 2001) and Senhance (Transenterix, since 2020). However, almost the totality of papers published in the international literature are focused on robotic procedures using the DaVinci platform. Analyzing the current literature, there is no evidence about the indications where robotics are preferable to conventional MIS approaches. Currently, the main indications of robotic surgery in pediatric urology are: pyeloplasty for ureteropelvic junction obstruction (UPJO), ureteral reimplantation according to Lich Gregoire technique, Mitrofanoff procedure, nephrectomy or partial nephrectomy for oncological indications, removal of renal cysts, bladder neck reconstruction or removal of urinary tract stones. The future developments in this field are certainly represented by intraoperative use of indocyanine green (ICG) fluorescence imaging that permits to have a better vision of vascular anatomy or clearly identify nodes in case of tumors, and by development of 5G technology. The main limitation of robotic surgery today remains the excessive cost of the machine itself and the limited lifespan of robotic instruments. We believe that robotic surgery will surely represent the new field of development in pediatric surgery, but its widespread application will depend on the introduction of new robotic platforms in the market, that will certainly low the costs, and also to the development of smaller size instruments more suitable for pediatric use.

Robotic Surgery in Pediatric Oncology: Lessons Learned from the First 100 Tumours. A Nationwide Experience

Background: The use of robotics has become commonplace in adult oncology but remains rare in paediatric oncologic surgery. We present the results of a large nationwide experience with robotic surgery in children with benign and malignant tumours. Methods: Prospective analysis (ClinicalTrials.gov NCT03274050) of robotic procedures performed between 2008 and 2019. Children received treatment according to the ongoing SIOP/SIOPEN protocols. Indications were approved by a certified tumour board. Findings: A total of 100 tumours were resected during 92 procedures in 87 children (56 girls). The median age at surgery was 7·4 years (3·5-12); 20% of children harboured germinal genetic alterations predisposing to cancer. Procedures were performed by laparoscopy for abdominal (71%) or pelvic tumours (10%) and by retroperitoneoscopy (5%) or thoracoscopy (14%). No intraoperative tumour rupture occurred during robotic-assisted dissection. Eight conversions (9%) to an open approach occurred. Neuroblastic tumour (n=29) was the main group (19 neuroblastomas, three ganglioneuroblastomas, seven ganglioneuromas). Renal tumour was the second largest group (n=24, including 20 Wilms’ tumours). The other 47 tumours were neuroendocrine (n=13), adrenal (n=11), pancreatic (n=3), germ-cell (n=7), thymic (n=4), inflammatory myofibroblastic (n=4) and five different rare tumours. Overall, 50 tumours were malignant, 2 were borderline and 48 were benign. The median hospital stay was 3 days (2-4). Five post-operative surgical complications occurred within the first 30 days in four patients. During a follow-up of 1 to 28 months, one child (Wilms’ tumour) presented pleural recurrence. One girl with Wilms’ tumour died of central nervous system metastasis. Interpretation: Robotic surgery for paediatric tumours is feasible and may be an option in highly selected cases. Indications should be discussed by tumour boards to avoid widespread and uncontrolled application of the approach. Children with genetic predisposition to cancer seem good candidates for the robotic approach. Trial Registration: ClinicalTrials.gov NCT03274050 Funding: The sponsor was Assistance Publique–Hopitaux de Paris (APHP, Clinical Research and Innovation Delegation) and this project was funded by a grant from Necker Hospital. Declaration of Interests: None to declare. Ethics Approval Statement: This prospective analysis received approval from institutional review boards and an independent ethics committee (Comite de Protection des Personnes, CPP Ile de France VII). The sponsor was Assistance Publique–Hopitaux de Paris (APHP, Clinical Research and Innovation Delegation).

The Potential and the Limitations of Esophageal Robotic Surgery in Children.

There have been numerous reports of robotic pediatric surgery in the literature, particularly regarding urological procedures for school-aged children. Thoracic procedures appear to be less common, despite the fact that encouraging results were reported more than 10 years. Our aim was to report a national experience of esophageal robotic-assisted thoracoscopic surgery (ERATS) and to discuss the most appropriate indications. A retrospective multicenter study was conducted to compile the ERATS performed at five French surgical centers that have been involved in spearheading robotic pediatric surgery over the past 15 years. The data were supplemented by a review of the literature. Over the study period, 68 cases of robotic thoracic surgery were performed at the five pediatric centers in question. ERATS was performed for 18 patients (mean age 7.1 years [ ± 5.6]) in four of the centers. These comprised seven esophageal duplications, four esophageal atresias, five Heller's myotomies, and two cases of esophagoplasty. A conversion was needed for two neonates (11%) due to exposure difficulties. Four other procedures for patients who weighed less than 15 kg were successfully completed without causing postoperative complications. In the past 12 years, 22 other cases of ERATS were published worldwide. The indications were the same, except for esophagoplasty, which was not found. Aside from accessibility issues with the robotic platform, the main limitation is still very much that the low body weight of children results in incompatibility between the size of the trocars and the size of the intercostal space. ERATS is clearly a feasible procedure with technical advantages for most pediatric cases with body weights more than 15 kg. A transdiaphragmatic abdominal approach should be considered for lower esophagus surgery.

Robotics in Pediatric Urology.

ABSTRACTRobotic surgery has been slow to be fully accepted in the world of pediatric urology largely because of its initial application directed towards adult use and because of the inherent high cost associated with it. However, as previously shown, it has now become the gold standard for adolescent pyeloplasty in The United States. As the adoption of robotic surgery in children has become more widespread, its use has been applied to a broader spectrum of procedures with similar success rates to standard laparoscopy. These procedures include nephrectomy, heminephrectomy, ureteral reimplantation, and ureteroureterostomy. However, it has also shown feasibility and comparable success when compared to open surgery in procedures that were previously deemed too complex to be done by standard laparoscopy. For example, bladder neck reconstruction with Mitrofanoff and Malone procedure as well as bladder augmentation. This review objective is to provide an overview of robotic surgery in pediatric urology, with a focus on the more common cases such as pyeloplasty and reimplantation as well as more complex bladder reconstruction procedures.

Thoracic surgery by minimally invasion robot-assisted in children: “experience and current status”

Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic. Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the “da Vinci surgical system” (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery. Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing’s tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases. Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.

Learning curve for robotic surgery in children: a systematic review of outcomes and fellowship programs

The learning curve (LC) of a new technique is fundamental for its application and assessment, and for the training. Literature was analysed to define the LCs of different surgical procedures and the impact of fellowship programs. MEDLINE, EMBASE and paediatric surgical journals' databases from January 1995 to December 2018 were systematically analysed. Two independent residents sought for articles providing description of robotic-assisted procedures' LCs in paediatric age/population. Seventeen articles were selected, describing LC of robotic-assisted pyeloplasty (n = 9), fundoplication (n = 4), cholecystectomy (n = 2), choledochal cyst resection (n = 1) and lingual tonsillectomy (n = 1), with 721 procedures. Ten studies refer to one single surgeon; six to more than one; one does not specify the number of operators. Eleven studies are unicentric retrospective, two multicentric retrospective, three prospective and one is a comparative analysis between a retrospective case series and a prospective cohort. The most recruited parameter is operative time alone in 3 articles, associated with complications in 12, length of hospital stay in 6, blood loss in 3, resolution in 4 and narcotic use in 2. The LC is described as impacting procedural planning (n = 17), training (n = 9) and economic costs (n = 2). To date, operative time is the most reported outcome to measure LC and proficiency. Efforts are needed to consider measures of surgical expertise and patient status. Robotic training should be standardized on targeted programs planned upon well-defined LCs.

Robotic Urologic Surgery in Infants: Results and Complications.

Over the last 30 years, robotic surgery has evolved into the preferred surgical approach for many operative cases. Robotics has been associated with lower pain scales, shorter hospitalizations, and improved cosmesis (1, 2). However, its acceptance in pediatrics have been hampered by longer operative times, smaller working space, and limited fine surgical instruments. Many find these challenges even more pronounced when performing robotic surgery in infants (i.e., children <1 year old). Although the data in infants is less robust, many studies have shown benefits similar to the adult population. Specifically, multiple reports of robotic surgery in infants have shown lower postoperative analgesic use. Additionally, hospital stays are shorter, which may lead to quicker return to work for parents and guardians. Multiple reports have shown low complication rates of robotic surgery in infants. When complications have occurred, they are usually Clavien Grade 1 and 2, with occasional grade 3. Often the complications are not from the robotic technique, but are linked to other factors such as the ureteral stents (3, 4). Most importantly, the success rates of surgery are comparable to open surgery. This chapter will review indications for the most common urologic robotic surgeries performed in infants. Also, we will review reported results and complications of robotic surgery in children, with specific attention to the infant population. However, data focused only on infants is limited. Many studies have some infant patients, but their results are often mixed with all pediatric patients.

Totally Endoscopic Robotic-Assisted Cardiac Surgery in Children.

Robotic surgery for intracardiac pathologies in children is relatively uncommon. This study presents our initial experience with robotic-assisted cardiac surgery in children. We also present the feasibility and safety of robotic surgery in children. From May 2013 to June 2018, 30 children underwent totally endoscopic robotic atrial septal defect closure (n=22), right-sided (n=5) or left-sided (n=1) partial anomalous pulmonary venous connection repair, tricuspid valve annuloplasty (n=4), and mitral valve replacement (n=2, due to Barlow and rheumatic diseases). The mean age of the patients was 16.1±1.1years (range, 13-17) and the mean weight was 56.7±0.1kg (range, 42-77). Associated anomalies included left persistent superior vena cava (n=2) and the absence of innominate vein (n=1). All procedures were completed uneventfully. Operation time was 4.1±0.6h. No patient was converted to thoracotomy or sternotomy. Cardiopulmonary bypass and aortic clamping times were 90.6±28.0 (range, 45-136) and 48.6±24.9 (range, 15-94) min, respectively. The mean ventilation time was 3.7±1.2h and hospital stay time was 3.3±0.7 days. No right phrenic nerve injury, hemorrhage, or blood transfusion were noted. One patient had postoperative pneumothorax, and 1 had supraventricular arrhythmia. Follow-up was a mean of 1.7years (range, 1-52months). Patients were healthy and no residual intracardiac defect was observed on echocardiography examinations. There was no operative or follow-up mortality. Robotically assisted cardiac surgery is a feasible and safe approach in selected pediatric patients. In the future, new generation robotic devices may offer an alternative surgical approach in cardiac surgery for younger children with lower body weight.

Survey on Robot-Assisted Surgical Techniques Utilization in US Pediatric Surgery Fellowships.

Robotic technology has transformed both practice and education in many adult surgical specialties; no standardized training guidelines in pediatric surgery currently exist. The purpose of our study was to assess the prevalence of robotic procedures and extent of robotic surgery education in US pediatric surgery fellowships. A deidentified survey measured utilization of the robot, perception on the utility of the robot, and its incorporation in training among the program directors of Accreditation Council for Graduate Medical Education (ACGME) pediatric surgery fellowships in the United States. Forty-one of the 47 fellowship programs (87%) responded to the survey. While 67% of respondents indicated the presence of a robot in their facility, only 26% reported its utilizing in their surgical practice. Among programs not utilizing the robot, most common reasons provided were lack of clear supportive evidence, increased intraoperative time, and incompatibility of instrument size to pediatric patients. While 58% of program directors believe that there is a future role for robotic surgery in children, only 18% indicated that robotic training should play a part in pediatric surgery education. Consequently, while over 66% of survey respondents received training in robot-assisted surgical technique, only 29% of fellows receive robot-assisted training during their fellowship. A majority of fellowships have access to a robot, but few utilize the technology in their current practice or as part of training. Further investigation is required into both the technology's potential benefits in the pediatric population and its role in pediatric surgery training.

Robotic surgery in children: adopt now, await, or dismiss?

The role of robot-assisted surgery in children remains controversial. This article aims to distil this debate into an evidence informed decision-making taxonomy; to adopt this technology (1) now, (2) later, or (3) not at all. Robot-assistance is safe, feasible and effective in selected cases as an adjunctive tool to enhance capabilities of minimally invasive surgery, as it is known today. At present, expectations of rigid multi-arm robotic systems to deliver higher quality care are over-estimated and poorly substantiated by evidence. Such systems are associated with high costs. Further comparative effectiveness evidence is needed to define the case-mix for which robot-assistance might be indicated. It seems unlikely that we should expect compelling patient benefits when it is only the mode of minimally invasive surgery that differs. Only large higher-volume institutions that share the robot amongst multiple specialty groups are likely to be able to sustain higher associated costs with today's technology. Nevertheless, there is great potential for next-generation surgical robotics to enable better ways to treat childhood surgical diseases through less invasive techniques that are not possible today. This will demand customized technology for selected patient populations or procedures. Several prototype robots exclusively designed for pediatric use are already under development. Financial affordability must be a high priority to ensure clinical accessibility.

Utilization and costs associated with robotic surgery in children

BackgroundTo evaluate utilization and costs associated with robotic surgery in children. Materials and methodsWe identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. ResultsThe number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. ConclusionsUse of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Comparison of Complications of Robot-Assisted Laparoscopic and Open Appendicovesicostomy in Children

Robot-assisted laparoscopic appendicovesicostomy in children has become increasingly popular. However, the literature on this technique mainly consists of small case series with only 1 small comparison to an open cohort. We compared the number of complications and surgical revisions required with open and robotic surgery in children undergoing appendicovesicostomy at our institution. We retrospectively reviewed the charts of all patients who underwent appendicovesicostomy by 3 surgeons between July 2002 and September 2013. Acute complications and surgical revisions were recorded and compared between groups with t-tests for continuous variables and Fisher exact test for categorical variables. A total of 28 open and 39 robotic appendicovesicostomies were included. At a mean followup of 2.7 years there was no difference in number of complications or reoperations (p = 0.788 and p = 0.791, respectively) between groups. Time to first reoperation was shorter in the robotic group. However, there was no significant difference between groups regarding number of patients who underwent reoperation within the first 12 months postoperatively (p = 0.346). Comparison of robotic and open appendicovesicostomy revealed no significant difference in the number of acute complications or reoperations between groups. However, the nature and timing of complications differed between groups.

Robotic Surgery may Not "Make the Cut" in Pediatrics.

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.

Robotic Surgery in Children

Robotic Surgery in Children

Clinical Pearls in Pediatric Otolaryngology: A Video Forum

Program Description: This video-based forum will provide audience members with state of the art concepts in pediatric otolaryngology. The speakers consist of: Carlton Zdanski: Transoral Robotic Surgery in Children: Indications and Results; Christopher Hartnick: Bevacizumab (Avastin) injection for pediatric RRP; Craig Derkay: Modifications of the Seldinger technique to secure the difficult pediatric airway; David White: Endoscopic division of the sternocleidomastoid muscle for treatment of torticollis; Ken Kazahaya: Endoscopic assisted otologic surgery; Michael Rutter: Tracheotomy tube fenestration; Sanjay Parikh: Diagnosis of sleep induced laryngomalacia; Soham Roy: Radiofrequency ablation of pediatric oral cavity lesions; Steven Goudy: Video-assisted pharyngeal surgery. Educational Objectives: 1) Consider contemporary airway management ideas for tracheotomy tubes, recurrent papillomatosis, and laryngomalacia. 2) Describe novel endoscopic laryngopharyngeal techniques with robotics, radiofrequency, and video-assistance. 3) Implement novel endoscopic otologic and neck techniques.

Robotic-assisted anorectal pull-through for anorectal malformations

Background/purpose Many reports have addressed the feasibility and safety of using robotic surgery in children. To our knowledge, no published report has described the use of a surgical robot in the repair of anorectal malformations (ARMs). Methods Included children underwent robotic-assisted repair of ARMs with rectourethral fistula between April 2006 and March 2010 at King Khalid University Hospital, Riyadh, Saudi Arabia, using the da Vinci Surgical System. Their medical records were reviewed with respect to demographic data, associated anomalies, techniques and operative procedures, complications, outcomes, and follow-up. Results Five male infants (mean age, 6.6 months) underwent robotic-assisted repair of ARMs with rectourethral fistula using the Georgeson technique. The fistulae were divided and ligated in 4 patients and was left open in 1. All procedures were successfully completed without conversion to an open technique. One patient developed left-sided epididymo-orchitis postoperatively. All the patients had their colostomy closed. The follow-up ranged from 6 to 36 months. Fecal continence was difficult to assess in 2 patients. Two patients have voluntary bowel movements without soiling. One infant has fecal soiling and is on a laxative/enema for constipation. Conclusions Robotically assisted repair of ARMs with rectourethral fistula is feasible and safe. It offers a good alternative to the criterion standard, posterior sagittal anorectoplasty (PSARP), for repair of ARMs with rectourethral fistula. More patients and a longer follow-up period are needed for further evaluation of this novel approach.

The use of robotics in pediatric surgery: my initial experience

Robotic assisted minimal invasive surgery (RMIS) is a new resource popular in some surgical specialties but not yet in pediatric surgery. There are numerous advantages of robotic surgical technology in adult patients well documented in the literature. The purpose of this study is to define the feasibility, safety, and benefits of RMIS in pediatric patients in my initial learning experience. In a period of 24 months, all consecutive abdominal RMIS were reviewed. Chart revision was conducted retrospectively. Demographic data were collected in each patient. Other data reviewed were indications for surgery, surgical procedures, complication rate, and conversion rate to open procedure. Four arms robotic equipment was used in all cases with 3 (5 mm) reusable robotic ports and a single (12 mm) disposable port. A total of 102 consecutive abdominal RMIS were performed in 77 pediatric patients. All cases were performed by the same pediatric surgeon in a teaching institution. The average patient age was 6.2 years (ranged from 4 months to 18 years) with 16 patients <1 year of age. The smallest patient was 4 kg. No cases required conversion to open technique. However, one case was converted to laparoscopy because of mesenteric bleeding. There were five intraoperative complications in three patients: minor bleeding (2), suture orogastric tube (1), and gastric opening (2) with repair. Postoperative complications were noted in four patients: mild dysphagia (2) and Nissen wrap breakdown (2). Although the use of RMIS in pediatric patients is still controversial, it is feasible and safe to perform robotic surgery in children with a low complication rate. In addition, excellent visualization with outstanding maneuverability of instruments is of great benefit. These benefits may offset the increased cost of robotic technology especially in technically complex surgical cases.

Initiation of a pediatric robotic surgery program: institutional challenges and realistic outcomes

Few institutions have reported their experience initiating a pediatric robot-assisted laparoscopic (RAL) program, and results vary regarding the outcomes for robotic surgery in children. We present the initiation of our pediatric robotic surgery program, provide suggestions for overcoming institutional challenges, and perform a comparative analysis to illustrate realistic outcomes during the learning curve. Outcomes from consecutive children who underwent RAL surgery since the 2006 acquisition of the da Vinci® surgical system were retrospectively reviewed. To evaluate the safety and outcomes during the introduction of this new technology, we performed an outcome analysis of ureteral reimplantations comparing RAL cases to matched open controls. The first 50 RAL cases were performed over 20 months by two general and two urologic surgeons. Fourteen different procedures were performed successfully. The average patient age was 8.6 ± 5.7 years with 10 patients weighing less than 10 kg (20%). Three urologic cases were converted to traditional laparoscopy and two general surgery cases were converted to open. There were five mechanical failures. Initial outcomes comparing RAL and open ureteral reimplantations revealed similar length of stay, complications, and success with lower estimated blood loss in the RAL group. Overall OR time was 53% longer in the RAL reimplant group (361 ± 80 vs. 236 ± 58 min, p < 0.0001). Robotic surgery appears to be safe in pediatric patients for many procedures. Proper instruction and training precedes technological proficiency. The institutional learning curve may be magnified when there are multiple participating surgeons. Operative times for initial RAL cases can be expected to be greater than their open correlates.