Two decades of minimally invasive pediatric surgery-taking stock

First Results of Pediatric Robotic Inguinal Hernia Repair with the Senhance® Surgical System: A Matched Cohort Study

INTRODUCTION

Inguinal hernia repair (IHR) is one of the most common procedures in pediatric surgery. In children, the application of robotic surgery is limited, meaning safety and efficacy is still to be assessed. This report is the first one worldwide that describes inguinal hernia repair in children using the Senhance® Surgical System (SSS®). The aim of this matched cohort study is to assess safety and feasibility of robot-assisted IHR (RIHR) in children, compared to conventional laparoscopic IHR (LIHR).

PATIENTS AND METHODS

This pilot study included 26 consecutive patients between 3 months and 8 years old who underwent RIHR (31 IH's) with the SSS® between 2020 and 2024. These cases were matched based on gender, age, and unilateral or bilateral IH, with 26 patients (32 IH's) who underwent conventional LIHR.

RESULTS

There was a significant difference in total anesthesia time, which is most likely due to the extra time needed to dock the robot in the RIHR cases. No significant difference was seen in surgical time. One recurrence (3.2%) was diagnosed in both groups. One patient in the LIHR group was readmitted on the day of discharge due to a hemorrhage. No intervention was necessary, and the patient was discharged 1 day later.

DISCUSSION

In this pilot study, the use of the robotic system was safe and feasible. More experience, further improvement of the system for use in very small children, and investigation in a larger sample size with long-term follow-up is necessary to evaluate efficacy.

The safe introduction of robotic surgery in a free-standing children's hospital

The aim of this study is to report the experience of implementing a pediatric robotic surgery program at a free-standing pediatric teaching hospital. A database was created to prospectively collect perioperative data for all robotic surgeries performed by the pediatric surgery department. The database was queried for all operations completed from October 2015 to December 2021. Descriptive statistics were used to characterize the dataset, using median and interquartile ranges for continuous variables. From October 2015 to December 2021, a total of 249 robotic surgeries were performed in the department of pediatric surgery. Of the 249 cases, 170 (68.3%) were female and 79 (31.7%) were male. Across all patients, there was a median weight (IQR) of 62.65 kg (48.2-76.68 kg) and a median (IQR) age of 16 years (13-18 years). The median (IQR) operative time was 104 min (79.0-138 min). The median console time was 54.0 min (33.0-76.0 min) and the median docking time was 7 min (5-11 min). The majority of procedures were performed on the biliary tree (52.6%). In the 249 procedures, there were no technical failures of the robot and only two operations (0.8%) were converted to open procedures and one (0.4%) to laparoscopic. This study highlights the ability to successfully integrate a pediatric robotic surgery program into a free-standing children's hospital with a low conversion rate. Additionally, the program extended across multiple surgical procedures and offered real-time exposure to advanced surgical techniques for current and aspiring pediatric surgery trainees.

Open versus minimally-invasive surgical techniques in pediatric renal tumors: A population-level analysis of in-hospital outcomes

INTRODUCTION

Minimally-invasive surgery (MIS) has been adopted slowly in pediatric oncology. We attempted to describe contemporary national trends in MIS use; we hypothesized that adolescents (who are more likely to have relatively small renal cell carcinomas) would have a higher proportion of MIS than younger children (who are more likely to have relatively large Wilms tumors) and that this relationship would vary by region.

OBJECTIVE

To explore whether pediatric urologic oncology outcomes vary by patient age or by surgical technique.

METHODS

We queried the 1998-2014 National Inpatient Sample (NIS) and included encounters in children aged ≤ 18 y, ICD-9 diagnostic code for renal tumor, and procedure code for open or MIS partial or radical nephrectomy. All analyses used weighted descriptive statistics and outcomes are compared based on age group (</>10 y) or surgery type; Wald-Chi square test was used for differences in proportions and unadjusted weighted ANOVA was used to test for differences in means.

RESULTS

9259 weighted encounters were included; 91% were <10 years old and 50.7% were female. MIS surgery accounted for 1.8% of encounters; there was a difference in proportions by age group (1% <9 y vs. 9.9% >9 y, p < 0.01). The proportion of surgery type was similar across regions within age groups, however. Complications occurred in 13.3% of encounters; mean inpatient length of stay was 8.9 days (SD: 0.3); mean cost was $ 34,457.68 (SD: $1197.00). There was no evidence of a difference between surgery type and proportion of post-operative complications, mean inpatient length of stay or mean inpatient cost.

DISCUSSION

The admission-based, retrospective design of NIS left us unable to assess long-term outcomes, repeated admissions, or to track a particular patient across time; this is particularly relevant for oncologic variables on interest such as tumor stage or event-free survival. We were similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions.

CONCLUSION

In this preliminary descriptive analysis, MIS techniques were infrequently used in children, but there was a higher proportion of MIS use among adolescents. There were similar proportions of surgery type across geographic regions within the United States. Whether this infrequent usage is appropriate is as yet unclear given the lack of Level I evidence regarding the relative merits of MIS and open surgery for pediatric and adolescent renal tumors.

Laparoscopic approach for abdominal neuroblastoma in Japan: results from nationwide multicenter survey

BACKGROUND

Some neuroblastoma (NB) cases are suitable for minimally invasive surgery (MIS), but indication and technical issue are unclear. We assessed the current status of MIS for abdominal NB after mass screening period in Japan.

METHODS

Preliminary questionnaires requesting the numbers of NB cases that underwent MIS from 2004 to 2016 were sent to 159 Japanese institutes of pediatric surgery. The secondary questionnaires were then sent to the institutions that reported MIS cases of NB in order to collect detailed data.

RESULTS

One hundred and thirty-four (84.2%) institutions responded to the preliminary questionnaires, and 83 (52.2%) reported managing operative cases. The total number of operative cases was 1496. MIS was performed for 175 (11.6%) cases, of which the completed forms of 140 patients were returned, including 100 abdominal NB cases. The male/female ratio was 51/49. Forty-seven cases underwent a laparoscopic biopsy, and 2 (4.3%) cases were converted to laparotomy due to bleeding. Sixty-five cases underwent MIS for radical resection, and 7 (10.8%) were converted to laparotomy. The reasons for open conversion were bleeding and severe adhesion. Regarding open conversion, there were no significant relationships between conversion and neo-adjuvant chemotherapy, biopsies, stage, size, or MYCN amplification. We found no relationship between resectability and vascular encasement in this study. There was relationship between the resected tumor size and the patients' height, which was expressed using the following formula: [Formula: see text] (x, patients height, y, tumor size; p = 0.004219, SE: 1.55566). Postoperative complications after radical resection were recognized in 7 (10.8%) cases.

CONCLUSIONS

MIS was performed in limited cases of abdominal NB. A laparoscopic biopsy with careful attention to bleeding is feasible. The resected tumor size was shown to correlate with the patients' height. Tumor size within 6 cm of maximum diameter can be resected safely.

Wilms tumor: a review of current surgical controversies

Overall survival (OS) for children with Wilms tumor (WT) currently stands at around 90%. This is markedly improved from the survival rates of around 30% reported in the middle of the last century. This improvement is due to the development of multimodal treatment for this disease, based on the evidence yielded through international collaboration on trials conducted by the Société Internationale d'Oncologie Pédiatrique (SIOP) and the Children’s Oncology Group (COG). In this article, we review some of the current surgical controversies surrounding the management of WT.

Outcomes of laparoscopic and open surgery in children with and without congenital heart disease

BACKGROUND

Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD.

METHODS

We performed a retrospective cohort study using the 2013-2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children <18years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay.

RESULTS

Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15-0.79]), inhospital mortality (OR 0.42 [0.22-0.81]) and 30-day morbidity (OR 0.61 [0.50-0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend=0.01) and in-hospital mortality (ptrend=0.05), but not for 30-day mortality (ptrend=0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children.

CONCLUSIONS

Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD.

LEVEL-OF-EVIDENCE

Level III: Treatment Study.

Comparing oncologic outcomes after minimally invasive and open surgery for pediatric neuroblastoma and Wilms tumor

BACKGROUND

Minimally invasive surgery (MIS) has been widely adopted for common operations in pediatric surgery; however, its role in childhood tumors is limited by concerns about oncologic outcomes. We compared open and MIS approaches for pediatric neuroblastoma and Wilms tumor (WT) using a national database.

METHODS

The National Cancer Data Base from 2010 to 2012 was queried for cases of neuroblastoma and WT in children ≤21 years old. Children were classified as receiving open or MIS surgery for definitive resection, with clinical outcomes compared using a propensity matching methodology (two open:one MIS).

RESULTS

For children with neuroblastoma, 17% (98 of 579) underwent MIS, while only 5% of children with WT (35 of 695) had an MIS approach for tumor resection. After propensity matching, there was no difference between open and MIS surgery for either tumor for 30-day mortality, readmissions, surgical margin status, and 1- and 3-year survival. However, in both tumors, open surgery more often evaluated lymph nodes and had larger lymph node harvest.

CONCLUSION

Our retrospective review suggests that the use of MIS appears to be a safe method of oncologic resection for select children with neuroblastoma and WT. Further research should clarify which children are the optimal candidates for this approach.

Minimal Access Surgery in Neonates

Despite the significant advancement of minimally invasive surgery (MIS) in the adults and even in pediatric population, its role as the standard of care in the neonates has not yet been established among the pediatric and neonatal surgeons universally. Lots of controversies still arise though several advanced centers in the world having very experienced surgeons performing MIS for neonatal surgical conditions with promising outcomes. The unique physiological characteristics of a neonate make MIS quiet a challenging subject among these tiny babies. We have tried to look into the recent literature on the issues related to the use of MIS for the surgical management of neonates.

Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease

OBJECTIVES

To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD).

STUDY DESIGN

Cohort study using the 2013-2014 National Surgical Quality Improvement Program-Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in-hospital postoperative mortality. Secondary outcomes included 30-day mortality and 30-day morbidity (any nondeath adverse event). Among 34?543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD.

RESULTS

Children with severe CHD had higher overall mortality and 30-day morbidity (OR 12.31, 95% CI 1.59-95.01; OR 2.51, 95% CI 1.57-4.01, respectively), compared with matched controls. Overall mortality and 30-day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49-8.06; OR 2.07, 95% CI 1.65-2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30-day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37-2.13).

CONCLUSIONS

Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.

Minimally invasive surgery in management of renal tumours in children

Minimally invasive surgery (MIS) in the management of malignant and benign renal tumours in children is gradually becoming more common. Experience is limited and restricted to case reports, retrospective chart reviews and a few cohort studies. There are currently no randomized controlled trials or controlled clinical trials comparing the laparoscopic and open surgical approach for the management of renal tumours in children. MIS may offer the same oncologic outcome in malignant renal tumours whilst providing the advantages associated with MIS in correctly selected cases. The technique for tumour resection has been shown to be feasible in regards to the recommended oncologic principles, although lymph node sampling can be inadequate in some cases. Preliminary reports do not show an increased risk of tumour rupture or inferior oncologic outcomes after MIS. However, the sample size remains small and duration of follow-up inadequate to draw any firm conclusions. Implementation of MIS is lacking in the protocols of the major study groups, and standardized recommendations for the indications and contra-indications remain undefined. The objective of this article is to present a review of the literature on the role of MIS in the management of renal tumours in children, with the main focus on Wilms' tumour (WT). Further studies on MIS in renal tumours are required to evaluate the incidence of oncological complications such as complete tumour resection and intra-operative tumour spillage. A long-term follow-up of patients managed by MIS is essential to compare recurrence rates and overall survival rates.

Robotic-Assisted Procedures in Pediatric Surgery: A Critical Appraisal of the Current Best Evidence in Comparison to Conventional Minimally Invasive Surgery

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.

Laparoscopy-assisted cutaneous ureterostomy at suprapubic creaseline facilitates subsequent reimplantation

BACKGROUND:

Cutaneous ureterostomy is still practiced despite a trend towards primary surgical correction for obstructive or refluxive uropathy. For future open reimplantation, ureterostomy can be created by minimal invasive technique at the end(s) of the suprapubic creaseline.

MATERIALS AND METHODS:

From 1 January 2009 to 31 July 2012, seven children were treated with laparoscopy-assisted cutaneous ureterostomy followed by ureteric reimplantation. Indications were primary obstructive megaureter 3, hugely dilated ureters with reflux 3 and posterior urethral valve with poor general health 1. The distal manoeuverable part of tortuous ureter was pulled to the surface at either end of suprapubic creaseline to create the stoma. During reimplantation, this stoma was dismembered and brought inside urinary bladder obviating the need for stoma-site repair.

RESULTS:

Mean age was 4.6 ± 2.8 years with six males. There were three bilateral cases with total 10 lesions. Mean operating time was 39.8 ± 12.5 minutes. Mean follow-up was 1.7 ± 0.8 years and except for peri-stomal excoriations no major complication occurred. All these were reimplanted 6-12 months after ureterostomy and faring well except in one case.

CONCLUSIONS:

Laparoscopy-assisted cutaneous ureterostomy can be fashioned at suprapubic creaseline to facilitate future reimplantation without much jeopardy and extra scar.

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.

International attitudes of early adopters to current and future robotic technologies in pediatric surgery

BACKGROUND

Perceptions toward surgical innovations are critical to the social processes that drive technology adoption. This study aims to capture attitudes of early adopter pediatric surgeons toward robotic technologies in order to clarify 1) specific features that are driving appeal, 2) limiting factors that are acting as diffusion barriers, and 3) future needs.

METHODS

Electronic surveys were distributed to pediatric surgeons with personal experience or exposure in robotic surgery. Participants were classified as experts or nonexperts for subgroup analysis. Coded Likert scale responses were analyzed using the Friedman or Mann-Whitney test.

RESULTS

A total of 48 responses were received (22 experts, 26 nonexperts), with 14 countries represented. The most highly rated benefits of robot assistance were wristed instruments, stereoscopic vision, and magnified view. The most highly rated limitations were capital outlay expense, instrument size, and consumables/maintenance expenses. Future technologies of greatest interest were microbots, image guidance, and flexible snake robots.

CONCLUSIONS

Putative benefits and limitations of robotic surgery are perceived with widely varied weightings. Insight provided by these responses will inform relevant clinical, engineering, and industry groups such that unambiguous goals and priorities may be assigned for the future. Pediatric surgeons seem most receptive toward technology that is smaller, less expensive, more intelligent and flexible.

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.

Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

Pediatric genitourinary tumors

PURPOSE OF REVIEW

We will review the 2007/2008 literature on pediatric genitourinary tumors.

RECENT FINDINGS

Newly identified constitutional epigenetic defects in Wilms tumor genes extend the understanding of Wilms tumor risk in children lacking syndromic features, and add to the complexity of the pathogenesis of these tumor suppressor genes. Pediatric renal cell carcinoma has distinct molecular characteristics and clinical associations from the adult counterpart. The pathway from PAX3-FKHR translocation to the development of rhabdomyosarcoma tumors has been further elucidated.

SUMMARY

Therapeutic strategies continue to be driven by developments in molecular diagnostics in pediatric genitourinary tumors.

Impact of minimally invasive surgery on the pediatric surgical profession

We conducted a survey among pediatric surgeons to examine the impact of the advent of minimally invasive surgery (MIS) on the pediatric surgical profession with respect to job satisfaction and training challenges. An invitation to participate in a web-based questionnaire was sent out to 306 pediatric surgeons. Apart from demographic details and training recommendations, parameters relevant to job satisfaction, including patient interaction, peer pressure, ethical considerations, academic progress, ability to train residents, and financial remuneration, were studied. The response rate was 38.2%. Working in a unit performing MIS was identified by 71% of respondents as the most effective and feasible modality of training in MIS. Inability to get away from a busy practice was the most common reason cited for inability to acquire MIS training. The overall responses to the job satisfaction parameters showed a positive trend in the current MIS era for patient interaction, ethical considerations, academic progress, and training residents, with a negative trend for peer pressure and financial remuneration. The enthusiastic minimally invasive surgeons (EMIS) were defined as those having more than 5 years of MIS experience and also performing more than 10% of their work using MIS. Of the 113 responses analyzed, 67 belonged to the EMIS category. Those belonging to the EMIS group were less likely to feel inadequate in training their residents, in meeting the felt needs of the patients, or to complain about peer pressure. They were more likely to consider MIS to be as relevant and beneficial in children as in adults. Embracing MIS, as represented by the EMIS group, correlated with an overall greater job satisfaction.