Paediatric robotic surgery

Robotic-assisted Proctosigmoidectomy Versus Laparoscopic-assisted Soave Pull-through for Hirschsprung Disease: Medium-term Outcomes From a Prospective Multicenter Study

OBJECTIVE

To compare the surgical outcomes of robotic-assisted proctosigmoidectomy (RAP) and laparoscopic-assisted Soave pull-through (LAP) for children with Hirschsprung disease (HD).

BACKGROUND

LAP and RAP have been developed for minimally invasive pull-through of HD, but the clinical benefits of robotic-assisted versus laparoscopic-assisted approaches have yet to be proven in a multicenter prospective study.

METHODS

This study was a prospective multicenter clinical trial conducted on children with rectosigmoid/descending HD from July 2015 to June 2022, with registration in the Chinese Clinical Trial Registry (ChiCTR2000035220). The primary outcome was the medium-term functional outcomes in children aged ≥4 years based on bowel functional scores, which were assessed and compared between LAP and RAP.

RESULTS

A total of 328 consecutive patients (RAP = 165, LAP = 163) were approached who were considered eligible for elective minimally invasive endorectal pull-through, and 219 patients aged ≥4 years of age completed follow-up (RAP = 109, LAP = 110). The transanal dissection length and anal traction time were significantly shorter in RAP than those in LAP (0.40 vs 3.70 cm, P < 0.001; 45 vs 62 min, P < 0.001). The RAP group had a significantly lower urinary retention rate (0% vs 5.52%, P = 0.006), whereas other short-term results between the two groups were not significantly different. The medium-term overall bowel function scores were comparable between the two groups; however, among the subgroup of children aged ≤3 months at surgery, the RAP group had better anal canal resting pressure at 1 year postoperatively and amounted to better annual postoperative fecal continence scores at 4 to 7 years old postoperatively (all P < 0.05).

CONCLUSIONS

RAP and LAP should have similar medium-term bowel functional outcomes in children with HD, but RAP may be associated with a slight functional benefit in infants operated on below age 3 months, requiring further investigation in larger case cohorts.

Correction of Congenital Hyperinsulinism by Robotic-Assisted Laparoscopy in an Infant

Background

Congenital hyperinsulinism (CHI) is a heterogeneous genetic disease characterized by increased insulin secretion, in which dysregulation of insulin secretion by pancreatic β cells causes persistent hypoglycemia in neonates and infants. Babies diagnosed with CHI require preferentially minimal invasive surgical treatment with near-total pancreatectomy (NTP).

Material and Methods

CHI was treated with robotic-assisted laparoscopy (RAL).

Results

The authors present an unreported case of CHI in an infant less than 10 kg, which was submitted to NTP treated by RAL. The procedure was performed with 3 arms of Da Vinci robot using adaptable size of trocars and the surgery was well succeeded.

Conclusions

The RAL is a challenge in pediatric pancreatic surgery to CHI due to the size of the trocars. To our knowledge, this is the first case reported in the English literature of an infant weighing less than 10 kg having been submitted to NTP by RAL.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review

INTRODUCTION

Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility.

METHODS

A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed.

RESULTS

Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room.

CONCLUSIONS

Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Original Clinical Research.

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

Purpose

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.

Methods

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.

Results

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.

Conclusion

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.

Single-port robotic-assisted laparoscopic synchronous surgery in pediatric patent processus vaginalis

PURPOSE

Patent processus vaginalis (PPV) is usually observed in pediatric abdominal surgery; however, robotic single-port surgery in repairing processus vaginalis has not been reported in children. Herein, we present our clinical experiences in single-port robotic surgeries for PPV repair to evaluate both efficacy and safety.

METHODS

Retrospective analysis of patients underwent single-port robotic-assisted laparoscopic surgery for genitourinary diseases from May 2020 and May 2023 in our center. Among these patients, 21 children had PPV repaired at the same time. The case characteristics and follow-up data were recorded.

RESULTS

Twenty-one of the 53 children were found to have PPV during genitourinary surgery. The simultaneous treatment of the primary disease and PPV with a single-port robotic-assisted platform was both convenient and safe. There was no significant increase in total operation time, and no excessive intraoperative hemorrhage was observed in any of the operations. There were no complications observed on follow-up.

CONCLUSION

With a high incidence of PPV in children, a single-port robotic-assisted procedure is feasible and effective if simultaneously performed when addressing a primary abdominal disease.

Biochemical implications of robotic surgery: a new frontier in the operating room

Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.

Robot-assisted thoracoscopic surgery for mediastinal tumours in children: a single-centre retrospective study of 149 patients

OBJECTIVES

The purpose of this retrospective study was to summarize our experience in performing robot-assisted thoracoscopic surgery (RATS) for mediastinal tumours in children to investigate its safety and feasibility.

METHODS

This retrospective study involved 149 patients with mediastinal tumours who were hospitalized in the Department of Thoracic Surgery of Beijing Children's Hospital, Capital Medical University, and underwent RATS for tumour resection from March 2021 to November 2022. Information on patient age, weight, tumour size, surgical incision selection, operative time, intraoperative bleeding, intraoperative complications, length of hospital stay, rate of conversion to thoracotomy and follow-up conditions were summarized.

RESULTS

All 149 surgeries were successfully completed with no cases of mortality. There were 77 male and 72 female patients, with a mean age of 5.9 years (range: 6 months-16 years, 8 months) and a mean weight of 23.6 kg (8.0-72.0 kg). The mean maximum tumour diameter was 5.5 cm (2.0-12.0 cm), the mean operative time was 106.7 min (25.0-260.0 min), the mean intraoperative bleeding volume was 11.3 ml (1.0-400.0 ml) and the mean hospital stay was 7.2 days (4.0-14.0 days). All patients recovered well with no cases of tumour recurrence or mortality during the postoperative follow-up period (3-23 months).

CONCLUSIONS

RATS is safe and feasible to apply in children with mediastinal tumours who are >6 months of age and weigh more than 8 kg in terms of short-term outcomes, but longer-term follow-up is needed to fully evaluate the benefits. For cases that are associated with greater surgical difficulty and risk, a comprehensive surgical plan should be fully prepared in advance of surgery.

Narrative review: robotic pediatric surgery-current status and future perspectives

Background and Objective

Robot-assisted surgery has been progressively involved in various fields of adult and pediatric surgery, demonstrating many advantages over either mini-invasive or open surgery. The aim of this review is to provide the most recent evidence on robot-assisted pediatric surgery, in all its subspecialties.

Methods

A comprehensive electronic literature search of PubMed, Embase, and Cochrane Library was conducted using appropriate Medical Subject Headings (MeSH) terms and keywords. The interval time considered was a 5-year period [2017-2022], and no language restrictions were applied.

Key Content and Findings

A total of 685 titles were identified. After applying exclusion criteria, 73 articles for robotic pediatric surgery have been published and were included in this review. We extrapolated and summarized the current evidence on robot-assisted surgery in pediatric age through all the fields of applicability.

Conclusions

Robot-assisted surgery is technically feasible in case of a selected pediatric cohort, and it is going to achieve similar or better surgical results if related to the standard open or mini-invasive procedures. Copious case series and randomized trials are still required. Due to the great potential that this new technology is demonstrating, in the close future, the evolution of robotic platform will offer a valid and solid alternative in the treatment of various pediatric pathologies.

Robotic-assisted colectomy in children: a comparative study with laparoscopic surgery

The aim of this study was to compare outcomes of laparoscopic and robotic-assisted colectomy in children. All children who underwent a colectomy with a laparoscopic (LapC) or robotic-assisted (RobC) approach in our institution (January 2010-March 2023) were included. Demographics, surgical data, and post-operative outcomes within 30 days were collected. Additional cost related to the robotic approach was calculated. Comparisons were performed using Fisher tests for categorical variables and Mann-Whitney tests for continuous variables. A total of 55 colectomies were performed: 31 LapC and 24 RobC (median age: 14.9 years). Main indications included: inflammatory bowel disease (n = 36, 65%), familial adenomatous polyposis (n = 6, 11%), sigmoid volvulus (n = 5, 9%), chronic intestinal pseudo-obstruction (n = 3, 5%). LapC included 22 right, 4 left, and 5 total colectomies. RobC included 15 right, 4 left, and 5 total colectomies. Robotic-assisted surgery was associated with increased operative time (3 h vs 2.5 h, p = 0.02), with a median increase in operative time of 36 min. There were no conversions. Post-operative complications occurred in 35% of LapC and 38% of RobC (p = 0.99). Complications requiring treatment under general anesthesia (Clavien-Dindo 3) occurred in similar rates (23% in LapC vs 13% in RobC, p = 0.49). Length of hospitalization was 10 days in LapC and 8.5 days in RobC (p = 0.39). The robotic approach was associated with a median additional cost of 2156€ per surgery. Robotic-assisted colectomy is as safe and feasible as laparoscopic colectomy in children, with similar complication rates but increased operative times and cost.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Evaluation of the Versius Robotic System for Infant Surgery-A Study in Piglets of Less than 10 kg Body Weight

BACKGROUND

We were able to demonstrate the feasibility of a new robotic system (Versius, CMR Surgical, Cambridge, UK) for procedures in small inanimate cavities. The aim of this consecutive study was to test the Versius^® system for its feasibility, performance, and safety of robotic abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg.

METHODS

A total of 24 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 4 piglets with a mean age of 12 days and a mean body weight of 6.4 (7-7.5) kg. Additional urological procedures were performed after euthanasia of the piglet. The Versius^® robotic system was used with 5 mm wristed instruments and a 10 mm 3D 0° or 30° camera. The setup consisted of the master console and three to four separate arms. The performance of the procedure, the size, position, and the distance between the ports, the external and internal collisions, and complications of the procedures were recorded and analyzed.

RESULTS

We were able to perform all surgical procedures as planned. We encountered neither surgical nor robot-associated complications in the live model. Whereas all abdominal procedures could be performed successfully under general anesthesia, one piglet was euthanized early before the thoracic interventions, likely due to pulmonary inflammatory response. Technical limitations were based on the size of the camera (10 mm) being too large and the minimal insertion depth of the instruments for calibration of the fulcrum point.

CONCLUSIONS

Robotic surgery on newborns and infants appears technically feasible with the Versius^® system. Software adjustments for fulcrum point calibration need to be implemented by the manufacturer as a result of our study. To further evaluate the Versius^® system, prospective trials are needed, comparing it to open and laparoscopic surgery as well as to other robotic systems.

Robotic-assisted surgery in pediatrics: what is evidence-based?-a literature review

BACKGROUND AND OBJECTIVE

The use of robotic-assisted surgery (RAS) has increased more slowly in pediatrics than in the adult population. Despite the many advantages of robotic instruments, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) still presents some limitations for use in pediatric surgery. This study aims to examine evidence-based indications for RAS in the different fields of pediatric surgery according to the published literature.

METHODS

A database search (MEDLINE, Scopus, Web of Science) was performed to identify articles covering any aspect of RAS in the pediatric population. Using Boolean operators AND/OR, all possible combinations of the following search terms were used: robotic surgery, pediatrics, neonatal surgery, thoracic surgery, abdominal surgery, urologic surgery, hepatobiliary surgery, and surgical oncology. The selection criteria were limited to the English language, pediatric patients (under 18 years of age), and articles published after 2010.

KEY CONTENT AND FINDINGS

A total of 239 abstracts were reviewed. Of these, 10 published articles met the purposes of our study with the highest level of evidence and therefore were analyzed. Notably, most of the articles included in this review reported evidence-based indications in urological surgery.

CONCLUSIONS

According to this study, the exclusive indications for RAS in the pediatric population are pyeloplasty for ureteropelvic junction obstruction in older children and ureteral reimplantation according to the Lich-Gregoire technique in selected cases for the need to access the pelvis with a narrow anatomical and working space. All other indications for RAS in pediatric surgery are still under discussion to date, and cannot be supported by papers with a high level of evidence. However, RAS is certainly a promising technology. Further evidence is strongly encouraged in the future.

Application and prospects of robotic surgery in children: a scoping review

As an innovative minimally invasive surgical technology, robot-assisted surgery (RAS) has greatly improved the accuracy and safety of surgery through the advantages of three-dimensional magnification, tremor filtering, precision and flexibility, and has been carried out by an increasing number of surgeries. In recent years, robots have been gradually applied to children, bringing new ideas and challenges to pediatric surgeons. This review will describe the advantages and limitations of robotic surgery in children, summarize its application in pediatric surgery, and provide an outlook. It is believed that clinicians should actively carry out RAS under the premise of rigorously ensuring surgical indications and strive to improve the efficacy of surgical treatment for children.

The Role of the Versius Surgical Robotic System in the Paediatric Population

The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, dexterity, and ergonomics, could make it a superior choice over the traditional laparoscopic approach. However, its implementation in the paediatric surgery arena has been limited primarily due to the unavailability of appropriately sized instruments as per paediatric body habitus, therefore, requiring more technologically advanced systems. The Versius surgical robotic system is a new modular platform that offers several benefits such as articulated instruments which pass through conventional 5 mm ports, compact arms for easier manoeuvrability and patient access, the ability to mimic conventional port placements, and adaptive machine learning concepts. Prior to its introduction to paediatric surgery, it needs to go through a careful pre-clinical and clinical research program.

[The application of Da Vinci surgical system in pediatric otolaryngology head and neck surgery]

Da Vinci surgical system （DVSS）, a novel surgical technology, is gradually applied in various surgical operations due to its accuracy and safety. In adult Otolaryngology Head and Neck Surgery, based DVSS the Transoral Robotic Surgery and neck robotic surgery have rich experience, and gradually being extended to pediatric with preferable initial results. The purpose of this article is to summarize the application of DVSS in pediatric otolaryngologyhead and neck surgery, and and to present future prospectives. Clinicians should actively learn to adopt new techniques and advantages of DVSS, and strive to improve the outcome of surgical treatment.

Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes

PURPOSE

To describe the long-term outcomes of the robotic Soave pull-through (RSPT) procedure for Hirschsprung's disease (HSCR) in children younger than 12 months.

METHODS

A prospective observational study was conducted on HSCR patients under 12 months of age who underwent RSPT at our institution between 2011 and 2020. Data regarding demographics, clinical features, technical details, operative time, hospital stay, postoperative complications, and long-term outcomes were prospectively collected.

RESULTS

A total of 15 patients (9 male; 6 female) were included, with a median age at surgery of 4 months (interquartile range 3-6), and a mean weight of 6.8 ± 1.3 kg. Twelve patients suffered from rectosigmoid aganglionosis and three from long HSCR (extending up to the hepatic flexure). The mean total operative time was 240 ± 72 min. The median hospital stay was 3 days (interquartile range 3-4). Partial anastomosis dehiscence was observed in one patient, requiring reoperation on the 4th postoperative day. With a median follow-up of 79 months (interquartile range 45-115), no fecal incontinence or mild soiling were observed. Constipation occurred in two patients and mild enterocolitis in one case.

CONCLUSION

RSPT procedure for Hirschsprung's disease in children younger than 12 months is a safe and effective procedure, with few complications and satisfactory long-term continence outcomes.

Robotic surgery in pediatric urology

Robotic surgery revolutionized minimally invasive surgery. Urology is the widest surgical field in implementing robotic technology. Pediatric urology followed the footsteps of adult urology in utilizing da Vinci™ surgical system for urinary tract reconstruction. Indeed, day after day robotics is gaining more applications and popularity in pediatric urology due to the need for less invasive approach to reconstruct the urinary tract in pediatric population. In this manuscript, we reviewed in this article the steps of evolution of robotic pediatric urology.

Laparoscopic robotic-assisted restorative proctocolectomy and ileal J-pouch-anorectal anastomosis in children

PURPOSE

Total proctocolectomy with ileal J-pouch-anorectal anastomosis (IPAA) remains the preferred surgical treatment for ulcerative colitis (UC) in children. Considering the well-known advantages of minimally invasive approach, and its main application for the deep pelvis, robotic surgery may be used in UC reconstructive procedures. The aim of the study is to report our experience with Robotic IPAA in children.

METHODS

Single surgeon experience on Robotic IPAA were prospectively included. Data on patient demographics, surgical details, complications, and length of stay (LOS), were collected.

RESULTS

Fifteen patients were included. Median age was 13.2 years, median body weight 45 kg. Median operative time was 240 min. Median LOS was 7 days and mean follow-up time 1 year. No intraoperative complication occurred. Five postoperative complications happened: 3 minors treated conservatively (CD I-II), 2 majors needing reintervention under anesthesia (CD IIIb). No mortality was observed.

CONCLUSION

Our preliminary experience reveals that Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. A bigger patient sample and a long-term follow-up are needed to confirm our findings.

Above and Beyond Robotic Surgery and 3D Modelling in Paediatric Cancer Surgery

Although the survival rates for children's cancers have more than doubled in the last few decades, the surgical practise has not significantly changed. Among the most recent innovations introduced in the clinic, robotic surgery and augmented reality are two of the most promising, even if they are not widespread. The increased flexibility of the motion, the magnification of the surgical field and the tremor reduction provided by robotic surgery have been beneficial to perform complex oncological procedures in children. Besides, augmented reality has been proven helpful in planning for tumour removal, facilitating early discrimination between cancer and healthy organs. Nowadays, research in the field of surgical oncology is moving fast, and new technologies and innovations wich will help to shape a new way to perform cancer surgery. Paediatric surgeons need to be ready to adopt these novel devices and intraoperative techniques to allow more radical tumour resections with fewer complications. This review aims to present the mechanism of action and indications of several novel technologies such as optical imaging surgery, high definition cameras, and intraoperative loco-regional treatments. We hope this will enhance early adoption and more research on how to employ technology for the benefit of children.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Technical aspects of paediatric robotic pancreatic enucleation based on a case of an insulinoma

BACKGROUND

Insulinomas are rare insulin-producing pancreatic neuroendocrine tumours leading to severe episodes of hypoglycaemia. Surgery is the predominant curative therapy.

METHODS

We report here the first paediatric case of an insulinoma of the pancreatic body resected completely robotically under ultrasound guidance in a 10-year-old male with multiple endocrine neoplasia type 1. The port set-up was adapted for the narrowed dimensions of the paediatric peritoneal space. We comment on technical key steps for the organ-preserving procedure that was performed in close proximity to critical anatomic structures, with supporting video. Preoperative diagnostics, including endoscopic ultrasound, to determine surgical management are highlighted.

RESULTS

Following an uneventful post-operative course, the boy was discharged on day 11 with normalised glucose-metabolism. A pseudocyst developing after 4 weeks was treated with endoscopic stenting.

CONCLUSIONS

The applicability of a robotic surgical system in limited space conditions such as found in the paediatric abdominal cavity is demonstrated here for pancreatic surgery.

Robotic infant surgery with 3 mm instruments: a study in piglets of less than 10 kg body weight

No data exist concerning the appication of a new robotic system with 3 mm instruments (Senhance®, Transenterix) in infants and small children. Therefore, the aim of this study was to test the system for its feasibility, performance and safety of robotic pediatric abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. 34 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 12 piglets with a median age of 23 (interquartile range: 12–28) days and a median body weight of 6.9 (6.1–7.3) kg. The Senhance® robotic system was used with 3 mm instruments, a 10 mm 3D 0° or 30° videoscope and advanced energy devices, the setup consisted of the master console and three separate arms. The amount, size, and position of the applied ports, their distance as well as the distance between the three operator arms of the robot, external and internal collisions, and complications of the procedures were recorded and analyzed. We were able to perform all planned surgical procedures with 3 mm robotic instruments in piglets with a median body weight of less than 7 kg. We encountered two non-robot associated complications (bleeding from the inferior caval and hepatic vein) which led to termination of the live procedures. Technical limitations were the reaction time and speed of robotic camera movement with eye tracking, the excessive bending of the 3 mm instruments and intermittent need of re-calibration of the fulcrum point. Robotic newborn and infant surgery appears technically feasible with the Senhance® system. Software adjustments for camera movement and sensitivity of the fulcrum point calibration algorithm to adjust for the increased compliance of the abdominal wall of infants, therefore reducing the bending of the instruments, need to be implemented by the manufacturer as a result of our study. To further evaluate the Senhance® system, prospective trials comparing it to open, laparoscopic and other robotic systems are needed.

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Totally robotic soave pull-through procedure for Hirschsprung's disease: lessons learned from 11 consecutive pediatric patients

INTRODUCTION

Since Hirschsprung's disease (HSCR) already proved to benefit from robotic surgery, we aimed at describing a wider series of patients with this rare disease who were operated on with a robotic approach.

PATIENTS AND METHODS

All consecutive HSCR patients who underwent totally robotic soave pull-through (TRSPT), between October 2015 and June 2019, have been included. Ethical Committee approval was obtained. Data regarding clinical features, technical details, complications, hospital stay, and functional outcome have been prospectively collected for each patient.

RESULTS

Eleven patients have been included. Mean age at surgery was 29 months. Median length of surgery was 420 min. Median console time was 180 min. Six patients suffered from rectosigmoid aganglionosis, three from long HSCR (extending up to the hepatic flexure), two from total colonic aganglionosis. No major intraoperative complications occurred. Four patients (three of whom carrying a stoma) experienced minor mucosal tearing during dissection. One anastomotic stricture required dilatation under general anesthesia and two cuff strictures required cuff release (both occurring in patients who experienced intraoperative mucosal tearing). Follow-up lasted a median of 12 months. One patient experienced mild postoperative enterocolitis. Continence scored excellent-to-good in all patients who could be assessed on that regard (7 out of 11).

CONCLUSIONS

Provided a number of technical key points are respected, the outcome of TRSPT for HSCR is promising. Younger patients, particularly those carrying a stoma, proved to be technically demanding and deserve a longer learning curve. Accurate preoperative bowel preparation, correct trocar placement and patient positioning proved to be crucial aspects of treatment. To conclude, TRSPT is particularly suitable for older HSCR patients, even those requiring a redo, and represents a valid alternative to available surgical option for this delicate subgroup of HSCR patients.

Robotic Approach for Median Arcuate Ligament Release in Pediatrics

Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.

Rare and special robotic surgery indications in the pediatric population: ectopic organs and differences of sexual development

BACKGROUND AND OBJECTIVE

Differences of sexual development (DSD) affect the development of internal reproductive organs and external genitalia. Ectopic kidney is a rare and challenging pathology causing amongst others incontinence and recurrent urinary tract infections. Those pathologies may in certain cases be an indication for surgery. This manuscript aims to evaluate the role of robot-assisted laparoscopy in the surgical treatment of patients with ectopic kidneys or DSD.

MATERIALS AND METHODS

A prospective database is maintained in a tertiary referral center with all robotic surgeries performed in children. From this database, a prospective series of robot-assisted resection of embryologic remnants located in the pelvis was extracted: resection of a prostatic utricle cyst, removal of ectopic non-functional kidneys, and resection of a hemi-uterus.

RESULTS

From an initial database including 72 patients, six patients met the inclusion criteria. Three male patients presenting with utricle cysts, two young girls presenting with ectopic kidneys, and one young boy with pelvic embryological remnants of the uterus, were further evaluated.

CONCLUSION

Surgical treatment of patients with DSD is safe, feasible, and a good indication for robot-assisted laparoscopic surgery, as both deep dissection and reconstruction in a limited surgical field are requested.

Evaluation of a new robotic-assisted laparoscopic surgical system for procedures in small cavities

No data exists concerning the application of a new robotic system with 3-mm instruments (Senhance™, Transenterix, Milano, Italy) in small cavities. Therefore, the aim of this study was to test the system for its performance of intracorporal suturing in small boxes simulating small body cavities. Translucent plastic boxes of decreasing volumes (2519-90 ml) were used. The procedures (two single stitches, each with two consecutive surgical square knots) were performed by a system-experienced and three system-inexperienced surgeons in each box, starting within the largest box, consecutively exchanging the boxes into smaller ones. With this approach, the total amount of procedures performed by each surgeon increased with decreasing volume of boxes being operated in. Outcomes included port placement, time, task completion, internal and external instrument/instrument collisions and instrument/box collisions. The procedures could be performed in all boxes. The operating time decreased gradually in the first three boxes (2519-853 ml), demonstrating a learning curve. The increase of operating time from boxes of 599 ml and lower may be attributed to the increased complexity of the procedure in small cavities as in the smallest box with the dimensions of 2.9 × 6.3 × 4.9 cm. This is also reflected by the parallel increase of internal instrument-instrument collisions. With the introduction of 3-mm instruments in a new robotic surgical system, we were able to perform intracorporal suturing and knot tying in cavities as small as 90 ml. Whether this system is comparable to conventional three-port 3-mm laparoscopic surgery in small cavities-such as in pediatric surgery-has to be evaluated in further studies.