Robotic-assisted surgery in the pediatric surgeons' world: Current situation and future prospectives

Robot-assited vs. laparoscopic Nissen fundoplication in children: an updated meta-analysis with systematic literature review

This updated meta-analysis with systematic review aimed to enhance the understanding of robotics in surgical GERD treatment by comparing the reliability and efficacy of two surgical approaches for Nissen fundoplication in pediatric patients: conventional laparoscopy (LNF- laproscopic Nissen fundoplication) and robot-assisted laparoscopy (RNF- robotic Nissen fundoplication). RF has gained increasing popularity among pediatric surgeons in recent years. Major electronic databases were searched for studies comparing LNF and RNF, including publications from their inception through October 2024. Safety outcomes assessed included intra- and post-operative complications and conversions to laparotomy. Efficacy measures included length of hospital stay (LOS), total operative time (OT), analgesia requirements, gastrostomy needs, and cost-per-procedure. This meta-analysis was conducted using a random-effects model. Initially 601 articles were identified, however only 10 met our inclusion criteria and were included in this study, comprising a study group of 499 children. The pooled analysis found no significant differences in patient characteristics between the LNF and RNF groups. Furthermore, no statistically significant differences were identified between the two techniques regarding conversions to open surgery, OT, LOS, or postoperative complications. We conclude, that the findings of this meta-analysis indicate that RNF and LNF are comparable in terms of safety and efficacy parameters. However, until certain clinical benefits are proven, the use of RF instead of LF can be justified by other advantages, such as better ergonomics, elimination of tremors, and a greater range of wrist motion, to offset the additional costs associated with its initial acquisition and monthly maintenance.

Robotic-assisted Swenson procedure for Hirschsprung's disease with a median age of 35 days: a single-center retrospective study

PURPOSE

The treatment of Hirschsprung's disease (HD) in infants with the robotic-assisted Swenson procedure has been rarely reported. In this investigation, we aimed to explore the safety and the efficacy of robotic-assisted Swenson procedure for the HD in infants.

METHODS

From November 2022 to July 2023, 17 cases of HD were treated with the Da Vinci robotic Xi surgical system using a three-port approach. Preoperative, intraoperative, and postoperative data were collected and compared with 43 cases of HD treated with laparoscopy by the same lead surgeon.

RESULTS

The robotic-assisted surgery (RAS) group included 17 infants, and the laparoscopic surgery (LS) group included 43 infants, with a median surgical age of 35 days for both groups. There were no statistically significant differences between the two groups in terms of surgical age, gender, preoperative weight, preoperative hospital stay, preoperative enema time, and incidence of preoperative enterocolitis. Estimated intraoperative blood loss and transfusion rate in the RAS group were both lower than in the LS group, with statistically significant differences. There were no statistically significant differences in early and midterm postoperative complications (anastomotic leaks, anastomotic strictures, enterocolitis, etc.) between the two groups.

CONCLUSION

This study demonstrates the efficacy and the safety of robotic-assisted Swenson procedure in infants.

Comparison of robotic vs. laparoscopic treatment in pediatric ovarian benign tumors

OBJECTIVE

To compare the differences in surgical outcomes of robot-assisted treatment and laparoscopy for benign ovarian tumors among pediatric patients.

METHODS

A total of 39 patients underwent robot-assisted surgery, and their outcomes were compared with 55 patients treated with laparoscopy during the same period by the same surgeons.

RESULTS

There were no significant differences between the two groups in terms of age (7.5 ± 4.5 vs. 8.8 ± 3.8 years, p = 0.2496), weight (29.3 ± 17.7 vs. 31.7 ± 14.6 kg, p = 0.4383), or tumor size (5.0 ± 3.3 vs. 5.1 ± 3.8 cm, p = 0.8541). However, the operative time was significantly longer in the robotic surgery group (102.7 ± 33.5 vs. 89.3 ± 50.9 min, p = 0.0112). There was no significant difference in intraoperative blood loss. Fewer patients in the robotic surgery group opted for day surgery compared to the laparoscopy group (15.4% vs. 54.5%, p < 0.001). There was no significant difference in the length of hospital stay between the two groups of patients who chose inpatient surgery (5.6 ± 3.4 vs. 4.4 ± 2.9 d, p = 0.1213). There was no conversion to open surgery and no early postoperative complications in both groups.

CONCLUSION

Robot-assisted surgery and laparoscopy yield comparable outcomes for the treatment of benign ovarian tumors in children, although robotic surgery has a longer operative time.

Minimally Invasive Surgery for Hirschsprung Disease: Current Practices and Future Directions

Hirschsprung disease (HD) is a congenital disorder characterized by the absence of ganglion cells in the distal colon and rectum, leading to functional obstruction and severe constipation. Over the past decades, the surgical management of HD has significantly evolved, with minimally invasive surgery (MIS) techniques revolutionizing treatment approaches. This review explores recent innovations in MIS for HD, focusing on laparoscopic, transanal endorectal pull-through (TERPT), and robotic-assisted techniques. These approaches offer numerous advantages over traditional open procedures, including reduced surgical trauma, improved cosmesis, faster recovery times, and potentially lower complication rates. Laparoscopic surgery has become widely adopted, providing excellent visualization and precise dissection. TERPT has gained popularity for short-segment disease, offering a completely transanal approach with minimal scarring. Robotic-assisted surgery represents the cutting edge, enhancing surgical precision and dexterity. The review also examines emerging technologies and future directions, such as advanced imaging techniques, artificial intelligence applications, and potential developments in tissue engineering. While MIS techniques have shown promising outcomes, challenges remain in standardizing approaches, addressing long-segment disease, and optimizing long-term functional results. The future of HD surgery lies in personalized approaches that integrate genetic and molecular profiling with advanced surgical technologies. As the field continues to evolve, comprehensive long-term studies and efforts to improve access to specialized care will be crucial to further enhancing outcomes for patients with HD.

Robotic-Assisted Surgery in Children Using the Senhance® Surgical System: An Observational Study

BACKGROUND

Robotic-assisted surgery (RAS) holds many theoretical advantages, especially in pediatric surgical procedures. However, most robotic systems are dedicated to adult surgery and are less suitable for smaller children. The Senhance® Surgical System (SSS®), providing 3 mm and 5 mm instruments, focuses on making RAS technically feasible for smaller children. This prospective observational study aims to assess whether RAS in pediatric patients using the SSS® is safe and feasible.

METHODS AND RESULTS

A total of 42 children (aged 0-17 years, weight ≥ 10 kg) underwent a RAS procedure on the abdominal area using the SSS® between 2020 and 2023. The study group consisted of 20 male and 22 female individuals. The mean age was 10.7 years (range 0.8 to 17.8 years), with a mean body weight of 40.7 kg (range 10.1 to 117.3 kg). The 3-mm-sized instruments of the SSS® were used in 12 of the 42 children who underwent RAS. The RAS procedures were successfully completed in 90% of cases. The conversion rate to conventional laparoscopy was low (10%), and there were no conversions to open surgery. One of the 42 cases (2%) experienced intraoperative complications, whereas six children (14%) suffered from a postoperative complication. Overall, 86% of the patients had an uncomplicated postoperative course.

CONCLUSIONS

The results of the current observational study demonstrate the safety and feasibility of utilizing the SSS® for abdominal pediatric RAS procedures. The study provides new fundamental information supporting the implementation of the SSS® in clinical practice in pediatric surgery.

Evaluation of the hinotori™ Surgical Robot System for accurate suturing in small cavities

The hinotori™ Surgical Robot System (hinotori™, Medicaroid, Kobe, Japan) is increasingly being utilized primarily in urology and adult surgery; however, data on its application in pediatric surgery are lacking. This preclinical study aimed to evaluate the limitations of this system for accurate suturing in small cavities designed for pediatric and neonatal applications. Two trained operators performed simple ligature sutures (easy task [ET]) and hepaticojejunostomy sutures (difficult task [DT]) within five differently sized boxes, ranging from 5123 to 125 mL. The suture time, number of internal and external instrument/instrument collisions, instrument/box collisions, and suture accuracy were evaluated. The suture accuracy was assessed using the A-Lap Mini endoscopic surgery skill assessment system. As a result, an increase in the number of collisions and extended suturing times were observed in boxes with volumes smaller than 215 mL. Despite these variations, there were no significant differences between the boxes, and all tasks were precisely performed in all boxes (p = 0.10 for the ET and p = 1.00 for the DT). These findings demonstrate the capability of the hinotori™ system to perform precise suturing techniques within tightly confined simulated neonatal cavities as small as 125 mL. To advance the integration of pediatric robotic surgery utilizing the hinotori™ system, additional trials comparing it with conventional laparoscopic and thoracoscopic techniques using pediatric and animal models are necessary to assess its clinical safety and applicability.

Advancements in robotic surgery: innovations, challenges and future prospects

The use of robots has revolutionized healthcare, wherein further innovations have led to improved precision and accuracy. Conceived in the late 1960s, robot-assisted surgeries have evolved to become an integral part of various surgical specialties. Modern robotic surgical systems are equipped with highly dexterous arms and miniaturized instruments that reduce tremors and enable delicate maneuvers. Implementation of advanced materials and designs along with the integration of imaging and visualization technologies have enhanced surgical accuracy and made robots safer and more adaptable to various procedures. Further, the haptic feedback system allows surgeons to determine the consistency of the tissues they are operating upon, without physical contact, thereby preventing injuries due to the application of excess force. With the implementation of teleoperation, surgeons can now overcome geographical limitations and provide specialized healthcare remotely. The use of artificial intelligence (AI) and machine learning (ML) aids in surgical decision-making by improving the recognition of minute and complex anatomical structures. All these advancements have led to faster recovery and fewer complications in patients. However, the substantial cost of robotic systems, their maintenance, the size of the systems and proper surgeon training pose major challenges. Nevertheless, with future advancements such as AI-driven automation, nanorobots, microscopic incision surgeries, semi-automated telerobotic systems, and the impact of 5G connectivity on remote surgery, the growth curve of robotic surgery points to innovation and stands as a testament to the persistent pursuit of progress in healthcare.

Robotic-Assisted Nissen Fundoplication in Pediatric Patients: A Matched Cohort Study

BACKGROUND

Nissen Fundoplication (NF) is a frequently performed procedure in children. Robotic-assisted Nissen Fundoplication (RNF), with the utilization of the Senhance® Surgical System (SSS®) (Asensus Surgical® Inc., Durham, NC, USA) featuring 3 mm instruments, aims to improve precision and safety in pediatric surgery. This matched cohort study assesses the safety and feasibility of RNF in children using the SSS®, comparing it with Laparoscopic Nissen Fundoplication (LNF).

METHODS AND RESULTS

Twenty children underwent RNF with the SSS® between 2020 to 2023 and were 1:1 matched with twenty LNF cases retrospectively selected from 2014 to 2023. Both groups were similar regarding male/female ratio, age, and weight. Two of the twenty RNF cases (10%) experienced intraoperative complications, whereas three in the LNF group of whom two required reinterventions. The observed percentage of postoperative complications was 5% in the RNF group compared to 15% in the LNF group (p = 0.625). The operative times in the RNF group significantly dropped towards the second study period (p = 0.024).

CONCLUSIONS

Utilizing SSS® for NF procedures in children is safe and feasible. Observational results may tentatively suggest that growing experiences and continued development will lead to better outcomes based on more accurate and safe surgery for children.

Robotic-assisted surgery for gynecological indications in children and adolescents: European multicenter report

Robotic-assisted surgery (RAS) is increasingly adopted in the pediatric population. This retrospective multicenter study aimed to report application of RAS for gynecological indications in pediatric patients. The medical records of all girls with gynecological pathology, operated in 4 different institutions over a 3-year period, were retrospectively collected. Robot docking time, total operative time, length of stay (LOS), requirement time of pain medication, complication rate, conversion rate, and pathology were analyzed. Twenty-three girls, with median age of 12.3 years (range 0.6-17.8) and median weight of 47.2 kg (range 9-73), received the following RAS procedures: ovarian cystectomy for ovarian cyst/mass (n = 10), salpingo-oophorectomy for ovarian complex mass (n = 6), bilateral gonadectomy for Turner syndrome SRY + (n = 1), salpingectomy for fallopian tube lesion (n = 1), paratubal cyst excision (n = 1), Gartner cyst excision (n = 1), paravaginal ganglioneuroma resection (n = 1), fistula closure in urogenital sinus (n = 1), and vaginoplasty using ileal flap in cloaca malformation (n = 1). Median operative time was 144.9 min (range 64-360), and median docking time was 17.3 min (range 7-50). Conversion to open or laparoscopy was not necessary in any case. Median LOS was 2.1 days (range 1-7), and median analgesic requirement was 2.2 days (range 1-6). One patient (4.3%) needed redo-surgery for recurrent Gartner cyst (Clavien 3b). This preliminary experience showed that RAS is safe and feasible for surgical treatment of gynecological pathology in pediatric patients, although no conclusive data are available to confirm its superiority over traditional laparoscopy. Randomized, prospective, comparative studies are needed to identify the gold standard approach for such indication.

Pyeloplasty in Children with Ureteropelvic Junction Obstruction and Associated Kidney Anomalies: Can a Robotic Approach Make Surgery Easier?

BACKGROUND

Robot-assisted pyeloplasty is widely used in pediatric surgery because of its well-known advantages over open or laparoscopic surgery. The aim is to explore our experience and evaluate the achievements we have made.

METHODS

We evaluated patients undergoing robotic pyeloplasty from January 2016 to November 2021, including those who presented with a ureteropelvic junction obstruction associated with other anomalies of the kidney. The parameters examined were: age, weight, associated renal malformations, conversion rate, operative time, and intra- and postoperative complications.

RESULTS

Of 39 patients, 7 (20%) were included, of whom 5 (71%) were male and 2 (29%) were female. The mean age at surgery was 84 months (range 36-180 months), and the mean weight at surgery was 24.4 kg (range 11-40 kg). In five (71%) patients the ureteropelvic junction obstruction (UPJO) was left-sided and in two (29%) it was right-sided. In four (57%) cases, UPJO was associated with a horseshoe kidney, right-sided in one (25%) patient, and left-sided in the other three (75%). A 180° rotation of the kidney was present in one (14%) patient. Nephrolithiasis was present in two (29%) patients. The mean operative time was 160 min (range 140-240 min). The average bladder catheter dwell time was 1 day (range 2-3 days), while the average abdominal drainage dwell time was 2 days (range 2-4 days). The mean hospitalization time was 4 days (range 3-9 days). On average, after 45 days (range 30-65) the JJ ureteral stent was removed cystoscopically. No intraoperative complications were reported, while one case of persistent macrohematuria with anemia requiring blood transfusion occurred postoperatively.

CONCLUSIONS

Ureteropelvic junction obstruction might be associated with other congenital urinary tract anomalies such as a duplicated collecting system, horseshoe kidney, or pelvic kidney. These kinds of malformations can complicate surgery and require more attention and accuracy from the surgeon. Our experience shows that, with regards to the robotic learning curve required for pyeloplasty, the treatment of the ureteropelvic junction in these situations does not present insurmountable difficulties nor is burdened by complications. The application of robot-assisted surgery in pediatric urology makes difficult pyeloplasties easier.