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Robotic Pediatric Surgery – An attractive way to see the future

A.Popalou, S.Hiridis, K.Konstantinidis

Introduction

Minimally invasive surgery is increasingly becoming the standard approach to the treatment of pediatric patients. Infants present a significant technical challenge due to the small size of structures and the small workspace available. Master-slave robotic surgical telemanipulators help overcome this challenge by facilitating microsurgery in a confined workspace.

Since their introduction in the late 90s, clinical robots have been tested and tried successfully in a growing range of surgical specialties, including urology, cardiac, thoracic, upper and lower GI, hepatobiliary, gynaecology, otolaryngology and paediatrics. Despite a decade in service, their application in both adult and paediatric surgical practices remains limited to specialized centres, mainly in the USA and parts of Europe. In children, robotic surgery is applicable to a wide range of paediatric surgical conditions.

Pediatric urology

Robotic surgery in pediatric urology is an evolving technology that holds promise for application to most urological surgeries. The daVinci robotic surgical system has been used to perform the following surgical procedures, from extirpative to reconstructive: orchidopexy of the intraabdominal testis, total and partial nephrectomy, dismembered pyeloplasty, pyelolithotomy, excision of calyceal diverticula, ureteroureterostomy, ureteropyelostomy, intra- and extravesical ureteral reimplantation, megaureter’ tapering and reimplantation, adrenalectomy, and resection of pelvic Mullerian remnants. The procedure mostly performed with the da Vinci® Surgical System in pediatric urology is pyeloplasty for ureteropelvic junction obstruction, with trans or retroperitoneal approach. The reconstructive aspect has been taken to the next level where more difficult procedures, such as creation of a Mitrofanoff continent catheterizable channel (appendicovesicostomy), and bladder augmentation, can be performed in children.

Digestive Surgery

Surgical robots are currently used clinically for procedures such as fundoplication (Thal and Nissen), Heller’s myotomy, cholecystectomy, splenectomy, redo rectal mobilization, appendectomy, meckelectomy. Robot-assisted laparoscopic Morgagni hernia repair is also feasible.

Hepatic surgery

Complex hepatobiliary procedures are ideally suited for robotic surgery in children. Although the laparoscopic approach to the treatment of complex biliary disease is possible, it is technically challenging. Complete resections of the choledochal cysts and Roux-en-Y hepaticojejunostomies were performed using the robotic surgical system. The three-dimensional visualization and wristed instrumentation greatly aids the dissection of the cyst and the biliary reconstruction. Kasai portoenterostomies for biliary atresia have also been performed.

Thorax and oncology

As for complex hepatobiliary cases the technology is ideal in thoracic surgery, particularly solid chest masses and esophagoesophagostomy in infants with esophageal atresia. Robot assistance for video-assisted thoracic surgical lobectomy is feasible and safe. Robotic surgery is now applied in surgical oncology, for example one child underwent bilateral salpingo-oophorectomy due to a gonadoblastoma.

Neonatal Surgery

Certainly, the advantages of robotic surgery have been presented and discussed. Operative view, precision, dexterity and ergonomics are greatly improved compared with conventional manual laparoscopy and the need for a human camera assistant is alleviated. Robotic surgical systems may expand our ability to perform minimally invasive surgery in premature infants by allowing the use of lower abdominal pressures. This is especially important in the premature infant, whose lungs may not tolerate the degree of pneumoperitoneum needed for standard laparoscopic surgery. The lower pressures create a smaller workspace that is ideally suited to the robotic surgical system, as are the microsurgical techniques that become even more important in these patients with extremely small structures and delicate tissues. These differences may make a wider range of applications of robotic surgery appropriate in the premature infant.Laboratory and early experience indicates that they may provide advantages for newborn procedures such as portoenterostomy for biliary atresia, enteroenterostomy for intestinal atresia, and repair of esophageal atresia and tracheoesophageal fistula. They have a potential for making possible MIS procedures, which can only be done open now, and for introducing entirely new procedures as well as for the performance of procedures by operators distant from the patient.

The Future

As for robotic general surgery, the potential advantages of robot-assisted pediatric surgery lie in its ability to convert the surgical act into digitized data. This digitized format can then interface with other forms of digitized data, such as pre- or intraoperative imaging studies, or be transmitted over a distance. This has the potential to revolutionize the way pediatric surgery is performed.

Conclusions

The application of robotic surgery to the pediatric population has the potential to dramatically expand the ability to provide minimally invasive surgery not only to smaller patients but also to patients with more complex congenital problems.Robotic surgery will give surgeons the ability to perform essentially tremorless microsurgery in tiny spaces with delicate precision and may enable procedures never before possible on children, neonates, and fetuses. Collaboration with radiologists, engineers, and other scientists will permit refinement of image-guided technologies and allow the realization of truly remarkable concepts in minimally invasive surgery. While robotic surgery is now in clinical use in several surgical specialties (heart bypass, prostate removal, and various gastrointestinal procedures), there’s possibility that the greatest promise of robotics could be hidden in pediatric surgery.

In Greece, the first robotic operations were performed in September 2006 from Dr.K.Konstantinidis and his surgical team (general surgery) who covered the wide spectrum of general surgery but also from the urological teams of Athens Medical Center which completed succesfully the most important laparoscopic urologic procedures, including radical prostatectomy, using the 4-armed DaVinci Surgical System. This first effort from a greek team has enabled the rest of the surgical specialties to see the future indeed in an attractive way!