The fundoplication is a key procedure in the training of a pediatric surgeon new to robotics. Along with the cholecystectomy, the fundoplication is a familiar laparoscopic procedure and is one of the most common operations in pediatric general surgery. Therefore, we must emphasize that the fundoplication is an important procedure in understanding the subtle differences between robotic surgery and laparoscopic surgery and will help a new robotic surgeon learn the basics before moving on to more complex procedures.

Most pediatric fundoplications are performed via the transabdominal approach, and the Nissen fundoplication is the most common fundoplication [4]. Other less common fundoplications are the Toupet and Thal partial wraps. The choice for the type of fundoplication is the surgeon’s preference, but all have been shown to be effective [5]. Laparoscopically, the fundoplication procedure has been performed regularly since the mid-1990s with good results [6]. The learning curve for the laparoscopic approach has been estimated somewhere between 25 and 30 cases [7]. Although many well-trained laparoscopic surgeons will argue about the futility of the robot for this procedure, we have found that it is an excellent training case. More importantly, the learning curve is much shorter, perhaps as short as five cases [8].

Trocar locations are slightly modified from the laparoscopic approach (Fig. 29.5).

While the camera location is still at the umbilicus, the left and right working ports are slightly more lateral in comparison to the laparoscopically placed trocars. The more lateral placement avoids robotic arm collisions between the instrument arms and the camera arm external to the patient. The retracting port for the liver is in the same location as is customarily placed along the patient’s right flank. The robot cart is positioned directly over the patient’s head. Dissection begins by exposing the hiatus and taking down the short gastric vessels. We prefer both a minimal hiatal dissection as well as a minimizing the number of short gastric we sacrifice. The wrap is constructed with nonabsorbable suture and generally should be at least 3 cm in length (Fig. 29.6).

Suturing the completed wrap to the underside of the diaphragm is optional and we recommend this additional step if the patient had a large hiatal defect that required repair. Occasionally, a patch for a congenital diaphragmatic hiatal hernia may be needed (Fig. 29.7). Results are similar to the laparoscopic approach.

Malrotation results from a failure of the intestine to return to the abdomen in the proper orientation during embryology. In normal embryogenesis, the bowel has two rotational axes that result in the proper orientation of the bowel. The rotations occur outside the abdominal cavity early in gestation. As the bowel reenters the abdomen, the small bowel becomes fixed along its most proximal segment to form the C-loop of the duodenum, which terminates with the ligament of Treitz. Meanwhile, the large bowel becomes fixed to the retroperitoneum by attachments along the right gutter. Most importantly, the mesentery to the small and large bowel lies in a long fan of mesenteric attachments that extend from the right lower quadrant all the way to the left upper abdomen and the ligament of Treitz. This fixed long fan of mesentery is why normally rotated bowel usually does not twist. However, in malrotation, the mesentery is very narrow. Upon return of the bowel to the abdomen, the small bowel that did not rotate properly usually has the majority of the small bowel off to the right of the abdomen. The duodenal loop never properly forms and the duodenum can often go straight inferiorly instead of making the proper C-loop. The ascending colon is often to the left of the small bowel and duodenum so the retroperitoneal attachments that were supposed to tether the ascending colon to the right gutter now grab onto anything in the right abdomen, usually the small bowel but in a random fashion. These attachment bands are called Ladd’s bands in reference to the pediatric surgeon William Ladd who first described the operation that also bears his name [9]. Ultimately, a patient can present with either partial or complete obstruction from these bands, and a chronic condition that is hard to diagnose may exist for years without an upper GI study. The biggest worry, however, is the development of a volvulus. This occurs as a result of the narrow vascular pedicle, and rapid operative intervention is critical before the bowel is lost from ischemia.

The Ladd’s procedure has four steps: (1) Detorse the bowel. The volvulus always occurs in a clockwise fashion, and the bowel must be turned counterclockwise until the mesentery is straight (remember the phrase “turn back time”). (2) After the torsion has been reduced, the Ladd’s bands are taken down freeing all adhesions. (3) The most important step in reducing the risk of a recurrence is widening the mesentery. The peritoneal surface of narrow pedicle between the duodenum and the ascending colon is incised on one side and the mesentery splayed out in order to widen it. (4) Finally, the appendix in a malrotated patient is never in the right lower quadrant, so an appendectomy is part of the procedure to reduce the possibility of diagnostic confusion if appendicitis ever developed in such a patient.

Malrotation can present with or without volvulus. The patient with malrotation and midgut volvulus is a true surgical emergency, and we do not advocate attempting a minimally invasive procedure in these patients. However, the patient who has chronic abdominal pain or partially obstructive symptoms who is found to have malrotation on upper GI but no evidence of volvulus or acute obstruction may be a good candidate for an elective minimally invasive procedure. Besides children, these patients could also be adults who have a long history of abdominal pain or emesis and have gone through a multitude of doctor visits over the years. The diagnosis is confirmed by an upper GI as stated previously. The robotic trocar locations for a Ladd’s procedure are shown in Fig. 29.8.

The key area of work is the right upper quadrant. Begin by taking down all Ladd’s bands, usually starting laterally and working medially (Fig. 29.9). The entire course of the duodenum should be freed along its lateral aspect. On the medial aspect of the duodenum, the anterior sleeve of mesentery is incised longitudinally and blunt dissection is used to widen the mesentery. Finally, the appendix is taken at the conclusion of the procedure.

Patients with biliary atresia require a Kasai procedure for biliary drainage where a Roux limb of intestine is brought up to the portal plate to facilitate drainage of the bile. The key step in the open Kasai operation is the precise dissection of the portal plate for the best chance of obtaining adequate biliary drainage. This procedure was done laparoscopically for several years, but the results were less than optimal [10]. A voluntary moratorium was placed on the MIS Kasai procedures by the International Pediatric Endoscopic Group (IPEG) at their annual scientific meeting in Buenos Aries in September of 2007 [11]. The lack of precision in the technique was suspected, although some data suggested that CO₂ insufflation may have also played a role [12]. This failure suggests that the Kasai procedure has no margin for error and exposes the deficiencies in standard laparoscopy for a procedure that requires precision like the Kasai for biliary atresia. Robotic surgery offers a level of precision and improved optics that may be the solution. The robotic approach allows the surgeon to dissect the portal plate at the appropriate angle and with absolute precision. The port placement for the robotic Kasai is shown in Fig. (29.10).