Introduction
Pediatric general and thoracic surgical conditions cover a wide range of diagnoses that span the breadth of being congenital, infectious, malignant, or acquired. The combination of increasing surgeon experience and advances in surgical technology have resulted in the successful application of minimally invasive techniques in the treatment of almost all conditions.
History
Open approaches were the mainstay of surgical treatment until the 1980s when endoscopic techniques gained popularity in abdominal and thoracic surgery. The applications of straight stick endosurgery (SSE) grew rapidly over the years with techniques for intestinal, pulmonary, and complex biliary surgery being described. With improvements in instrumentation through optimization of ergonomics and miniaturization, minimally invasive techniques were applied to even the smallest of neonates. In 2001, the Frankfurt Group reported the first successful application of the robotic platform in pediatric surgery by performing a Nissen fundoplication. Since then, multiple authors have performed and subsequently reported their experiences on robotic abdominal and thoracic surgery in children.
Benefits
The benefits of robotic surgery for abdominal and thoracic surgery in pediatric patients include and surpass some of the advantages of SSE. Similar to SSE, robotic surgery allows for smaller incisions and improved cosmetic outcomes, decreased postoperative pain and therefore limited opioid use, shorter length of stay, and decreased time to return to school and other activities.
Robotic surgery, however, has several added benefits that differentiate it from SSE. From an optical standpoint, the platform provides an enhanced, magnified, three-dimensional visualization that surpasses the magnification provided by loupes or traditional two-dimensional endoscopes. Additionally, the operating surgeon can manipulate both the camera and the robot’s remaining arms, allowing for optimal visual angles without requiring assistants. From a mechanical standpoint, one of the significant advantages of the platform is that instruments can be “locked in position” by the user at their discretion. This allows for a robust, reliable, and indefinite amount of retraction or control. Human fatigue or motion is not an issue in retraction or maintaining exposure or control in robotic surgery.
Additionally, unlike the straight, rigid instruments used in SSE, which allow for four degrees of freedom, robotic instruments were designed to allow for seven degrees of freedom. Due to this difference in design, robotic instruments are able to function like human hands, wrists, and arms with the added benefit of tremor filtration. This allows for enhanced access to previously challenging areas of dissection, including the biliary tree and pelvis, as well as more natural movements during surgical techniques such as intracorporeal suturing. , , Robotic surgery can uniquely facilitate enhanced, precise dissection and reconstruction of the more diminutive anatomy found in neonates and smaller children. ,
Limitations
Despite the numerous benefits of robotic surgery, the field of pediatric general and thoracic surgery has been relatively slow to adopt this modality into practice. Much like other facets of surgery, robotic surgical systems were initially designed for adult patients. This has led to a few limitations in their application to younger pediatric patients. The primary disadvantage of robotic surgery is related to the size of the robot and its instruments relative to younger and smaller patients. , First, the robot itself is approximately 6 feet tall and can appear massive in relation to a neonate or toddler. This has the potential to restrict a surgical assistant’s or anesthesiologist’s access to the patient. Second, robotic instruments currently approved for pediatric use are only available in 8 mm and 5 mm sizes, which are considerably larger than the 3 mm instruments available with traditional laparoscopy for infants and toddlers. The 8 mm and 5 mm instruments use pitch-roll-yaw and snake-like mechanisms for articulation, respectively. , , Although the 5 mm instruments are smaller, their design utilizes multiple joints to enhance their “snake-like” flexibility and articulation. This requires them to be longer, which can minimize the work space in the body cavity of a small child. , , In addition, robotic endoscopes currently measure 12 mm or 8.5 mm. , , These larger sizes can be prohibitive in neonatal surgery. Endoscopes of this size would likely be too large to easily and safely traverse between the rib spaces in thoracoscopic operations for children less than 5 kg. For this reason, the manufacturer briefly marketed a two-dimensional 5 mm endoscope from 2005 to 2009 to circumvent this restriction; however, it was discontinued due to lack of market penetration, as pediatric surgeons were the only physicians interested. ,
Trocar placement in robotic surgery also differs from that of traditional laparoscopy. Traditional laparoscopy mandates the triangulation of trocars toward the target anatomy, with ergonomic benefits provided to surgeons when placing ports relatively closer together to minimize muscle fatigue and excessive stress on their shoulders. This is unnecessary in robotic surgery; however, manufacturers typically suggest eight centimeters of distance between trocars to mitigate collisions between robotic arms. This can be a challenge in infants and smaller children. Suggested trocar depth can further minimize available working space. Robotic manufacturers recommend that the remote center of the trocar be placed at the inside edge of the body cavity. The distance from the remote center to the end of the trocar measures 2.9 cm. When using even the shortest of available instruments, the distance from the inside edge of the patient to the tip of the instrument is at least 5.61 cm, which can equate to the entire width of a neonate’s hemithorax or hemiabdomen.
The benefits of robotic surgery, including increased accessibility to previously challenging anatomy, improved precision of dissection with tremor filtration, and enhanced ease of suturing and knot tying, would make robotics ideal for complex procedures in neonates, such as esophageal atresia repairs. The aforementioned limitations, however, have impaired its utilization in practice. Further research and development targeted toward the creation of finer instruments is required to facilitate further use of robotics in neonates and toddlers. In their prospective case series of 41 patients and 42 procedures, Bütter et al. performed most operations using 5 mm instruments. Interestingly, due to the lack of fine 5 mm instruments or diathermy scissors, the 8 mm instruments had to be used as well. Di Fabrizio et al.’s retrospective review of 39 pediatric patients who underwent robotic-assisted operations analyzed causes of conversion to open procedures. Three procedures were converted to open due to inadequate working space. Affected patients were of lower age (2.97 ± 1.03 vs. 9.83 ± 0.77 years, P = .01) and lower weight (11.83 ± 1.74 vs. 35.47 ± 3.16 kg, P = .03). This further emphasizes the need for innovation of smaller and finer technology for the youngest and smallest of patients.
An additional cited limitation of robotic surgery is the lack of haptic feedback relative to laparoscopic and open surgery; however, many surgeons state that this limitation is significantly mitigated by the enhanced visualization afforded by the binocular endoscope that provides a three-dimensional view. , , ,
Arguably the most prohibitive limitation of the widespread implementation of robotics in pediatric surgery is cost. , , In addition to the initial cost of purchasing the robotic system, which could cost between 1 and 2.3 million US dollars, hospital systems must also be prepared to pay an annual service contract of 100,000 to 170,000 US dollars as well as the costs of additional disposable or replacement instruments and drapes. , , Several pediatric institutions mitigate this cost by sharing the system with their adult hospital counterparts; however, this severely limits the time blocks available for its use per surgeon. Hospital organizations aiming to minimize costs and increase their profit margin must weigh the costs of using the robot for a given operation versus the potentially decreased costs associated with a shorter length of stay and potential marketing advantage over regional competitors.
Tips for success
Training
The implementation of an effective pediatric robotic surgery program requires the establishment and training of a robotic surgery team. As with the introduction of laparoscopy several decades ago, the integration of robotics into surgical practice requires the training and supervision of novice users. During the establishment of the first pediatric robotic surgery program in Canada, Bütter et al. developed a rigorous training program for novice surgeons that included preclinical training with simulation, inanimate models, and in vivo animal models prior to progressing to operations on human patients under the guidance of an experienced proctor in the corresponding specialty. They found that the presence of a representative from the robotic company was also instrumental in mitigating and troubleshooting any system issues on the day of surgery.
Currently, practicing surgeons embarking on robotic surgery complete a series of training modules, directly observe a certified surgeon, and then perform several proctored cases. Each hospital/program has its own requirements for competency. In addition to inanimate simulation models, there are groups that have developed curricula using biotissue.
The learning curve
Case selection is of vital importance during the training period. Despite the benefits of utilizing the robot for complex procedures, many experienced robotic surgeons suggest initially using the robot for at least five common or less challenging procedures. , Typical general surgery cases, such as cholecystectomies or fundoplications, allow surgeons in training to become more comfortable with the functionality and nuances of the robot prior to using it for more complex cases. , Both the pediatric and adult literature suggest that surgeon comfort with the robot can be achieved after 15 to 20 cases. , This is less than the reported 25 to 50 cases needed when learning new laparoscopic procedures. The shorter learning curve of robotics is attributed to its intuitive design and three-dimensional visualization, in contrast to the fulcrum effect of laparoscopic trocars and the two-dimensional camera used for laparoscopy. Increased utilization of and comfort with the robotic platform has been associated with a corresponding decrease in operative time. , ,
Robotic surgical team
A dedicated team of operating room (OR) personnel and physicians is critical to the success of a robotics program. Coordinators can be instrumental in expediting scheduling and staff assignment for robotic cases. An OR team consisting of technicians and nurses who work frequently with the robot and its associated instrumentation will reduce turnover time, confusion with instruments, and setup errors. Periodic simulations with the robot can also increase efficiency. Frustration resulting from unnecessary delays and unfamiliarity with the equipment will lead to surgeon reluctance to schedule cases using the robot if the case could be done more efficiently with nonrobotic techniques.
Having a small pool of surgeons certified in robotics from each discipline will assure limited competition for the equipment, particularly when a hospital has only one robot. If a large number of surgeons are competing for block time on a single robot, it may decrease the frequency of each surgeon’s exposure to robotics. This in turn may lead to decreased efficiency and inhibit the surgeon’s ability to develop expert robotic surgery skills.
A robotic surgery program consisting of untrained OR personnel or an unfavorable ratio of surgeons to robots will likely not flourish due to inefficiency and frustration. Furthermore, it is likely that the resulting suboptimal experience and infrequent exposure would lead to unacceptable complication rates. When everyone involved in the case has undergone training with appropriate repetition, all aspects of the case can be streamlined, including case and OR setup, positioning and docking of the robot, troubleshooting of any robot maintenance issues, and case turnover. ,
Operating room setup
Optimizing the positioning of the patient and the patient cart can increase working space and decrease the risk of conversion to an open procedure ( Figs. 59.1 and 59.2 ). Meehan and Sandler found that the need to alter the locations of the robot, console, and equipment tower within the OR for each different case was time intensive and put additional stress on nursing staff. By maintaining the positioning of these large pieces of equipment, and instead rotating the OR table as needed for each case, preparation time was decreased and OR setup was streamlined without adversely affecting anesthesiologists’ access to the patient. It is our practice to schedule similar types of procedures together, when possible. Scheduling procedures with similar OR setups (e.g., foregut procedures followed by hindgut procedures) can streamline OR efficiency.
