Robotic Surgery: Is There a Possibility of Increasing Its Application in Pediatric Settings? A Single-Center Experience

Abstract

Introduction: Robotic surgery has shown explicit benefits and advantages in adults, but it is not yet strongly established in the pediatric population, even though its popularity is increasing, especially in the urologic field. Materials and methods: In this article we present our experience with the Da Vinci System (SI first and XI nowadays) at our pediatric institution in order to analyze our progress over the years. We considered all patients from the start of the robotic surgery program in 2016 until the end of 2021, dividing them into general abdominal surgery and genitourinary surgery. Analyzed data were the patient's demographic, details of surgery, and intra and post-operative complications. Results: The total number of patients (pts) included in this study was 76, of whom 40 (52%) were male and 36 (48%) were female. The mean age at surgery was 90.9 months (range 10-207 months), and the mean weight at surgery was 29.3 kg (range 9.5-68 kg). There were 18 general abdominal robotic surgeries and 58 genitourinary robotic surgeries performed. The most performed surgeries in these two categories were fundoplication for gastro-oesophageal reflux disease (11%) and Anderson-Hynes pyeloureteroplasty. The mean operative time was 224.2 min (range 72-530 min): the mean times in the two groups (general abdominal surgery and genitourinary surgery) were 165 min (range 84-204 min) and 194 min (range 95-360 min), respectively. A total of four (5%) minor complications were reported. The total conversions were two (2.6%) and the mortality rate was 0%. Conclusions: Pediatric robotic surgery is a field of considerable interest and it is rapidly expanding. In our experience, it is evident how the learning curve has increased gradually, but steadily, allowing us to advance from standardized surgery, such as fundoplication and pieloplasty, towards a more technically complex one, achieving the same good results. We believe that robotic surgery is very respectful of tissues and feasible, especially for reconstructive surgery. For these reasons, it could become of common use also in the pediatric population, overcoming impediments such as excessive cost and the lack of pediatric instruments, in order to be able to treat children with a progressively lower age and weight.

Keywords: minimally invasive surgery; robot-assisted surgery; robotic learning curve.

Figure 1

Number of surgeries by anatomical district.

Figure 2

Major surgeries in General Abdominal Surgery.

Figure 3

(A) Robotic exeresis of choledochal cyst and (B) subsequent hepaticojejunanastomosis.

Figure 4

Major surgeries in Genitourinary Surgery.

Figure 5

Robotic pyeloureteroplasty: renal pelvis (black arrow) and ureter (green arrow).

Figure 6

Ureteral reimplantation in patient with bladder diverticulum. (A) The ureter (green arrow) is isolated and (B) detached from the bladder with exeresis of the diverticulum (red arrow); (C) uretero-vesical anastomosis and (D) extravesical reimplantation according to Lich–Gregoir is then performed.

Figure 7

Increase in cases performed by robotic technique during the study period (the decrease in early 2020 is due to the SARS-CoV-2 emergency that led to the cancellation of elective surgeries for a period).

Figure 8

Fundoplication: trend of operating times over the years.

Figure 9

Pyeloplasty: trend of operating times over the years.