Robotics for the surgical treatment of pediatric patients: An overview

KEY POINTS

■ Pediatric surgeons have begun to incorporate the advancements of robotic surgery by adapting the equipment to accommodate the pediatric surgical patient. The da Vinci SI Surgical System, introduced in April 2009, boasts advanced three-dimensional (3D), high-definition (HD) visualization, EndoWrist Instrumentation, and Intuitive Motion technology.

■ Current limitations to using robotic surgery include its high cost and the current size of the instruments and minimum port distance, which limit the size and weight of patients who are candidates for robotic surgery, particularly small children.

"Anyone who could operate on bunny rabbits could operate on a newborn," a prominent Boston surgeon once said to Dr. William Ladd in the early 1900s.¹ Fortunately for any parent who has had a child with a disease requiring surgical treatment, Ladd did not practice on rabbits but instead focused his energy on helping to develop the field of pediatric surgery. Since then, this field has continued to progress by incorporating the technological advances of the 21st century into new procedures. Some of the latest surgical innovations include natural orifice transluminal endoscopic surgery (NOTES) and single-port laparoscopic surgery. Also included in this renaissance is robotic-assisted surgery. As the usefulness of adult robotic procedures has expanded to urology, gynecology, and otolaryngology, they have also found a role in pediatric surgery. Pediatric surgeons have begun to utilize these procedures and have adapted the equipment to accommodate the pediatric surgical patient.


CURRENT ROBOTIC ABILITIES AND SYSTEMS


In 1917 and 1921, the Čapek brothers wrote science fiction works describing automated beings and coined the term robot.^2-4 Although robots have since been developed for use in a variety of fields, the use of robotics in surgery remains in its early stages. Robotics were first used during surgery in 1985, when a robotic arm was used to assist during brain biopsy.³ Worldwide, large, randomized, controlled, multicenter studies in robotic-assisted pediatric surgery still have not been performed, and most publications offer only case reviews.


In 1994, the first FDA-approved surgical robotic system was put on the market.⁵ Called the Automated Endoscopic System for Optimal Positioning (AESOP), it was manufactured by Computer Motion, Inc. (later acquired by Intuitive Surgical, Inc. in 2003). Computer Motion, Inc. also developed several other robotic surgical systems including the HERMES Control Center, a voice command and recognition system; the SOCRATES Robotic Telecollaboration System, which allows integrated telecommunication with the robotic devices to facilitate remote surgeries; and the ZEUS Robotic Surgical System, which is no longer marketed. In 2001, the ZEUS Robotic Surgical System was utilized to perform the first transatlantic surgical procedure, during which a patient in Strasbourg, France underwent a robot-assisted laparoscopic cholecystectomy performed by a surgeon sitting at a console 3,800 miles away in New York.³ 


In 1995, Intuitive Surgical, Inc. developed the da Vinci Surgical System. Originally, the system touted a three-armed patient side cart and surgeon console. Eventually a fourth arm was added to the system, and in April 2009, the da Vinci SI Surgical System was unveiled, which boasts advanced three-dimensional (3D) high-definition (HD) visualization, EndoWrist Instrumentation, and Intuitive Motion technology, which replicates the experience of open surgery. This system has an optional dual-console capability that can support training and collaboration during procedures (Figure 1). The console allows the surgeon to sit throughout the procedure and has fingertip controls that translate in real time to the robotic arms. The EndoWrist instruments utilized with the da Vinci system are modeled after the human wrist, thus allowing for 90-degree articulation (Figure 2). The instruments are now available in 5-mm and 8-mm diameters. The Vision System for the da Vinci system works by utilizing the 12-mm endoscope to transfer a 3D HD vision of the operative field to the surgeon console (Figure 3). Its panoramic 16:9 aspect ratio, 10× magnification, and 3D vision help to achieve laparoscopic depth perception (Figure 4). An 8-mm, two-dimensional version of the system is also available.⁶


ROBOTIC SURGERY IN OTOLARYNGOLOGY


In otolaryngology, the da Vinci Surgical System has enabled transoral robotic surgery to be safely conducted in the pediatric airway. In 2007, one institutional review board-approved study published in the Archives of Otolaryngology—Head and Neck Surgery evaluated the efficacy of the da Vinci surgical robot. For the study, four cadaveric pediatric larynxes were used as control subjects. Upon completion of the cadaveric phase, robot-assisted procedures were used to correct laryngeal clefts in five pediatric patients. The authors were successful in only two of the five robotic attempts, attributing the three failed attempts to limited transoral access. However, the surgeons were impressed with the system's "great dexterity and precision, delicate tissue handling, good three-dimensional depth perception, and relatively easy endolaryngeal suturing."⁷


CARDIOVASCULAR APPLICATIONS


Currently, ligation of a patent ductus arteriosus (PDA) is the most common cardiovascular procedure performed by robot-assisted surgeons.³ A French study conducted from 2000 to 2001 reported a case-control study in which 56 patients with a PDA underwent surgical closure. The mean patient weight was 12 kg (about 26 lb). Twenty-eight patients underwent procedures using the ZEUS robot and 28 underwent procedures using video-assisted thoracoscopic ligation. The researchers found that there was no comparable difference between the two procedures other than that the operating time was nearly double with the robotic approach, which does question the efficacy of the robotic application for surgical closure of PDAs.⁸ 


A 2006 Japanese study reported similar findings using the AESOP 3000 system. The results were similar in 13 infants with an average weight of 6.6 kg (about 14.6 lb) compared to conventional video-assisted thoracoscopic surgery.⁹ However, PDA is more common in premature infants and is present in up to 60% of very-low-birth-weight (VLBW) infants who weigh less than 3.3 lb. Although these studies were successful, the participants were well above the average weight of a premature infant with a PDA. The robotic arms and video system may be too large to accommodate smaller patients.


Recently, the da Vinci system also assisted in the first totally robotic/endoscopic repair of an atrial septal defect without a sternotomy, thoracotomy, or cardioplegic arrest. The procedure was performed on a 14-year-old girl who weighed 35 kg (about 77.2 lb). The authors cited less postoperative pain, much better cosmetics, and improved visualization and precision using the robotic system.¹⁰


THORACIC PROCEDURES


As with cardiovascular procedures, the hemithorax of small children does not always allow for the needed articulation of surgical instruments. Surgeons are becoming more proficient and have been adapting to these impediments. In 2007, Meehan and Sandler reported a review of the first 100 consecutive cases that used the da Vinci system. Included in the study were 11 thoracic cases, 2 of which required conversion to an open procedure because of anatomical difficulty and lack of domain. However, the researchers were successful in performing a pulmonary segmentectomy and removing posterior mediastinal masses, congenital cystic adematous malformations (CCAMs), bronchogenic cysts, and intralobar sequestrations. They remarked that the robot's articulation instruments seemed particularly well-suited for solid chest masses.¹¹


ABDOMINAL PROCEDURES 


The precision, decreased motion tremor, and 3D optics of robots afford surgeons dexterity and vision they would otherwise lack when operating in the abdomen and pelvis. Robotic-assisted pediatric Nissen fundoplications have already established their place in pediatric surgery. Meehan and colleagues demonstrated great success using the da Vinci system. During their study, no open conversion and superior suturing caused by loss of the fulcrum effect occurred while using the da Vinci system or in laparoscopic suturing.^11,12 Furthermore, although the operative time was longer in robotic cases than in laparoscopic cases (a mean time of 213 min versus 189 min, respectively), the benefit of improved suturing skills compensated for the increased operative time. In addition, operative times will likely shorten as with any learning curve for a new technique.^4,13 


Cholecystectomy and splenectomy followed close behind fundoplications in the number of procedures performed. Of the 100 cases Meehan and colleagues performed, 89 were abdominal, including four total proctocolectomies with endorectal pullthroughs, adrenalectomy, and a Kasai procedure.¹² The smallest child in the series weighed only 4.9 lb and was born with a Bochdalek congenital diaphragmatic hernia (CDH). Meehan and his team were able to correct this defect with the robotic system without any reported sequelae despite the high recurrence rate of Bochdalek CDH after minimally invasive surgery (MIS).¹⁴ Shortly after this success, Meehan and colleagues also completed the repair of a Morgagni diaphragmatic hernia in a 22.4 lb girl.¹⁵ 


Both of these repairs were done from an abdominal approach because the patients were small in size and had hemithorax restraints. As with the Nissen fundoplications, the authors concluded that the articulations of the robotic system allowed for better suturing and knot tying that was far superior to that done using laparoscopic instruments to repair a posterolateral Bochdalek CDH defect.^12-15 


UROLOGY


In urology, the optics and 3D visualization of robotic surgery have given the surgeon access to an excellent field of vision. This in turn allows for superior reconstructive techniques in ureteral reimplantation.¹⁶ For this reason, robotic-assisted pyeloplasty is one of the most common procedures performed with the robotic systems. Operative time during urology procedures was very similar between the open and robotic techniques. In fact, robotic-assisted procedures required a mean time of only 7 minutes longer than open pyeloplasty (221 minutes versus 214 minutes, respectively).⁴ 


TRAINING RESIDENTS TO USE ROBOTICS


Concern about training residents to use robotic techniques and how effective they would be at these procedures developed as early as robotic systems began to evolve. In 2003, junior residents were tested on their ability to perform both robotic and conventional laparoscopic tasks. It was discovered that although the residents' speed using conventional laparoscopy was superior to their speed when they used robots, accuracy scores were higher when they used robots.¹⁷ Meehan and colleagues demonstrated that residents could easily be trained to perform robotic procedures in a relatively short amount of time, with operative times for fundoplications averaging 122 minutes.¹² 


As robotic surgery gains popularity, residency programs are developing methods for training young surgeons. Rashid and colleagues were successful in developing a systematic approach for training residents to use the da Vinci system.¹⁸ The operating room staff, surgical technician, and circulating nurse can be taught these systems with relative ease. First assistants should be well-trained to understand the system and procedure, as they play a key role in robotic surgeries. Although the da Vinci system can operate with up to four arms—one for the camera and three for instrumentation—an accessory laparoscopic port is usually required to allow for additional retraction and suture passage.


BENEFITS VERSUS DISADVANTAGES


The obvious benefits of a robotic system include clearly improved dexterity, loss of motion tremor, improved optics, loss of fulcrum effects, precision, and superior suturing skills.^4,7,10-15 Unfortunately, the use of robots during surgery does have some limitations. Although multiple studies have proven that robotic systems are superior to the human hand at performing procedures, the current size of the instruments and minimum port distance limits the size and weight of patients who are candidates for robotic surgery, especially in smaller children.^8,9,11,16 The smallest child observed in these studies weighed 4.9 lb.^12,14 Meehan and colleagues recommend that until technology produces even smaller instruments, children under 4.4 lb should not be candidates for robotic surgery because of the necessary intracorporeal length required for adequate instrument articulation.


In addition, the da Vinci system costs $1.2 to $1.5 million, which does not include software, instrumentation, support, and disposable equipment. In a time of health care reform and budget cuts, it will become more difficult to justify the extra cost of a robotic procedure that could be performed safely and effectively with standard laparoscopy or an open procedure.


THE FUTURE


The potential applications of pediatric robotic-assisted surgeries are endless. Currently, the cost, size of instrumentation, and long intraoperative times that accompany robotic systems limit the pediatric surgeon. Nevertheless, prior to 1991, a laparoscopic appendectomy was considered to be "space age" technology; now, it has become the standard of care. Eventually, more surgeons may use robotic technology to operate on patients across the globe. As residency programs incorporate robotics into their curricula, residents will perform more robotic procedures. As a result, these procedures will become more efficient, the costs will decrease, and more difficult and technically demanding cases will be tackled. One day, robotic-assisted procedures may become the "gold standard" of care. PAs should become familiar with these systems and capabilities as potential treatments for their patients and should be aware of new developments in the field. As Dr. Ladd prophetically stated in 1935, "Undoubtedly great strides have been made in the field of surgery in the last few years, and I have confidence that greater advances are soon to follow."¹⁹ JAAPA


Michael Sumpter practices in pediatric general surgery at Cardon Children's Medical Center, Banner Pediatric Specialists, Mesa, Arizona. The author has indicated no relationships to disclose relating to the content of this article.


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