Innovations in Robotic Technology That Enhance Safety in Pediatric Surgeries

Introduction:

Children are undergoing routine and difficult surgeries, such as cholecystectomy, mediastinal mass or thoracic tumor excision, pulmonary lobectomy, colectomy, proctectomy with ileal pouch, adrenalectomy, and hepatectomy, using robotics. The robotic platform is also being used for procedures like portoenterostomy, congenital diaphragmatic hernia, and choledochal cyst excision, which are typically reserved for children. Although these treatments are effectively carried out, only a few centers can do them. In pediatric subspecialties other than general pediatric surgery, such as urology, robotic surgery is used far more frequently.

What Is a Robot Assisted Surgical System?

A robotic tool used by a surgeon to carry out surgery is known as a robot-assisted surgical system (RAS). Using a viewing screen and controllers, the surgeon can manipulate the robotic arm of the device, which is capable of holding small surgical instruments. To guide each device, the robot interprets in real time the movements of the surgeon's hand, wrist, and fingers.

What Is Da Vinci Surgical System?

Surgeons can execute a wide range of surgeries with the aid of the da Vinci surgical system, including gynecological, urological, head and neck, thoracic, colorectal, cardiac, and general surgeries. Da Vinci requires fewer large incisions, which means that the body will be less traumatized, experience less pain, have fewer difficulties, and have a quicker recovery period.

A da Vinci surgery is when the da Vinci surgical system, a device with four slender robotic arms, is used to perform the surgery. The range of motion of the robotic instruments is greater than that of the human hand. The surgical system allows surgeons to perform numerous procedures.

The three parts of the da Vinci surgical system are:

• The Surgeon Console: The surgeon uses hand and foot controls and a magnified, high-definition, three-dimensional image while operating from a console unit while seated.

• The Patient Cart: The camera and surgical instruments are stored on the cart.

• The Vision Cart: The medical professionals in the room can view what is happening during the procedure thanks to the video screen on this cart.

What Is the Senhance Surgical System?

Senhance surgical robotic system is a novel robotically assisted surgical tool designed to aid in minimally invasive surgery. Surgeons using this robotic platform can remotely control three different robotic arms while seated at a console with a 3D high-definition vision. One of the additional components is an improved eye-sensing camera control that enables the surgeon to manipulate the camera using eye movements. Zooming motions need head movements forward and backward. The surgeon can "feel" tissue stiffness thanks to the system's inclusion of haptic force feedback.

The robotic platform works with a set of reusable, non-wristed 5mm laparoscopic instruments and standard laparoscopic trocars. The console consists of two master laparoscopic controllers, an eye-tracking camera, a control pedal for instrument energy activation, and a 3D high-definition monitor that requires special 3D glasses.

What Are the Advantages of Robotic Surgery?

Robotic surgery has numerous advantages, these include:

• The instruments' range of motion.

• Endoscopic visualization.

• Surgeon ergonomics.

• The advantages of less invasive procedures after surgery.

• Access to difficult-to-reach laparoscopic and even open regions, like the diaphragm, esophageal hiatus, pelvic, and areas requiring substantial and continuous retraction.

• Any robot arm can be locked into position and utilized as a retractor to minimize repositioning and enable optimal exposure.

• Smaller in size incisions.

• Reduced hospital stays.

• Reduced need for painkillers following surgery.

• Improved aesthetic look following surgery.

What Is the Current Use of Robotic Technology in Pediatric Surgery?

1. Heart Surgery:

• Thymectomy (a thymus gland surgical removal procedure).

• Patent ductus arteriosis (a congenital cardiac condition brought on by the ductus arteriosus, a blood channel that connects the pulmonary artery to the aorta, not closing after birth).

• Aortic coarctation (a narrowing of the aorta, which is the body's main artery).

• Arterial septal defect repair (a treatment used to seal a hole in the heart that develops when the tissue that divides the upper two heart chambers, the septum, fails to form correctly).

• Pulmonary artery banding (is a surgical technique used on children with congenital heart disease who have high pulmonary blood flow to limit blood flow to the pulmonary artery).

• Mitral valve repair (is a heart surgical treatment used to address stenosis or regurgitation of the mitral valve).

• Epicardial lead placement (is a process where, after other attempts have failed, a lead is implanted into the left ventricle (LV) of the heart).

2. Pediatric Gynecology:

• Hysterectomy (is uterine excision surgery).

• Elimination of congenital gynecological anomalies.

• Myomectomy (a surgical process to remove leiomyomas, or uterine fibroids, from the uterus).

• Ovarian cyst removal (typically advised if a cyst is big, bothersome, causing symptoms, or if there is a chance it could be malignant).

3. Pediatric Surgery:

• A choledochal cyst (a birth defect of the tube/duct that carries bile from the liver to the small intestine and gall bladder).

• Imperforate anus repair (a surgical technique to fix a congenital condition that obstructs the rectum's ability to pass stool).

• Splenectomy (a surgical technique that involves the partial or whole removal of the spleen).

• Nissen fundoplication (a surgical technique that involves wrapping the upper stomach over the lower esophagus to cure hiatal hernia and gastro-oesophageal reflux disease).

• Gastric tube placement.

• Malone antegrade continence enema procedure (a surgical technique that makes a passageway between the colon and abdomen).

• Cholecystectomy (a surgical technique to remove the gallbladder, a little organ situated beneath the liver in the upper right section of the abdomen).

• Esophageal resection (a surgical treatment to treat benign or malignant esophageal tumors that involves removing all or part of the esophagus).

• Heller myotomy (a surgical method for treating achalasia that entails severing the lower esophageal sphincter's muscles).

• Portoenterostomy (a surgical technique that permits patients with hepatic portoenterostomies to remove their bile).

• Morgagni hernia repair (uncommon congenital diaphragm abnormalities that, if untreated, can cause bowel blockage).

4. Pediatric Urology:

• Varicocelectomy (a surgical technique termed varicoceles to remove enlarged veins inside the scrotum).

• Nephrectomy (the kidney's surgical removal).

• Bladder cuff excision (a difficult aspect of nephroureterectomy, the usual treatment for cancer of the upper tract urothelial cells).

• Urethral sling placement (a surgical method that is less intrusive and cures stress urine incontinence).

• Bladder neck suspension (a surgical treatment used to treat female stress incontinence)

• Orchiopexy (a surgical technique used to treat testicular torsion and undescended testicles that involve moving a testicle into the scrotum).

• Partial nephrectomy (a minimally invasive kidney transplant that preserves the healthy kidney tissue while removing a piece of it).

• Pyeloplasty (a surgical technique to remove obstructions from the tubes that transport urine from the kidneys to the bladder, known as ureters).

• Retroperitoneal lymph node dissection (a surgical technique called retroperitoneum that removes lymph nodes from the rear of the abdomen).

• Urachal cyst excision.

• Ureteral reimplantation (a surgical treatment for reflux, a disorder in which urine from the bladder flows back up into the kidneys).

• Ureterectomy (a surgical operation where a ureter is removed entirely or in part).

• Bladder augmentation (a surgical technique that increases the bladder's size to enhance its capacity to expand and hold pee).

• Mitrofanoff (Appendicovesicostomy).

• Orchiectomy (Intra-abdominal).

• Adrenalectomy (an operation to surgically remove one or both adrenal glands).

What Are the Challenges and Limitations of Robotic Technology in Pediatric Surgery?

• Size of the Patient: The most often mentioned and believed to be a significant barrier to or contraindication for robotic surgery in children is size. Every phase of robotic surgery is affected by the patient's size, which modifies the standard adult protocol. Small patients require considerable modifications to several aspects of robotic surgery, including docking the robot, port placement, robotic arm configuration, instrument size, and interior working space.

• Preoperative Patient Factors: Intraoperative complications may arise due to preoperative patient variables. Bowel distention and inadequate muscular relaxation impede vision, which may result in the switch from robotic to open operations—especially in pediatric patients' already difficult working environments.

• Gastro-intestinal Decompression: Especially in children, it is crucial to avoid excessive or prolonged bag valve oxygenation during intubation, use a nasogastric drainage tube for gastro-intestinal decompression, decompress the bladder with a urinary catheter, and optimize neuromuscular blockade to preserve intraabdominal working space.

What Is the Future of Robotic Technology in Pediatric Surgery?

Implementation obstacles include training, the "learning curve," and the expense of any robotic device. The change from open to laparoscopic surgery involved a significant learning curve for surgeons; the leap from laparoscopic to robotic surgery was less drastic. In pediatric general surgery, laparoscopic surgery is widely used, and the majority of pediatric surgeons carry out a variety of intricate laparoscopic procedures. Surgeons with laparoscopic training are said to acquire comfort and skill quickly when switching from laparoscopic to robotic surgery.

The easiest method to incorporate robotic surgery into practice is to begin with routine, basic cases and gradually progress to more complex ones after receiving training on the robotic system, certification for use, and docking procedures.

Financial investment is necessary for all robotic systems, particularly in free-standing children's hospitals where utilization may be restricted. Robotics may be a shared resource for the centers that collaborate with adult facilities, however securing block time and managing case scheduling present difficult logistical challenges.

Conclusion:

The current status of robotic surgery in pediatric surgery is centered on the necessary technology advancements and the impractical constraints of the current environment. Although the use of robotic surgery in pediatrics has not grown as quickly as it has in adult surgery, it is becoming more common. As this occurs in pediatric robotic surgery, smaller equipment and pediatric-specific setups will be necessary. The development of size-appropriate instruments will be aided by industry activities, which should encourage further advancements in safe, effective, and more widespread robotic surgery for children.