Paediatric robotic surgery: A narrative review

Abstract

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

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Vol.:(0123456789)
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Journal of Robotic Surgery (2023) 17:1171–1179
https://doi.org/10.1007/s11701-023-01523-z
REVIEW
Paediatric robotic surgery: anarrative review
LukasPadraigO’Brien1· EndaHannan2· BriceAntao1· ColinPeirce2,3
Received: 11 July 2022 / Accepted: 2 January 2023 / Published online: 16 January 2023
© The Author(s) 2023
Abstract
The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative
pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the
technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working
angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex
major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of
laparoscopic surgery by offering a stable3-dimensional view, improved ergonomics and greater range of motion. Such
advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller
working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However,
some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an
increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics
within the field of paediatric surgery.
Keywords Paediatric robotic surgery· Paediatric surgery· Robotic surgery· Minimally invasive surgery
Abbreviations
MIS Minimally invasive surgery
RAP Robot-assisted pyeloplasty
UR Ureteral reimplantation
RATS Robot-assisted thoracoscopic surgery
VATS Video-assisted thoracoscopic surgery
Introduction
The advent of minimally invasive surgery (MIS) represents
one of the most important surgical developments of the
modern era and has seen significant growth and develop-
ment over the past 30 years [1]. The benefits of MIS com-
pared with traditional open surgery are well recognised [1].
These include a reduction in post-operative pain, inpatient
length of stay, wound complications, improved cosmesis
and an earlier return to normal activity [2]. MIS techniques
were quickly embraced by adult general surgeons follow-
ing the first adult laparoscopic cholecystectomy in 1987 by
Philippe Mouret [3]. This in turn led to rapid advancements
in complexity of surgery performed by MIS as expertise
and skillset evolved with increasing volume and comfort,
with complex major surgery by MIS now being the gold
standard in adult patients [3, 4]. In contrast to this, utilisa-
tion of MIS in the paediatric community has progressed at a
much slower rate [5, 6]. A significant barrier for paediatric
MIS has been the technical challenge posed by laparoscopic
surgery in small working spaces, where clashing of instru-
ments and restrictive working angles may act as a barrier to
safe dissection [5–7]. Thus, open surgery remains relatively
commonplace in paediatrics, with significant debate exist-
ing over utilisation of laparoscopy even in index operations
such as appendicectomy or inguinal hernia repair [5–7]. Sig-
nificant controversy also exists regarding whether or not a
high-fidelity oncologic resection of childhood malignancy
can be achieved via laparoscopic surgery [6].
The limitations of laparoscopic surgery are well described
[8, 9]. These include an unstable two-dimensional view,
exaggerated tremor, limited ergonomics and reduced
* Enda Hannan
endahannan@rcsi.com
1 Department ofPaediatric Surgery, Children’s Health Ireland
atCrumlin, Dublin, Ireland
2 Department ofColorectal Surgery, University Hospital
Limerick, St Nessan’s Road, Dooradoyle, Limerick,
CoLimerick, Ireland
3 School ofMedicine, University ofLimerick, Limerick,
Ireland
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1172 Journal of Robotic Surgery (2023) 17:1171–1179
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dexterity offered by rigid instruments [8, 9]. Such limita-
tions become even more pronounced in smaller working
spaces, and thus may be more apparent in smaller paediatric
patients [5–7]. Robotic surgical platforms were developed
to overcome the limitations of laparoscopic surgery [10].
This is achieved by offering a stable three-dimensional view,
improved ergonomics, tremor elimination and greater range
of motion [10]. Such advantages may be particularly ben-
eficial in paediatric surgery by empowering the surgeon in
the limited working space of a small abdominal or thoracic
cavity [11]. Despite this, robotic platforms are currently not
widely used in paediatric surgery, with issues relating to
cost, operative time, availability and the lack of dedicated
paediatric equipment being frequently quoted as barriers to
utilisation [11, 12]. The purpose of this article is to provide
a comprehensive and up to date review of the current state
of robotic surgery in paediatric patients.
Urology
Arguably the most significant uptake of robotics within the
realm of paediatric surgery has been witnessed in urology
[13, 14, 99]. This follows a similar trend as seen in adult
surgery [10]. One of the first described robotic operations
performed in children was a pyeloplasty for pelviureteric
junction obstruction performed by Peters etal. in 2002 [13,
15, 16]. In this case, the author specifically noted that the
robot platform was favourable due to the significant tech-
nical challenge in creating a ureteropelvic anastomosis by
means of conventional non-articulating laparoscopic instru-
ments [15]. Following this, a wide range of urological pro-
cedures have been performed using robotic platforms in the
paediatric population, including ureteral reimplantation, ure-
teroureterostomy, appendicovesicostomy, nephrectomy and
nephroureterectomy [17]. In 2018, a bibliometric analysis by
Cundy etal. categorised 151 publications reporting on 3688
paediatric robotic urological procedures performed in 3372
patients from 2003 to 2016 [17]. This analysis revealed that
the most common application was pyeloplasty (n = 1923)
followed by ureteral reimplantation (n = 1120), with these
two procedures dominating the literature (83%) [17].
Robotic‑assisted pyeloplasty (RAP)
The first paediatric laparoscopic pyeloplasty was per-
formed in 1995, at which point the technique was noted to
be highly technically challenging with a very steep learn-
ing curve due to the challenge of intracorporeal suturing
in a restricted working space [18, 19]. Following the first
paediatric RAP by Peters etal. in 2002, the inherent ben-
efits of the robotic platform for this procedure became
apparent, with a three-dimensional view and articulating
instruments anecdotally allowing for greater precision in
suturing and anastomosis formation [15, 20]. Numerous
authors have subsequently reported a shorter learning
curve for RAP compared with a laparoscopic approach
[14, 21]. In most studies, success rates of greater than
90% have been widely reported with the technique [19].
In 2014, a meta-analysis of 12 retrospective studies that
compared RAP with open and laparoscopic techniques was
published [22]. This demonstrated a higher rate of suc-
cess in RAP compared to laparoscopic pyeloplasty and
equivalence with open surgery. No difference in complica-
tion rates or re-operation was observed between the three
modalities. As is frequently observed in robotic literature,
RAP was associated with greater cost and a longer opera-
tive time. However, a statistically significant reduction in
inpatient length of stay was demonstrated in RAP [22].
In 2016, a multicentre study comprising of 575 patients
demonstrated a shorter hospitalisation period and reduced
post-operative complication rate in RAP compared to lapa-
roscopic pyeloplasty [23]. A further multicentre experi-
ence with 2219 patients also supported that RAP resulted
in a statistically significant reduction in length of stay
compared to open and laparoscopic surgery with otherwise
equivalent post-operative outcomes [24]. Further studies
have consistently reported that RAP have a shorter hos-
pital stay but longer operative times [15, 21]. RAP has
also proven successful in small infants, with two studies
examining its application in patients under 10kg show-
ing success and complication rates equivalent with open
surgery [18, 25].
Ureteral reimplantation (UR)
UR is performed for the treatment of vesicoureteral reflux
(VUR) [13]. While the standard operative approach has
been by open surgery, UR now represents the second most
commonly performed paediatric robotic procedure, with
81% of minimally invasive implantation procedures per-
formed utilising the robotic platform [13, 26, 27]. Sev-
eral published studies describe this technique as safe and
effective. Kasturi etal. demonstrated resolution of VUR
in 99.3% of patients, while a case-matched study by dem-
onstrated equivalent outcomes with open surgery (97% vs
100%) [28, 29]. One multicentre study comprising of 260
patients across 9 institutions reported a VUR resolution
rate of 87.9% and an overall complication rate of 9.6%,
equivalent with open outcomes [30]. A further prospective
study demonstrated a 93.8% rate of radiographic resolution
of VUR [31]. Marchini etal. also reported no significant
difference in post-operative outcomes when compared
with open surgery [32]. A reduced length of stay and post-
operative pain is also widely reported [29, 33].
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1173Journal of Robotic Surgery (2023) 17:1171–1179
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Nephrectomy
In paediatric urology, partial or complete nephrectomy
is most commonly indicated for benign disease rather
than malignancy and is most commonly performed by
open approach [34]. Of those performed by MIS, con-
ventional laparoscopic approach remains more common
than robotic surgery [34]. In 2019, a two-centre study
comparing open, laparoscopic and robotic approaches
demonstrated comparable post-operative complication
rates between all groups [35]. Unsurprisingly, an open
approach was associated with greater post-operative pain,
while both laparoscopic and robotic surgery had signifi-
cantly longer operative times [35]. When directly com-
paring robotic and laparoscopic approaches, Malik etal.
demonstrated equivalent lengths of stay and incidence
of complications [36]. Two subsequent series of robotic
nephrectomies reported the incidence of complications at
8.3% and 9.5% respectively, comparable with published
laparoscopic and open outcomes [37, 38].
Miscellaneous
Paediatric ureteroureterostomy is performed for a num-
ber of indications, including obstructed ureterocoele or
duplex systems with an upper pole ectopic ureter [13]. A
small number of case series report on successful robotic-
assisted ureteroureterostomy [39–42]. One study, which
made comparison with an open cohort, concluded that
operative times and complication rates were compara-
ble with a shorter length of stay for robotic cases [42].
Reconstructive bladder surgery, such as the ‘Mitrofanoff’
appendicovesicostomy, has also been demonstrated to be
safe and feasible when performed by a robotic approach,
with Grimsby etal. showing no difference in complication
rates [43]. Successful cases of robotic excision of blad-
der diverticulum, prostatic utricles, varicocoele, seminal
vesicle cyst, posterior urethral diverticulae and urachal
cyst have all also been described in case reports and small
case series [13, 44–46].
Currently, the robotic paediatric urology approach
appears to offer similar outcomes and complication rates
to open and laparoscopic approaches [13, 14, 99]. When
compared directly with open surgery, robotic approaches
appear to offer shorter lengths of stay and reduced postop-
erative pain [14]. Robotic paediatric urology does appear
to come with greater cost and operative time, but is advan-
tageous in procedures that require intracorporeal sutur-
ing, such as pyeloplasty [13–15]. As with adult urology,
procedures that require access to the pelvis and thus have
a narrow operative field may be particularly suited to the
robotic approach [13].
General surgery
Robotics have not yet reached the level of utilisation in pae-
diatric general surgery that has been observed in paediatric
urology [13, 14, 47]. Nonetheless, it is the field within which
there has been the second greatest uptake of robotic technol-
ogy in paediatric surgery [13, 14, 47]. The most common
applications of the robot in paediatric general surgery have
been in gastric fundoplication and choledochal cyst excision
[13, 14, 47]. As both of these procedures demand precise
intracorporeal suturing, robotic platforms may render this
less challenging than utilising rigid non-articulating laparo-
scopic instruments in a restricted working space [47]. Other
robotic procedures that have been described in the literature
include hepatectomy, colectomy, proctectomy with ileal
pouch-anal anastomosis, resection of mediastinal masses
and congenital diaphragmatic hernia repair [14, 47].
Gastric fundoplication
Fundoplication is the most commonly performed and
reported robotic procedure in paediatric general surgery [14,
48]. In 2014, Cundy etal. published a meta-analysis compar-
ing outcomes in robotic versus conventional laparoscopic
fundoplication in children. Here, it was observed that laparo-
scopic procedures had a greater tendency towards conversion
to open surgery than robotic surgery (6.1% vs 3%) while
the incidence of post-operative complications was equiva-
lent between the two cohorts; however, all included studies
were limited by a lack of long-term follow-up [49]. A prior
systematic review that compared 89 robotic fundoplications
with 85 laparoscopic procedures showed a statistically sig-
nificant reduction in post-operative complications in robotic
cases, albeit with a longer operative time [50]. The authors
theorised that the reduced complications may be a result of
greater dexterity and precision within the subphrenic space
[47, 50]. It has also been suggested that robotic surgery may
be advantageous in challenging cases, such as those in obese
patients, large hiatal defects and in cases of redo fundopli-
cation, which are all recognised as being highly technically
demanding with conventional laparoscopic approaches [47,
51, 52].
Choledochal cyst excision
Minimally invasive hepatobiliary surgery in children, such
as choledochal cyst resection with Roux-en-Y hepaticojeju-
nostomy, is highly challenging and requires high levels of
precision [53]. For this reason, it is unsurprising that many
still elect to perform such procedures by open techniques
[53]. In described laparoscopic techniques, anastomosis is
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1174 Journal of Robotic Surgery (2023) 17:1171–1179
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often performed in an extracorporeal manner by extension of
the umbilical incision, which may have a detrimental impact
on the recovery benefits offered by MIS [53]. The ergonomic
advantages and stability offered by a robotic platform may
facilitate intracorporeal anastomosis in a manner that is not
feasible by laparoscopic surgery and thus, limit the need for
bowel exteriorisation [54]. This is an opinion which has been
expressed by many with experience in both laparoscopic and
robotic approaches [54–57]. Kim etal. retrospectively com-
pared open and robotic techniques, concluding that there was
no difference in the incidence of post-operative complica-
tions [58]. A shorter length of stay was noted in the robotic
cohort, albeit with a statistically significant increase in oper-
ative time [58]. It is also important to note that those in the
robotic group were significantly larger in size and of an older
age, perhaps suggesting a larger workspace more favour-
able for MIS [58]. However, Dawrant etal. did demonstrate
that a robotic approach was feasible in smaller children in
a series of patients under 10 kg [59]. In 2018, Wang etal.
published a review article that analysed a combined 86 cases
from 8 studies, demonstrating a postoperative complication
rate of 11.6% and conversion rate of 8.1% [60]. While this
study lacked a control group, these outcomes would appear
similar to those reported in open and laparoscopic modali-
ties, with the added advantage of facilitating intracorporeal
reconstruction [53].
Surgical oncology
While robotics is widely used in adult oncological surgery,
open techniques currently remain the standard of care for
resection of paediatric abdominal tumours, with a lack of
high-level evidence supporting the relatively recent develop-
ment of robotic approaches [13, 47, 47]. Despite this, there
does exist a wide range of literature mostly in the form of
individual case reports or small case series. One case of
successful robotic resection of a stage IV neuoroblastoma
has been reported, with the authors noting that the enhanced
vision and precision of the robotic platform allowed for skel-
etalisation of tumour vasculature that may not have been fea-
sible laparoscopically [61]. Another case described the man-
agement of a 4cm juvenile cystic adenomyoma by a robotic
approach in a 15-year-old girl, with improved ergonomics
allowing for four-layered closure of the uterus, followed
by an uneventful post-operative recovery [62]. Anderberg
etal. also reported on a robotic radical cystoprostatectomy
for management of rhabdomyosarcoma in a 22-month old
child weighing 8kg, with the robot proving advantageous
in the confines of the paediatric bony pelvis [63]. Successful
robotic partial adrenalectomy for phaeochromocytoma in a
child has also been described [64].
A common theme discussed in many of these cases is
the advantages offered by a robotic approach to extended
lymph node dissection resulting from enhanced 3-dimen-
sional vision [13, 61–64]. A recent case series of 12 robotic
resections of paediatric abdominal tumours concluded that
oncological surgical principles were maintained by this
approach, with all achieving R0 resection status, low post-
operative morbidity and good long-term results. The authors
concluded that robotic surgery brings potential benefits to
children with cancer but its place and indications still need
to be better defined [65]. Concerns regarding the adherence
to sound oncological principles, with clear resection margins
and avoiding tumour spillage, have been raised in relation
to paediatric robotic surgery, with some theorising that the
loss of haptic feedback affecting the surgeon’s ability to dif-
ferentiate between tumour and normal tissue [13, 47]. How-
ever, it has equally been suggested that improved vision may
compensate for this loss in tactile feedback [63]. Ultimately,
long-term data are required to demonstrate whether onco-
logical outcomes in paediatric robotic surgery are acceptable
and this data is not currently available [47]. However, a well-
recognised contraindication for laparoscopy in paediatric
malignancy is large or fragile tumours that pose high risk of
tumour spillage or fracture, and this should be respected in
regard to robotic approaches also [47].
Miscellaneous
Robotic cholecystectomy has been well described in pae-
diatric literature, including both single-port and multi-port
approaches, with the consensus that it is safe and effective,
albeit costly and time-consuming [66–68]. Given that this
offers no true benefit to a laparoscopic approach, it is diffi-
cult to advocate for routine robotic cholecystectomy [66–68].
Nonetheless, robotic cholecystectomy serves a valuable role
as an introductory procedure for paediatric surgeons that
wish to develop a robotic skillset and is widely supported as
a training operation [66–68]. Similarly, while robotic sple-
nectomy has been shown to be safe and effective, it offers
no demonstrable benefit to the quicker and cheaper laparo-
scopic approach [69]. Conversely, it has been demonstrated
that a robotic approach to Heller’s myotomy in children may
be advantageous to laparoscopic surgery by a lower risk of
inadvertent mucosal perforation [70, 71].
Similarly, it has been suggested that the robot may be
advantageous in gynaecological surgery, with improved
vision and ergonomics in the narrow bony pelvis in cases of
paediatric ovarian tumours [72, 73]. The precision offered
by robotics has also been suggested to be beneficial in main-
taining ovarian morphology where possible, especially in
benign disease, thus allowing for recovery in post-operative
ovarian function [47, 73]. The advantages offered by the
robot in pelvic dissection have also been reported in cases of
robotic anorectal pull-through for anorectal disorders [74].
Robotics have also been demonstrated to be beneficial in
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1175Journal of Robotic Surgery (2023) 17:1171–1179
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the management of Hirschsprung’s disease, with a recent
prospective series of robotic Soave pull-through procedures
in patients under 12months demonstrating low morbidity,
a short inpatient length of stay and acceptable long-term
outcomes [75].
Another example in the literature where robotic platforms
have allowed paediatric surgeons to overcome limitations
of laparoscopy is in the management of superior mesen-
teric artery syndrome by means of Roux-en-Y duodenoje-
junostomy [76]. In this case, the authors note that a robotic
approach facilitated safe intracorporeal anastomosis in a
manner that would be highly challenging laparoscopically
[76].
Cardiothoracic surgery
In the context of thoracoscopic surgery in children, which
has continued to evolve over the past 3 decades, paediatric
robotic-assisted thoracic surgery (RATS) is in its relative
infancy, with significantly less published literature than in
both urology and general surgery [13, 14, 47]. Nonetheless,
early reports have been promising, with a reduction in learn-
ing curve noted in RATS compared with thoracoscopic sur-
gery [47]. The recovery benefits of minimally invasive tho-
racic surgery are well documented, and it has been reported
that MIS also reduces risk of spinal and thoracic deformity
in children following lung resection [47].
Thoracic surgery
Lobectomy is the most widely reported RATS in paediat-
ric patients. First described in 2006, multiple case series
with modest patient cohorts have since shown equivalent
post-operative outcomes with thoracoscopic surgery and a
quicker postoperative recovery than open surgery, albeit with
a prolonged operative time than both approaches [77–79].
Successful cases of robotic congenital diaphragmatic hernia
repair, both via thoracic and abdominal approaches, have
been reported, with the authors stating preference for a
robotic approach over thoracoscopic and laparoscopic tech-
niques, which render satisfactory closure of the diaphrag-
matic defect challenging [80]. Other successfully described
RATS procedures include thymectomy for treatment of
myasthenia gravis, resection of bronchogenic cysts and tra-
cheopexy for tracheomalacia [81–83]. A consistent theme
in RATS literature, however, appears to be equivalent out-
comes to thoracoscopic surgery albeit with a longer opera-
tive time, although many authors anecdotally note improved
ergonomics and a shallower learning curve [47, 77–83]. In
one series of 11 patients, it was noted that the neonatal tho-
rax represented an obstacle in adapting 5mm or 8mm ports
required for most robotic platforms, with the conclusion that
RATS should be reserved for patients weighing more than 20
kg [84]. With regard to the management of thoracic tumours,
it has been noted that the robot may be well adapted to the
required intricate mediastinal dissection for a safe minimally
invasive approach, with the authors of one series noting that
RATS allowed for better visualisation of the tumour and
its anatomic connections than typically experienced even in
open surgery [85].
Cardiac surgery
Currently, experience with robotic platforms in the manage-
ment of cardiac conditions is limited. In one study, which
examined RATS for the division of congenital vascular
rings, the conclusions was that while both safe and effective,
RATS offered no demonstrable benefit to video-assisted tho-
racic surgery (VATS) [86]. Similarly, in a retrospective study
of paediatric patients with patent ductus arteriosus, RATS
was noted to take longer than VATS without any difference
in post-operative outcomes [87]. Hassan etal. described a
case of robotic excision of a left ventricular myxoma in a
child, concluding that the technique is safe and feasible [88].
Ear, nose andthroat surgery
The most frequent application of robotics in otorhinolaryn-
gology has been in transoral approaches which have proved
beneficial in accessing base of tongue lesions in a manner
that limits morbidity and improves cosmetic outcomes [47,
89]. Typically, access to the oropharynx would require phar-
yngotomy or division of the lip and jaw [89]. The robotic
transoral approach avoids the potential disfigurement and
pain associated with such access [89]. A case series consist-
ing of 41 paediatric patients managed by a robotic transoral
approach for a variety of indications, including oropharyn-
geal sarcoma and laryngeal cleft cysts, showed encouraging
results, with more than 90% of cases completed successfully
without conversion and low post-operative morbidity [90].
While still a relatively novel approach, it has been suggested
that robotic transoral surgery may become the standard of
care for base of tongue lesions [90].
Neurosurgery
The utilisation of robotic technology in neurosurgery has
been described in the form of the robotised stereotactic
assistant, or ROSA®, whereby a computer-controlled robotic
arm with an integrated platform that combines image-guided
neurosurgical planning software with robotic navigation to
assist neurosurgeons with minimally invasive procedures,
such as deep brain stimulation lead placement, stereotactic
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1176 Journal of Robotic Surgery (2023) 17:1171–1179
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biopsies, laser ablation of epileptogenic foci, endoscopic
third ventriculostomy and electrode placement for seizure
monitoring [91]. ROSA® has generated particular interest
in the paediatric population. As a child’s developing brain
is extremely vulnerable to injury, an accurate image-guided
minimally invasive approach to paediatric neurosurgery is
highly desirable [91]. The largest published case series, con-
sisting of 123 children managed with ROSA® for a variety
of indications, showed a high rate of success (97.7%) with
low post-operative morbidity (3.9%). No patients in this
series experienced any long-term neurological deficit [92].
The robot has seen similar applications in paediatric spi-
nal surgery, where it plays a role in accurate placement of
surgical prostheses supported by image-guided software
[93]. A recent development has been the management of
idiopathic scoliosis in children by robotic-assisted placement
of pedicle screws [93]. It has been demonstrated that this
utilisation of robotic technology can reduce the incidence
of pedicle malposition, a complication seen more commonly
in paediatric populations owing to a smaller size of pedi-
cle and target location than in adults [93, 94]. Incidence of
pedicle screw malposition has been reported to be as high as
17.9% previously, but with image-guided robotic assistance,
an accuracy of 97.6% in screw placement has been demon-
strated in a recent literature review [93].
Benets andlimitations
Benefits
All of the benefits that laparoscopic surgery offer in com-
parison to open surgery also apply to robotics, with reduced
post-operative pain, reduced opioid requirements, improved
cosmesis, a shorter inpatient length of stay, reduced wound
complications and a faster return to normal activities [2].
However, advocates of robotic surgery argue that the
inherent characteristics of the robotic platform allow it to
supersede the minimally invasive capabilities of traditional
laparoscopic surgery [47]. Robotic instruments have been
specifically designed to emulate the range of movements
possible with a human wrist, as opposed to the restricted
movements available with standard long, rigid laparoscopic
instruments that are incapable of bending [10, 11]. This
enhanced dexterity may be particularly advantageous in the
reduced working space of smaller paediatric patients, mak-
ing steps such as intracorporeal suturing or anastomosis pos-
sible in a way that may either be technically impossible or
highly challenging with laparoscopic instruments [5–7]. Fur-
ther to this, robotic platforms are equipped with motion scal-
ing, which acts to reduce the scale of the surgeon’s move-
ments 5:1, allowing for greater precision in smaller cavities
[47]. It has also been suggested that robotic surgery may
offer a gentler learning curve than traditional laparoscopic
surgery [94, 95]. This has been attributed to the symmetrical
movements of robotic instruments with the surgeon’s hands,
unlike laparoscopy that requires inverted movements [47].
Rapidly decreasing operative times in robotic surgery with
experience have been widely observed [94, 95].
Clear visualisation of paediatric anatomy can prove
highly challenging with traditional laparoscopic cameras,
where an unstable two-dimensional view not controlled
by the primary surgeon may create a barrier to clear iden-
tification of critical structures and planes [8, 9]. Even in
traditional open surgery, paediatric surgeons may struggle
with visualisation, with the use of surgical loupes often
required [47]. Robotic platforms are capable of magnifying
images between 10 and 15 times, which is further enhanced
by 3-dimensional vision, tremor elimination and operator-
controlled views [47]. This yields steadier and more precise
visualisation with enhanced depth perception [47].
Limitations
Frequent points of criticism aimed at robotic surgery have
been in relation to both an increased cost of surgery as well
as a longer operating time compared to traditional laparo-
scopic surgery, and these points are equally applicable in
the realm of paediatric robotic surgery [11, 12]. A variety of
factors contribute to a longer operative time in robotic sur-
gery, including time spent with setup of the robotic platform
and for troubleshooting; it has been shown that this shortens
significantly with time and experience [95]. A disadvantage
of robotic surgery specific to paediatrics relates to the size
of the surgical robotic platforms and associated instruments
[47]. Robotic instruments approved for paediatric use are
usually only available in two sizes (8mm and 5mm), both
of which are larger than 3mm instruments typically used
in laparoscopic procedures for smaller paediatric patients
[47]. Similarly, robotic cameras typically exist in 12mm
and 8mm sizes, with a previously utilised 5mm endoscope
having been discontinued due to low utilisation [96]. While
the 8mm endoscope may be appropriate in many paediatric
patients, it is possible that this is prohibitively large in some
children, particularly in cardiothoracic surgery where the
port must fit between the confines of the intercostal space
[47, 97]. It is also recommended for the da Vinci platform
that ports be placed 6–10cm apart, which may be difficult
to achieve in small children [96].
The Senhance platform (Transenterix) does have 3mm
instruments available, and while this has not yet been
approved for use in paediatric patients, laboratory based
experimentation utilising these instruments within boxes
designed to mimic the dimensions of paediatric abdomens
have shown that high precision tasks, such as intracorporeal
suturing and knot-tying, have been achievable in cavities
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1177Journal of Robotic Surgery (2023) 17:1171–1179
1 3
with a volume as small as 90 ml [98]. This platform also
allows for direct insertion of these 3mm instruments into
the abdomen without ports, reducing the necessary distance
between insertion points [14]. The Senhance platform also
offers haptic feedback [98].
Conclusion
This review demonstrates the use of robotic platforms for
paediatric surgery as an exciting and promising develop-
ment that may allow children to benefit from the advantages
of MIS, particularly in cases where the limitations of rigid
laparoscopic instruments are prohibitively restrictive in the
smaller working spaces found in children. Particular interest
in robotic techniques has been observed in paediatric urol-
ogy and general surgery, where the ergonomic advantages
prove advantageous in procedures that require intracorporeal
suturing and anastomosis. It is evident from this review that
paediatric robotic surgery is currently still in its infancy,
with larger and more robust prospective studies needed to
truly ascertain the benefits and limitations of this approach
in comparison to open and laparoscopic surgery. Nonethe-
less, paediatric robotic surgery offers great potential to allow
a young and very vulnerable patient cohort to benefit from
the advantages of MIS supported by the improved ergonom-
ics and dexterity afforded by robotics in reduced working
spaces.
Author contributions LOB: initial literature review, draft, and submis-
sion.EH: manuscript review and edits.BA: manuscript review and edits.
CP: manuscript review and edits.
Funding Open Access funding provided by the IReL Consortium. No
funding was received for the purposes of this study.
Declarations
Conflict of interest The authors declare no conflicts of interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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