Robot-Assisted Laparoscopic Fundoplications in Pediatric Surgery: Experience Review.

INTRODUCTION: Laparoscopic fundoplicature for gastroesophageal reflux disease has become the gold standard because of the improvement of postoperative rehabilitation compared with the open procedure. The robot-assisted surgery has brought new advantages for the patient and the surgeon compared with laparoscopy. We studied this new approach and the learning curve. MATERIALS AND METHODS: Sixty robot-assisted fundoplicatures were performed in two university pediatric surgery centers. Data of the patients were recorded, including peroperative data (operation length and complications), postoperative recoveries, and clinical evolution. The learning curve was evaluated retrospectively and each variable was compared along this learning curve. RESULTS: We observed a flattening of the learning curve after the 20th case for one surgeon. The mean operative time decreased significantly to 80 ± 10 minutes after 20 cases. There were no conversions to an open procedure. A revision surgery was indicated for 4.7% of the patients by a surgical robot-assisted laparoscopic approach. CONCLUSION: The robotic system appears to add many advantages for surgical ergonomic procedures. There is a potential benefit in operating time with a short technical apprenticeship period. The setting up system is easy with a short docking time.

A Simulation Model to Support Laparoscopic Pyloromyotomy Teaching.

INTRODUCTION: A key concern regarding laparoscopic pyloromyotomy (LP) lies with the process of learning this skill. The learning processes for open pyloromyotomy and LP appear to be different, with an earlier increased risk of perforation or incomplete pyloromyotomy (IP) for LP. Our aim was to develop a simple simulation tool to reduce these specific complications. MATERIALS AND METHODS: A model of hypertrophic pyloric stenosis was created and inserted into a pediatric laparoscopic surgery simulator. A cohort of experts completed a six-item questionnaire, using a 4-point scale regarding the model's realistic nature and accuracy. Evaluation of the LP procedure was based on a dedicated Objective Structured Assessment of Technical Skills score. Surgical residents and students were enrolled for the final evaluation to assess the relative performance of trainees who had practiced with this model (Group 1) versus those who had observed its use (Group 2). RESULTS: Reproducibility of the model construction was considered to be satisfactory. The experts agreed that the model accurately simulated essential components of LP (mean 3.03 ± 0.7). They scored significantly better than the residents (27.2 ± 1.8 versus 22.8 ± 2.9; P < .001), with a lower rate of complications. Group 1 (39 trainees) performed significantly better than Group 2 (26 trainees), with a significant decrease in the risk of an IP (P < .05). CONCLUSIONS: This model appears to be sufficiently accurate to teach LP. In light of this, it can be considered to be an efficient tool for LP simulation teaching in our fellows' educational program.

Comparison of 8 and 5 mm robotic instruments in small cavities : 5 or 8 mm robotic instruments for small cavities?

INTRODUCTION: Robotic surgery has seen increasing use in the field of pediatric surgery. Our clinical experience suggested instrument size can impact on the surgical ability. This study aimed to compare the performance of robot-assisted laparoscopic skills in confined spaces using either 5 or 8 mm instruments. METHODS: A preclinical randomized crossover study design was implemented. 24 assessors performed three different reproducible drill procedures (M1: peg transfer, M2: circle cutting, M3: intracorporeal suturing). To assess surgical proficiency in confined working spaces, these exercises were performed with 5 and 8 mm instruments of the da Vinci® Surgical Systems Si in a cubic box with 60 mm-sized edges. Each performance was recorded and evaluated by two reviewers using both objective structured assessment of technical skills (OSATS) and global evaluative assessment of robotic skills (GEARS) scores. Parietal iatrogenic impacts and instrument collisions were specifically analyzed using a dedicated scoring system. RESULTS: Regardless of their experience, trainees performed significantly better when using 8 mm instruments in terms of OSATS scores (20.5 vs. 18.4; p < 0.01) and GEARS scores (23.4 vs. 21.9; p < 0.01) for most items, except for "depth perception" and "autonomy." The 8 mm performances involved significantly less parietal box damage (4.1 vs. 3.4; p < 0.01), and tool collisions (4.1 vs. 3.2; p < 0.01). CONCLUSIONS: In light of the better performances with 8 mm tools for specific tasks and parietal sparing constraints in restricted spaces, this study indicates that 5 mm instruments can be deemed to be less effective for reconstructive procedures in small children.

How robotic-assisted surgery can decrease the risk of mucosal tear during Heller myotomy procedure?

We report the first description of robotic-assisted Heller myotomy in children. The purpose of this study was to improve the safety of Heller myotomy by demonstrating, in two adolescent patients, the contribution of the robot to the different steps of this procedure. Due to the robot's freedom of movement and three-dimensional vision, there was an improvement in the accuracy, a gain in the safety regarding different key-points, decreasing the risk of mucosal perforation associated with this procedure.

Differential learning processes for laparoscopic and open supraumbilical pyloromyotomy.

PURPOSE: To compare the learning curves for mastering OP and LP surgical techniques, in terms of effects on completion times and postoperative outcomes/complications. METHODS: A retrospective analysis was performed for 198 patients with hypertrophic pyloric stenosis. The learning curves were in regard to two groups of surgeons: three of whom performed 106 OPs while three others performed 92 LPs. Treatment-related complications were divided into two categories: specific complications relating to the pyloromyotomy and non-specific complications. A logistic regression model with repeated data was used to explore the occurrence of complications. RESULTS: The overall postoperative complication rates were not significantly different between the OP (15.1 %) and the LP (11.8 %) groups. Specific complications were more frequent in the LP group (6.4 versus 2.8 %), while non-specific complications were more frequent in the OP group (12.1 versus 5.3 %). The occurrence of complications exhibited a statistically decreasing risk with each supplementary procedure that was performed (p = 0.0067) in the LP group, but not in the OP group (p = 0.9665). CONCLUSION: From a learning process perspective, laparoscopy is mainly associated with a significantly higher risk of specific complications. This risk decreases in line with the surgeon's level of experience, whereas non-specific complications remain stable in open procedures.

What are the prospects for non-scheduled robotic procedures in pediatric surgery?

Robotic technology allows for the management of complex surgical cases with a minimally invasive approach. The aim of this study was to communicate our experience using robotic technology for non-scheduled pediatric procedures (NSP). We performed a prospective study over the last 5 years including all consecutive cases where surgery was performed with a robot. NSP procedures were defined as a time to surgery of <24 h. Preoperative time, operative time, overall completion rate, and postoperative course were analyzed. Of the 85 cases recorded, five corresponded to robot-assisted NSP with a mean weight of 10 kg (3-36 kg). The mean time before surgery was 19 h (11-24 h). Conversion rate to open procedure was 40 %. Fifteen NSP had to be performed without robotic plateform. Robotic surgery is a potentially relevant option for most pediatric thoracic or abdominal procedures performed in a non-scheduled setting and offers technical advantages.

Assessment of paediatric thoracic robotic surgery.

OBJECTIVES: Many studies have reported that robotic-assisted surgery is safe and feasible for paediatric cases. However, very few paediatric thoracic robotic cases have been described. The aim of this study was to share our preliminary experience with robot-assisted thoracic surgery (RATS). METHODS: We reviewed our first, consecutive thoracic robotic procedures between January 2008 and December 2013. Data describing the perioperative and intraoperative periods were prospectively collected in two surgical paediatric centres and then retrospectively analysed. Operation time, completion rate, length of hospitalization and postoperative complications were compared with thoracoscopic results in the literature. RESULTS: Eleven patients were operated on with the robot, and this included operations for oesophageal atresia (3), mediastinal cyst (4), diaphragmatic hernia (2), oesophagoplasty (1) and oesophageal myotomy (1). The mean age at surgery was 72 (range 0-204) months, and the mean weight was 24.4 (range 3.0-51.5) kg. Three of the operations were converted to thoracotomies. The total operation time was 190 (120-310) min, and the average length of hospital stay was 13 (3-35) days. RATS offers similar advantages to thoracoscopy for mediastinal cyst excision in patients weighing more than 20 kg. Appropriate patient positioning and trocar placement were necessary for neonatal patients and thereby resulted in longer preparation times. Despite cautious adjustments, technical feasibility was reduced for low-weight patients. CONCLUSIONS: These data support mediastinal cyst excision as a suitable indication for larger children. Currently, there is a lack of evidence that lower weight children, and particularly neonates, are good candidates for RATS.

A comparison of robotic surgery in children weighing above and below 15.0 kg: size does not affect surgery success.

BACKGROUND: Initial results in pediatric surgery are encouraging, particularly in the field of pediatric urology. However, there is limited experience with its application in infants and neonates. The aim of this study was to compare the feasibility and safety of robotic-assisted surgery in two populations of children, one weighing less and one weighing more than 15.0 kg. METHODS: A multicentric study was performed comparing the success of robotic-assisted surgery in patients who weighed less than 15.0 kg (group A) to patients heavier than 15.0 kg (group B), with a total of 178 procedures performed between January 2008 and December 2012. Data concerning the perioperative and intraoperative periods were prospectively collected and retrospectively analyzed. RESULTS: The success of robotic-assisted surgery was compared between group A (62 patients, 11.1 kg) and group B (116 patients, 30.2 kg), with a mean follow-up of 37 months (16-75 months). The conversion rate was superior for group A (5 vs. 2%) and involved three neonatal thoracic procedures. Focusing on three common procedures for both groups (pyeloplasty, partial nephrectomy, and fundoplication), the amount of time for set up was longer for group A (p < 0.05). We found no statistical differences in the mean total operative time and length of hospital stay. The postoperative follow-up revealed similar results for both groups. CONCLUSIONS: Cautious adjustments in the patient positioning and trocar placement were necessary in a subset of this pediatric population. For these three particular procedures, with the exception of the longer set up time, the results between the two groups were comparable. These data support the feasibility of robotic-assisted surgery for small children, despite the lack of dedicated instruments.

Neurofibroma and epidermoid cyst: unexpected findings after first foreskin retraction.

We report here 2 unusual cases of tumor of the glans penis in children. Abnormal findings were found on a 12-year-old and a 13-year-old boy soon after their first foreskin retraction. Initial medical examination suggested inclusions of smegma and they were referred to our Department of Pediatric Urology. Complete resection was performed under general anesthesia. Histologic examination revealed an epidermoid cyst in the first patient and a solitary neurofibroma in the second. These patients represent respectively the third and the second cases of such entities described in the pediatric age group. Cautious examination is required for persistent inclusions of smegma.

How to successfully implement a robotic pediatric surgery program: lessons learned after 96 procedures.

BACKGROUND: Both our teams were the first to implement pediatric robotic surgery in France. The aim of this study was to define the key points we brought to light so other pediatric teams that want to set up a robotic surgery program will benefit. METHODS: We reviewed the medical records of all children who underwent robotic surgery between Nov 2007 and June 2011 in both departments, including patient data, installation and changes, operative time, hospital stay, intraoperative complications, and postoperative outcome. The department's internal organization, the organization within the hospital complex, and cost were evaluated. RESULTS: A total of 96 procedures were evaluated. There were 38 girls and 56 boys with average age at surgery of 7.6 years (range, 0.7-18 years) and average weight of 26 kg (range, 6-77 kg). Thirty-six patients had general surgery, 57 patients urologic surgery, and 1 thoracic surgery. Overall average operative time was 189 min (range, 70-550 min), and average hospital stay was 6.4 days (range, 2-24 days). The procedures of 3 patients were converted. Median follow-up was 18 months (range, 0.5-43 months). Robotic surgical procedure had an extra cost of 1934 compared to conventional open surgery. CONCLUSIONS: Our experience was similar to the findings described in the literature for feasibility, security, and patient outcomes; we had an overall operative success rate of 97 %. Three main actors are concerned in the implementation of a robotic pediatric surgery program: surgeons and anesthetists, nurses, and the administration. The surgeon is at the starting point with motivation for minimally invasive surgery without laparoscopic constraints. We found that it was possible to implement a long-lasting robotic surgery program with comparable quality of care.

Dorsal distal radius fractures in children: role of plaster in redisplacement of these fractures.

The aim of this study was to retrospectively identify the role of plaster in redisplacement of dorsal distal radius fracture in children. A total of 60 children with displaced dorsal distal radius fractures were included in this study. All these fractures were reduced under general anesthesia. A total of 22 redisplacements were observed. Statistical analysis was performed to search for risk factors of redisplacement. Poor modeling immobilization of the wrist in the cast, studied by the three-point index was the only significant risk factors for redisplacement. The three-point index is an excellent index to predict redisplacement and assess the quality of the cast treatment of these fractures. The type of study or level of evidence is therapeutic IV.