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.

Reconstruction of the Lateral Ligaments of the Ankle Using a Periosteal Flap in Children and Teenagers: A Midterm Follow-up Survey.

BACKGROUND: The rate of chronic lateral ankle instability has increased in children and teenagers. However, studies concerning its management within this population are rare. Current repair techniques involve use of the peroneus brevis tendon. Herein, we have described and evaluated a method utilizing a regional periosteal flap for reconstructing the lateral ligaments of the ankle. METHODS: We conducted a single-center, retrospective study over a 4-year period. For functional assessment, we used the American Orthopedic Foot and Ankle Society (AOFAS) score as well as Gould's criteria. For radiologic assessment, we calculated the tibiotalar tilt and anterior translation of the talus. RESULTS: A total of 14 children were included in this study. The mean age of patients was 12.7 years old, and the mean follow-up was 3.1 years. The mean AOFAS score evolved from 61 points (before surgery) to 95 points after surgery (P<0.001). The Gould classification revealed 11 excellent, 2 good, 1 average, and no bad outcomes. Further, surgical intervention led to evolution of the tibiotalar tilt from 14 to 4 degrees (P<0.001), whereas the anterior translation of the talus went from 11 to 2 mm (P<0.001). The mean skeletal age was 12.5 years. No case of epiphysiodesis of the lateral malleolus or heterotopic bone was found. It appears that nonanatomic reconstruction involving the peroneus brevis can be avoided in young patients. Because of the frequent impossibility of ligament suturing within this population, we have developed a reconstruction technique involving the use of a regional periosteal flap. Notably, in the case of recurrence, the patients' peroneus brevis tendons remain intact for future procedures. CONCLUSIONS: Repair involving the periosteal flap yields good clinical and radiologic results. Our preliminary findings are encouraging and suggest that this technique should be evaluated in a larger patient population with long-term follow-up. LEVEL OF EVIDENCE IV: Retrospective study.

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.

Primary repair of sternal cleft with a double osteochondroplasty flap.

Sternal cleft is a rare congenital malformation affecting the anterior part of the chest wall. Surgical closure is recommended. It should be done early during the neonatal period because of the chest's flexibility. Associated abnormalities may have been previously excluded. Different surgical repairs have been described, but none has been proved to be superior to the others. We present the description of 2 cases managed with an original surgical technique. After dissecting the two sternal bars, they were approximated with several intercostal sutures under close cardiac and respiratory monitoring. A double perichondrium flap technique was then used and resulted in a double perichondrium layer. This technique is suitable for most cases and offers satisfying anatomical restoring and cosmetic results.