Shifting from Conventional Minimally Invasive Surgery to Robotic Surgery

Robotic surgery has been introduced into clinical practice in the late 1990s to overcome well-recognized limitations of the conventional minimally invasive approach, including two-dimensional imaging, restricted range of motion of the instruments, hand tremors, and poor ergonomic positioning of the surgeon. Since then, robotic surgical systems have rapidly evolved and are used for an increasing number of complex minimally invasive surgical procedures [1–6]. Historically, new surgical techniques have had a more difficult and slower acceptance by the pediatric surgical community compared to the adults’ one. Indeed, small spaces and anesthesiological management have limited the use of these technologies. In the pediatric age, robotic surgery has been accepted and utilized by a small number of pediatric surgeons around the world. Since the first reported case in a child in April 2001, the use of robotic technology has rapidly expanded within pediatric surgery. During the last decade, it has successfully been applied to a large variety of gastrointestinal, genitourinary, and thoracic procedures in infants and children, thus demonstrating the safety and feasibility of this approach. The number of pediatric robotic procedures performed per year using this emerging method is growing rapidly, with no evidence that this will change in the future. The early functional outcomes of robotic procedures are promising; however at present, most of the comparative studies are from single institutions, and lack a high level of evidence. Although increasing numbers of larger pediatric robotic surgery case series have been published over the years, authors mainly focused on the comparison with open surgery. However, in order to identify potential advantages of a particular type of robotic procedure over the corresponding conventional laparoscopic or thoracoscopic approach, comparative studies providing evidence-based information are needed [6–10]. Performing robotic surgery in pediatric patients requires a complete new redesigned concept of the surgical techniques and modifications in the surgical operating room. The introduction of this innovative technology brings new advances in instrumental maneuverability, and better optics. However, robotic surgery also brings new challenges and limitations that will require improvement in the future. The successful transition from laparoscopy to robotic surgery requires some steps. These include developing a specific robotic team that should be well informed on setting up the robot and can deal with intraoperative problems. Another task of the team is to ensure that the surgeon has spent sufficient time on the robot to be familiar and proficient, and to help in the selection of patients, thus avoiding difficult cases in the beginning. During the first procedures it is important to have sufficient time so that no one is rushed or harassed by lack of time, and, of course, to make sure that a proctor is present. Finally, when the surgical session is over, a debriefing with the whole team will minimize problems, develop enthusiasm for this new technology, and allow checklists and protocols to be developed. With these simple steps, this transition can be performed relatively painlessly [11].