**1. Introduction**

Pediatric robotic surgery offers unique challenges within this rapidly advancing field. There has been a slow rate of uptake within most pediatric surgical centers around the world due to both finance, and difficulties associated with equipment primarily designed for adults. The ergonomics required for the da Vinci® master–slave-type platform currently challenge the small working space in very small children.

Currently, there are three options for surgical treatment for a wide variety of pathologies in the pediatric population, open surgery (traditional) and MIS, which include: conventional laparo-thoracoscopic surgery and RAS.

Minimally invasive techniques are applicable in more than 60% of abdominal and thoracic operations in children, and according to evidence-based data and ethical principles can be used properly [1].

In 1994, the first robotic system used in the urological practice known as AESOP was introduced. Later, the evolution of these devices would bring the Zeus system and finally the Da Vinci system while continuously increasing their precision and effectiveness [2].

Since these initial reports, robotic surgery has seen widespread application within the adult population, especially in urologic and gynecologic procedures. As is often the case for new devices, technology, and therapeutic options in surgery, the application of robotic surgery for children has occurred more slowly than in adults. This caution is due in part to technical limitations with developing appropriately sized instruments for the pediatric patient; however, in recent years broader implementation has been seen [3–6].

In April 2001, Meininger et al. [7] published the first cases of RAS in children. The first of these two Nissen fundoplication procedures was reported as occurring in July 2000 [7–10]. Shortly afterward, the first robotic urological procedure in a child was undertaken in March 2002 by Peters et al. (personal communication, July 2002) who performed a pyeloplasty using the da Vinci® [11, 12]. Since then to date, more than 70 different surgical techniques have been published [13, 14].

Currently, the only robotic system that is approved for pediatric use is the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) [7]. The da Vinci robot is well suited for children of all ages, including infants and newborns, using careful preoperative planning, this allows the da Vinci to be used for numerous procedures in small children [14, 15].

The evolution of conventional laparoscopic surgery highlights the transitory stages that follow adoption and diffusion of surgical innovation [16–18]. RAS was introduced to the specialty of pediatric surgery following initial case reports in the early 21st century. Subsequently, this promising surgical technology has undergone a formative 10-year period of introduction, development, early dispersion, exploration and preliminary assessment [13].

Cundy et al. [13], performed a 2013 systematic literature search for all reported cases of RAS in children during an 11-year period. During this time, 2,393 procedures in 1,840 patients were reported and the most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively.

Due to the limitations of conventional laparoscopic surgery in pediatric patients, expert pediatric surgeons should only perform the more complex or reconstructive laparoscopic techniques [19].

There have been few reports that have been published about robotic general pediatric surgery [20–29]. Thus, far, the largest number of procedures and publications have been produced about robotic urological pediatric surgery [11–13, 30–45]. Trends in the literature indicate that pediatric RAS is continuing to be globally utilized [11, 13, 30–35, 43–46].

The safety of RAS in children is reported to be similar to open procedures, and the outcomes are at least equivalent to conventional laparoscopy [47]. Robotic surgery on smaller children and infants require special considerations when discussing robotic surgery [48].

Numerous case reports, case series, and comparative studies have unequivocally demonstrated that robotic surgery in children is safe [13].

In systematic investigations of databases of pediatric RAS, the global surgical conversion rate was 4.7% [22], and a net overall surgical conversion rate of 2.5% was reported [13]. In published studies of pediatric RAS, transoperative complications are infrequent, and in the postoperative period, the frequency varies from 0 to 15% [22, 49–51].

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*Robotic-Assisted Minimally Invasive Surgery in Children DOI: http://dx.doi.org/10.5772/intechopen.96684*

surgery and conventional laparo-thoracoscopic surgery [52].

**robotic surgery**

**2.1 Characteristics**

**2.2 Advantages**

tremors are reduced [53].

**2.3 Benefits**

**2.4 Limitations**

capnia and acidosis [61].

paralyzed when the robot is docked [59].

typically be mitigated by adequate volume expansion [60].

**2. Characteristics, advantages, benefits, limitations and applications of** 

In RAS robotic devices are used, such as the Da Vinci system from Intuitive Surgical, which has a miniaturized camera and the surgeon operates seated at a console close to the patient (telesurgery), with three-dimensional and magnified images of the operative field, and manipulates articulated instruments controlled by their hands and feet; It is supported by a second surgeon positioned next to the patient at the exposure of the operative field, with retraction, suction and exchange of instruments in the arms of the robot. There is greater precision than in open

RAS enables more refined hand-eye coordination, superior suturing skills, better dexterity, and precise dissection. It is achieved by the characteristics of robotic surgical platforms that include motion scaling, greater optical magnification, 3D, and stereoscopic vision, increased articulated instrument tip dexterity, tremor filtration, operator-controlled camera movement, and elimination of the fulcrum effect [13], all of this translates into greater safety for patients and advantages for the surgeon. Robotic instruments were specifically designed to mimic human wrist movements, allow 7 degrees of freedom of movement, and can be particularly advantageous for newborns, infants, and young children, as well as, certain hard-to-reach anatomical areas [29, 46]. By operating seated at the console, surgical fatigue and

Robotic enhancements offer improvements in the technical capacity of human performance for surgery within spatially restricted workspaces in children [13]. Less time is required to acquire the right skills and confidence with RAS, "The learning curve is shorter" [46, 54–56]. Robotic assistance will allow more pediatric surgeons to perform a greater volume of minimally invasive procedures [57].

It also has a real benefit for the pediatric patient in terms of: minimizing operative trauma, minimal scarring, less postoperative pain, less need for opioids, less bleeding and transfusions, fewer complications, less risk of infection, shorter hospitalization, and quick return to daily activities, this also benefits parents [46, 47, 58].

There are limitations in RAS, this includes, access to the patient by the anesthesiologist is limited after the robot is docked, changes to patient position or access to the patient requires detachment of the robot, and patients must remain entirely

In addition, RAS frequently requires Trendelenburg or reverse Trendelenburg steeper positioning, which has hemodynamic consequences. This situation can

Infants are typically more susceptible to the respiratory effects of pneumoperitoneum than older children or adults, abdominal insufflation decreases respiratory compliance and increases airway pressures, and the instilled CO2 can cause hyper-
