**6. Oncologic robotic surgery**

Presently, the use of MIS in patients with cancer is progressing. However, the role of MIS in children with solid neoplasms is less clear than it is in adults. Although the use of diagnostic MIS to obtain biopsy specimens for pathology is accepted in pediatric surgical oncology, there is limited evidence to support the use of MIS for the resection of malignancies (solid tumors) in the thorax and abdomen in children [150].

Open surgery remains the main technique for the resection of solid tumors in children. RAS offers technical and ergonomic advantages that can make MIS more achievable in this environment, allowing benefits for both the patient and the surgeon. Reduced postoperative recovery time and faster initiation of adjuvant therapy are the most important benefits for the patient [104].

A systematic search of multiple electronic databases, of 23 publications, reported 40 cancer cases in total. The indications for surgery were more than 20 different pathologies. One third of the tumors were malignant. Most of the procedures involved abdominal or retroperitoneal tumors in adolescent patients. Oncological adverse events were two isolated events, one tumor spillage and one residual disease. The evidence is limited to case reports and small case series only. Pediatric cancer surgery is an area of opportunity for robotic surgery. Its technical challenges create the opportunity to develop robotic approaches that meet the challenges of complex cancer procedures [151].

#### **6.1 Thoracic tumors**

As an anecdote, the robot appears to be well adapted to complex mediastinal dissection and has been used in excision of left ventricular myxoma [152], and in excision of complex massive leiomyoma of the esophagus [153]. The robot offered

**39**

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

surgical principles should be applied [154].

postoperative period was uneventful [157].

lymph node dissection is suitable [159].

node dissection [160].

**6.2 Abdominal tumors**

cal surgery in children.

neuroblastoma [155, 156].

excellent visualization and ease of resection. The other case of complex massive retrocardiac esophageal leiomyoma was successfully removed using RAS. In the latter case, intraoperative esophagoscopy and transillumination were useful adjuncts to identify the esophagus and develop a safe extramucosal dissection plane.

There is a publication with five pediatric patients with a mean age of 9.8 years and weight of 41.5 kg, who underwent robotic resection of a mediastinal thoracic mass, including a ganglioneuroma, ganglioneuroblastoma, teratoma, germ cell tumor, and a large inflammatory mass of unclear etiology. The application of RATS in malignant solid tumors in children in selected cases is an option, but oncological

There are mostly individual case reports for robot-assisted abdominal oncologi-

Juvenile cystic adenomyoma is the focal presence of ectopic endometrial glands and stroma within the uterine myometrium. Another case, a 15-year-old adolescent girl underwent RAS of a 4 cm cyst, and the uterus was closed in four layers, the

Management of rhabdomyosarcoma. A 22-month-old, 8-kg boy with an embryo-rhabdomyosarcoma in the urinary bladder and prostate, the treatment was a robot-assisted radical cystoprostatectomy, and the postoperative course was uneventful [158]. Another application of RAS is in the dissection of retroperitoneal lymph nodes in selected pediatric and adolescent patients with paratesticular rhabdomyosarcoma or germ cell tumor of the testicle, a report of a case of each of these conditions, they were treated with good results. The robotic approach to extended

Robotic partial nephrectomy has been reported in appropriately selected children with renal cell carcinoma. However, there are limited reports of laparoscopic or robotic partial nephrectomy for cancer surgery in children. RAS allows for an oncologically sound resection of partial nephrectomy, as well as extended lymph

Robotic adrenalectomy is an increasingly used procedure in patients with a variety of surgical adrenal lesions, including adenomas, aldosteronomas, pheochromocytomas, and adrenal gland metastases. Emerging literature also supports the role of RAS in partial adrenalectomy [161]. With robotic partial adrenalectomy,

RAS is an emerging technique for the treatment of pancreatic neoplasms. Robotic spleen-preserving distal pancreatectomy for a solid pseudopapillary tumor in pediatric patient, can be considered in younger patients presenting with a solid pseudopapillary tumor in the distal pancreas, and its use as an alternative to open pancreatectomy [163]. A report with 15 adolescents with pancreatic head tumor treated with MIS. Pancreaticoduodenectomy was performed, 10 cases with conventional laparoscopic surgery and 5 cases with RAS. The pathological diagnoses were solid pseudopapillary neoplasms (8), neuroendocrine neoplasms (3), intraductal papillary mucinous neoplasm (1), cystic fibroma (1), serous cystadenoma (1), Ewing's sarcoma (1). Six patients presented postoperative complications. The median follow-up was 37 months. The patient with Ewing's sarcoma was diagnosed

successful preservation of adrenocortical function is achieved [162].

Neuroblastoma is the most common extracranial solid tumor in children and the most common malignancy in infants. Complete resection is curative in low-stage disease. Robotic surgery can skeletonize abdominal blood vessels in the tumor and cut the tumor into pieces, including stage IV retroperitoneal *Robotic-Assisted Minimally Invasive Surgery in Children DOI: http://dx.doi.org/10.5772/intechopen.96684*

excellent visualization and ease of resection. The other case of complex massive retrocardiac esophageal leiomyoma was successfully removed using RAS. In the latter case, intraoperative esophagoscopy and transillumination were useful adjuncts to identify the esophagus and develop a safe extramucosal dissection plane.

There is a publication with five pediatric patients with a mean age of 9.8 years and weight of 41.5 kg, who underwent robotic resection of a mediastinal thoracic mass, including a ganglioneuroma, ganglioneuroblastoma, teratoma, germ cell tumor, and a large inflammatory mass of unclear etiology. The application of RATS in malignant solid tumors in children in selected cases is an option, but oncological surgical principles should be applied [154].

## **6.2 Abdominal tumors**

*Latest Developments in Medical Robotics Systems*

**5.4 Other robotic thoracic procedures**

resection of a bronchogenic cyst [148, 149].

are the most important benefits for the patient [104].

lenges of complex cancer procedures [151].

**6. Oncologic robotic surgery**

in children [150].

**6.1 Thoracic tumors**

with RATS [14, 139].

**5.3 Thymectomy**

patients [142].

Acquired anomalies, such as diaphragmatic paralysis, can also be resolved

Radical thymectomy is the comprehensive treatment of myasthenia gravis. The feasibility and effectiveness of robotic thymectomy is evident in this cohort study [140]. In addition, performing the "early thymectomy" (performed within a year of diagnosis) resulted in higher remission rates compared to "late thymectomy" [141], including minimizing the adverse effects of immunosuppression in pediatric

In recent studies including 49 children, thoracoscopic thymectomy was also safe for children with juvenile myasthenia gravis (JMG) [143, 144]. Two other studies with 9 and 18 children, reported the same results [145, 146]. Robotic thymectomy is a safe procedure, complications were low, and without mortality. Thymectomy should be offered as a part of multimodal therapy for treating children and adolescents with acetylcholine receptor antibody-Positive JMG [146].

There are RATS publications of other specific procedures, such as tracheopexy for the treatment of severe tracheomalacia [147], and reports of pediatric cases of

Presently, the use of MIS in patients with cancer is progressing. However, the role of MIS in children with solid neoplasms is less clear than it is in adults. Although the use of diagnostic MIS to obtain biopsy specimens for pathology is accepted in pediatric surgical oncology, there is limited evidence to support the use of MIS for the resection of malignancies (solid tumors) in the thorax and abdomen

Open surgery remains the main technique for the resection of solid tumors in children. RAS offers technical and ergonomic advantages that can make MIS more achievable in this environment, allowing benefits for both the patient and the surgeon. Reduced postoperative recovery time and faster initiation of adjuvant therapy

A systematic search of multiple electronic databases, of 23 publications, reported 40 cancer cases in total. The indications for surgery were more than 20 different pathologies. One third of the tumors were malignant. Most of the procedures involved abdominal or retroperitoneal tumors in adolescent patients. Oncological adverse events were two isolated events, one tumor spillage and one residual disease. The evidence is limited to case reports and small case series only. Pediatric cancer surgery is an area of opportunity for robotic surgery. Its technical challenges create the opportunity to develop robotic approaches that meet the chal-

As an anecdote, the robot appears to be well adapted to complex mediastinal dissection and has been used in excision of left ventricular myxoma [152], and in excision of complex massive leiomyoma of the esophagus [153]. The robot offered

**38**

There are mostly individual case reports for robot-assisted abdominal oncological surgery in children.

Neuroblastoma is the most common extracranial solid tumor in children and the most common malignancy in infants. Complete resection is curative in low-stage disease. Robotic surgery can skeletonize abdominal blood vessels in the tumor and cut the tumor into pieces, including stage IV retroperitoneal neuroblastoma [155, 156].

Juvenile cystic adenomyoma is the focal presence of ectopic endometrial glands and stroma within the uterine myometrium. Another case, a 15-year-old adolescent girl underwent RAS of a 4 cm cyst, and the uterus was closed in four layers, the postoperative period was uneventful [157].

Management of rhabdomyosarcoma. A 22-month-old, 8-kg boy with an embryo-rhabdomyosarcoma in the urinary bladder and prostate, the treatment was a robot-assisted radical cystoprostatectomy, and the postoperative course was uneventful [158]. Another application of RAS is in the dissection of retroperitoneal lymph nodes in selected pediatric and adolescent patients with paratesticular rhabdomyosarcoma or germ cell tumor of the testicle, a report of a case of each of these conditions, they were treated with good results. The robotic approach to extended lymph node dissection is suitable [159].

Robotic partial nephrectomy has been reported in appropriately selected children with renal cell carcinoma. However, there are limited reports of laparoscopic or robotic partial nephrectomy for cancer surgery in children. RAS allows for an oncologically sound resection of partial nephrectomy, as well as extended lymph node dissection [160].

Robotic adrenalectomy is an increasingly used procedure in patients with a variety of surgical adrenal lesions, including adenomas, aldosteronomas, pheochromocytomas, and adrenal gland metastases. Emerging literature also supports the role of RAS in partial adrenalectomy [161]. With robotic partial adrenalectomy, successful preservation of adrenocortical function is achieved [162].

RAS is an emerging technique for the treatment of pancreatic neoplasms. Robotic spleen-preserving distal pancreatectomy for a solid pseudopapillary tumor in pediatric patient, can be considered in younger patients presenting with a solid pseudopapillary tumor in the distal pancreas, and its use as an alternative to open pancreatectomy [163]. A report with 15 adolescents with pancreatic head tumor treated with MIS. Pancreaticoduodenectomy was performed, 10 cases with conventional laparoscopic surgery and 5 cases with RAS. The pathological diagnoses were solid pseudopapillary neoplasms (8), neuroendocrine neoplasms (3), intraductal papillary mucinous neoplasm (1), cystic fibroma (1), serous cystadenoma (1), Ewing's sarcoma (1). Six patients presented postoperative complications. The median follow-up was 37 months. The patient with Ewing's sarcoma was diagnosed with liver metastasis 41 months after surgery and died 63 months after surgery. All other patients survived without a tumor [164].

Robotic gynecological surgery in girls with ovarian disease, the ideal is to maintain the morphology of the ovary, which is beneficial for the recovery of postoperative ovarian function, especially in benign diseases. In centers where robotic surgery is available, ovarian tumors are a suitable entry procedure [128].

Robotic surgery can also be used in supportive care in pediatric oncology including placement of gastrostomy tubes and ovarian transposition [104].

The fundamental oncological principles of no tumor spillage and total resection of tumor margins can be adhered to by RAS; a specific concern being the lack of haptics having an impact on the surgeon's ability to differentiate cancerous from healthy tissue. However, it has been noted that the loss of tactile feedback is, very well compensated for by the excellent optical system [158]. Cancer patients are necessarily followed for recurrences, and only long-term prospective studies of robotic resections can guarantee adherence of the RAS to oncological principles.

Contraindications in children for MIS in tumors, including robotic surgery, are large or fragile tumors that carry a high risk of fracture and tumor spillage, significant adhesions from previous operations, and significant deterioration of respiratory or cardiovascular physiology [104].
