**2.4 Limitations**

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 paralyzed when the robot is docked [59].

In addition, RAS frequently requires Trendelenburg or reverse Trendelenburg steeper positioning, which has hemodynamic consequences. This situation can typically be mitigated by adequate volume expansion [60].

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 hypercapnia and acidosis [61].

The primary disadvantage of robotic surgical technology in pediatric surgery is related to the size of the surgical robot and its associated instruments [4, 5, 46], the robotic instruments are only available in 2 sizes, 8 mm and 5 mm. Similarly, robotic endoscopes (lens) are currently only available as 12.0 mm and 8.5 mm.

The cost analysis for the use of the robot is not strictly measured by numerical cost in dollars, but should be considered as value equating to quality (as defined by positive outcomes/cost). Naturally, there is the initial cost of purchasing and maintaining the robot itself, as well as the increased costs from the disposable robotic equipment and the longer operative times [4]. It should be noted other factors associated with the robotic portion of a procedure, such as increased operating room or anesthesia time, staff training, and cost of marketing campaigns [62].

In contrast, patient and parent satisfaction, as well as emotional and professional benefits, should also be considered when evaluating cost/satisfaction of this type of investment [63]. One study found that it takes at least 3 to 5 cases per week in a program to demonstrate a net gain from robotic surgery [64].

Other cost analyses suggest that robotic surgeries are more expensive than those associated with laparoscopic or open surgery [65, 66]. However, RAS is associated with a 2% decrease in anastomotic leaks [67, 68]. This reduces hospitalization and costs of managing the resulting surgical morbidity, and benefits the earlier return of the patient to the workforce [66]. In addition, by preferably performing difficult and complex cases in which robotic surgery adds value to patient care; it should be a solution with the best profitability in hospitals that have a robotic system. In some countries such as in Latin America, costs represent a great inconvenience for the advancement of robotic surgery in children, especially in private hospitals.

A short hospital stay, prudent use of instruments, reduced operating room times, and competent robotic equipment reduce costs [69]. Therefore, future comparative analyses of outcomes in children should include financial factors such as loss of human capital, parents [70].

### **2.5 Applications**

Robotic surgery has been used in almost all pediatric surgical subspecialties, including urology, general surgery (gastrointestinal-hepatopancreatobiliary), thoracic, oncology, and otorhinolaryngology. Among pediatric disciplines, robotic surgery is used most frequently in urology.

The best indications for robotic surgery are procedures that require a small surgical field, fine and precise dissection, and secure intracorporeal sutures [71]. The RAS have special application in complex and reconstructive surgery, for these procedures, from the open technique; surgeons often jump to RAS [14]. RAS in otorhinolaryngology with the application of the transoral approach is particularly useful in masses of the tongue base [72]. Furthermore, RAS has performed a wide spectrum of surgical procedures in children [13].
