**4. General surgery (gastrointestinal and hepatopancreatobiliary)**

RAS in general surgery, and thoracic surgery have not yet reached the magnitude that it has in pediatric urology. Robotic procedures that have been reported include, fundoplication, cholecystectomy, choledochal cysts resection, hepatectomy, colectomies, proctectomy with ileal pouch-anorectal anastomosis [104]. Other techniques are, Thal fundoplication and salpingo-oophorectomy [8], Soave pullthrough procedure for Hirschsprung's disease [105]. Others that are less common, RAS for the treatment of duodenal obstruction, such as the Ladd cure in intestinal malrotation, the duodenojejunostomy for superior mesenteric artery syndrome [106], the repair of congenital duodenal atresia [107], and gastroduodenal obstruction due to trichobezoar [14].

Hepatopancreatobiliary RAS in children inevitably involves high complexity, such as Kasai portoenterostomies and choledochal cyst resection [108–109]. Furthermore, liver resection, robot-assisted generally indicated for treatment of tumors [110].

### **4.1 Fundoplication**

Fundoplication is the most widely performed and reported robotic-assisted surgery in pediatric general and thoracic surgery [3].

When comparing conventional laparoscopic primary fundoplication and RAS in children, there were no differences between the two groups in terms of operative time, length of hospital stay, conversions, and complications. The conclusion is that RAS is a safe alternative to conventional laparoscopic surgery [111]. Regarding the advantages of RAS, a systematic review of primary fundoplication showed that postoperative complications are reduced in the robotic group. Because in the RAS there is greater dexterity and precision in the subphrenic space, than with laparoscopy [112]. In addition, RAS plays an important role in difficult cases, such as obese patients, large hiatal hernias, and redo fundoplication [113, 114]. On the other hand, with conventional laparoscopy, only skilled pediatric surgeons resolve difficult cases [114].

#### **4.2 Choledochal cyst resection**

Choledochal cyst resection and reconstructive Roux-en-Y hepaticojejunostomy are technically complex and, only in Southeast Asian centers there is extensive experience in the laparoscopic technique. In the rest of the pediatric centers of the world, most of this surgeries are performed with the open technique [115].

In 2006, the first pediatric RAS choledochal cyst resection was reported [116]. Since that time and up to 2019, several authors have reported cohorts of 1 to 39 pediatric patients undergoing RAS choledochal cyst resection [109]. A recent publication informed 70 cases with RAS and 70 cases by conventional laparoscopy, and concluded that RAS choledochal cyst excision and hepaticojejunostomy were associated with better short-term intraoperative and postoperative outcomes, and proved the safety and feasibility of RAS in children with choledochal cysts [117].

**35**

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

and effectiveness [109].

**4.4 Pancreatic pathology**

**4.5 Soave pull-through**

**4.3 Kasai procedure**

The ideal treatment for children with choledochal cyst, nowadays, is MIS, laparoscopic, through expert pediatric surgeons or RAS, in institutions where technology is available. But, if one or another situation is not present, the author recommends continuing with the open approach to offer children the greatest safety

The Kasai procedure can be ideal for RAS because it is a complex technique, it has an ideal instrumentation to dissect the hepatic portal and find the portal plate [118]. To date, there are very few reported cases of Kasai operation for RAS for biliary atresia. The experience is larger with conventional laparoscopy, especially in Southeast Asian countries, where the pathology is more frequent than in other latitudes of the world [115].

There are very few publications of pancreatic pathology in children treated with RAS, we find only case reports about: tumor enucleation, distal pancreatectomy, subtotal pancreatectomy, and pancreaticoduodenectomy. The traditional open surgeries have been largely replaced by MIS, including laparoscopic surgery and RAS. RAS distal spleen-sparing pancreatectomy is safe and feasible in pediatric patients with insulinoma [119]. Also, robotic enucleation is indicated in small neuroendocrine tumors of the pancreas. This technique provides the dual benefits of minimal invasiveness and good preservation of the pancreatic parenchyma. The experience has demonstrated the feasibility and safety of the RAS enucleation, with

Hirschsprung's disease (HSCR) has also been shown to benefit from robotic surgery, the outcome of totally robotic soave pull-through for HSCR is promising. This technique is particularly suitable for older HSCR patients, even those requiring a redo surgery, and represents a valid alternative for HSCR patients. In cases of total colonic aganglionosis, for the hepatic angle or only recto sigmoid, RAS has been used and its versatility has been confirmed. The published results are promising, continence scored from excellent to good in all patients who could be evaluated in this regard [105]. In the first series of infants less than 6 kg who underwent the

Superior mesenteric artery syndrome is a rare condition that results from intermittent functional obstruction of the third part of the duodenum. The diagnostic criteria are clinical, radiological and endoscopic. The classic approach has been open surgery [123]. There are case reports of robotic Roux-en-Y duodenojejunos-

Robotic repair of congenital duodenal atresia may help overcome the obstacles

tomy as a surgical option for the treatment of this condition [106, 124].

disorder, with success and without postoperative morbidity [14].

presented by the use of traditional rigid laparoscopic instruments, due to the difficulty in constructing a precise duodenal anastomosis, with robotic surgery the procedure is relatively straightforward [107]. About gastroduodenal obstruction due to trichobezoar in children and laparoscopy, we found several reports. We operated with RAS on a 12-year-old girl weighing 23 kg with pica and psychological

an excellent curative effect for pediatric insulinoma [120, 121].

Swenson RAS, morbidity did not increase [122].

**4.6 Treatment of duodenal obstruction**

The ideal treatment for children with choledochal cyst, nowadays, is MIS, laparoscopic, through expert pediatric surgeons or RAS, in institutions where technology is available. But, if one or another situation is not present, the author recommends continuing with the open approach to offer children the greatest safety and effectiveness [109].
