**9. Implementation of a pediatric robotic surgery program**

## **9.1 Planning**

The success of a pediatric robotic surgery program (PRSP) depends on a wellstructured plan. Implementing a PRSP requires institutional support and requires a comprehensive, detail-oriented plan that takes into account training, supervision, cost, and cases volume. Given the lower prevalence of robotic surgery in children, in many cases it may be more feasible to implement pediatric robotic surgery within an adult robotic surgery program. The pediatric surgery team determines its goals for volume expansion, surgical case selection, surgeons training, and surgical innovation within the specialty. In addition to the clinical model, a robust economic model that includes marketing must be present, especially in private hospitals [167].

### **9.2 Development of the program**

The development of a robotic surgery program is associated with significant initial costs due to the initial investment in the robotic surgical system [168]. Adequate surgical volume is essential for both feasibility and ensuring adequate results for patients [64]. The surgeon should start with less complex index cases and gradually progress to more advanced reconstructive procedures with growing experience [61].

Less complex cases, such as a fundoplication, are excellent robotic training cases not only for surgeons and anesthesia personnel, but also for technical and nursing personnel assisting in the operating room [169].

Additionally, robotic cholecystectomy is a suitable procedure for first few surgeries when pediatric surgeons are beginning robotic surgery [125]. It is imperative to have a core group of specific personnel familiar with robotic procedures to increase efficiency. Adequate and systematic performance of the entire team in simple cases, then translates into better performance in more complex cases.

It is estimated that approximately 100 cases are required to obtain consistent results in pediatric robotic surgery cases by a surgical team [167]. The learning curve for each procedure varies, but is shorter than with laparoscopy, for example for robotic pyeloplasty there are 15 to 20 cases, to obtain similar results and surgical success [170]. Experience shows that in complex or reconstructive techniques, surgeons using the open approach switch to the robot-assisted approach, such as pyeloplasty, ureteral reimplantation, biliodigestive and pulmonary lobectomy, among others.

#### **9.3 Robotic pediatric surgery team**

There are three main actors involved in the implementation of a pediatric robotic surgery program: i. Surgeons and anesthetists, ii. Nurses and iii. Administration [168].

Successful robotic surgery is mentioned as requiring four elements, i. Good understanding of the surgical procedure, ii. Excellent surgical skills, iii. Frequent teamwork training, and iv. Trocar placement [171]. Adequate surgical volume is critical both for feasibility and to ensure good patient outcomes. Cases should be performed once a week to maintain surgical skill and advance to more advanced reconstructive procedures.

There has been a growing role for simulation and surgical training. Currently, the robotic surgery simulators available for training are the Mimic and da Vinci simulators. The simulators evaluate the skills in the different tasks that the surgeon performs. It is desirable that surgeons have previous experience in conventional laparo-thoracoscopy.

#### **9.4 Training, accreditation and credentialing**

Training and accreditation. In the present, the certification process to be a robotic surgeon depends on the manufacturer. Intuitive Surgical (Sunnyvale, CA,

**43**

surgery [173].

the adoption of these technologies [174].

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

cases with support from a proctor.

the curve of learning.

**9.5 Program information data log**

**10. The future of robotic surgery in children**

USA), the manufacturers of the da Vinci Surgical System, have a separate training program that takes surgeons from console setup to the monitoring phase for initial

This process should be more structured and create a curriculum for robotic surgeons, this is essential for the training and objective evaluation of future robotic surgeons. Defining results, specific training tasks and their validation; as well as, establishment of measurements and approval criteria to improve the quality of robotic surgery should be included in the plan [172]. Academic organizations and hospital institutions can lead the implementation of a structured curriculum. An accreditation proposal for the robotic surgeon is the following; After the intuitive surgery training program (step 1), then do the first five cases with a co-surgeon (step 2), who has the dual role of preceptor and supervisor, assesses the surgeon who is learning and also imparts new skills and takes control of the operative case if the clinical situation warrants it (the tutor allows the trainee to gain robotic experience safely in the first index cases). This is followed by 6 to 10 cases in which the tutor / supervisor is a bedside assistant (step 3). The preceptor/supervisor reports the findings to the Institution's Robotics Committee on the skills and progress of the trainee, evaluating whether the independent practice can be continued by the surgeon (step 4), based on the favorable evaluation of the preceptor [167]. The author's experience supports this accreditation proposal so that the learning curve of the surgeon, who is starting his foray into robotic surgery, is a satisfactory experience for him, and the patient is offered the greatest security from the stage of

Data collection is very important. Collecting, analyzing, and presenting data prospectively to Institutional colleagues, at a minimum, allow objective analysis of results for comparative studies against other approaches, as well as to publish them.

Recently, the Senhance Robotics System (Transenterix, Morrisville, NC) has begun offering 3 mm instrument sizes, which could make robotic surgery more technically feasible for even the smallest pediatric patient. Although not currently approved for use in pediatric surgery, the Transenterix platform, was evaluated in an experimental study where surgeons were able to successfully perform intracorporeal and knotted sutures in body cavities as small as 90 ml, and the instruments could be inserted directly without the need for ports, reducing the required distance between ports [5]. This Transenterix platform has haptic feedback.

With advancing technology and the demand for more compact robotic platforms, the future for robotic surgery will doubtlessly result in a reduction of instrument size and an improvement in haptic feedback. This puts the pediatric patient in particular, the newborn at the forefront. Reconstructive surgery such as esophageal and intestinal anastomosis, all of which require a delicate and more magnified approach will benefit enormously from these advances. The pediatric and neonatal patient must be at the forefront of research into the future of robotic

We are at a dawn of a new age in surgery, as we witness the dramatic growth in robotic surgery. The proliferation and commercialization of new robotic surgical systems over the next few years will drive competition, lower cost, and accelerate

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

*Latest Developments in Medical Robotics Systems*

**9.2 Development of the program**

personnel assisting in the operating room [169].

comprehensive, detail-oriented plan that takes into account training, supervision, cost, and cases volume. Given the lower prevalence of robotic surgery in children, in many cases it may be more feasible to implement pediatric robotic surgery within an adult robotic surgery program. The pediatric surgery team determines its goals for volume expansion, surgical case selection, surgeons training, and surgical innovation within the specialty. In addition to the clinical model, a robust economic model that includes marketing must be present, especially in private hospitals [167].

The development of a robotic surgery program is associated with significant initial costs due to the initial investment in the robotic surgical system [168]. Adequate surgical volume is essential for both feasibility and ensuring adequate results for patients [64]. The surgeon should start with less complex index cases and gradually progress to more advanced reconstructive procedures with growing experience [61]. Less complex cases, such as a fundoplication, are excellent robotic training cases not only for surgeons and anesthesia personnel, but also for technical and nursing

Additionally, robotic cholecystectomy is a suitable procedure for first few surgeries when pediatric surgeons are beginning robotic surgery [125]. It is imperative to have a core group of specific personnel familiar with robotic procedures to increase efficiency. Adequate and systematic performance of the entire team in simple cases, then translates into better performance in more complex cases. It is estimated that approximately 100 cases are required to obtain consistent results in pediatric robotic surgery cases by a surgical team [167]. The learning curve for each procedure varies, but is shorter than with laparoscopy, for example for robotic pyeloplasty there are 15 to 20 cases, to obtain similar results and surgical success [170]. Experience shows that in complex or reconstructive techniques, surgeons using the open approach switch to the robot-assisted approach, such as pyeloplasty, ureteral reimplantation, biliodigestive and pulmonary lobectomy,

There are three main actors involved in the implementation of a pediatric robotic surgery program: i. Surgeons and anesthetists, ii. Nurses and iii.

Successful robotic surgery is mentioned as requiring four elements, i. Good understanding of the surgical procedure, ii. Excellent surgical skills, iii. Frequent teamwork training, and iv. Trocar placement [171]. Adequate surgical volume is critical both for feasibility and to ensure good patient outcomes. Cases should be performed once a week to maintain surgical skill and advance to more advanced

There has been a growing role for simulation and surgical training. Currently, the robotic surgery simulators available for training are the Mimic and da Vinci simulators. The simulators evaluate the skills in the different tasks that the surgeon performs. It is desirable that surgeons have previous experience in conventional

Training and accreditation. In the present, the certification process to be a robotic surgeon depends on the manufacturer. Intuitive Surgical (Sunnyvale, CA,

**42**

among others.

Administration [168].

reconstructive procedures.

**9.4 Training, accreditation and credentialing**

laparo-thoracoscopy.

**9.3 Robotic pediatric surgery team**

USA), the manufacturers of the da Vinci Surgical System, have a separate training program that takes surgeons from console setup to the monitoring phase for initial cases with support from a proctor.

This process should be more structured and create a curriculum for robotic surgeons, this is essential for the training and objective evaluation of future robotic surgeons. Defining results, specific training tasks and their validation; as well as, establishment of measurements and approval criteria to improve the quality of robotic surgery should be included in the plan [172]. Academic organizations and hospital institutions can lead the implementation of a structured curriculum.

An accreditation proposal for the robotic surgeon is the following; After the intuitive surgery training program (step 1), then do the first five cases with a co-surgeon (step 2), who has the dual role of preceptor and supervisor, assesses the surgeon who is learning and also imparts new skills and takes control of the operative case if the clinical situation warrants it (the tutor allows the trainee to gain robotic experience safely in the first index cases). This is followed by 6 to 10 cases in which the tutor / supervisor is a bedside assistant (step 3). The preceptor/supervisor reports the findings to the Institution's Robotics Committee on the skills and progress of the trainee, evaluating whether the independent practice can be continued by the surgeon (step 4), based on the favorable evaluation of the preceptor [167].

The author's experience supports this accreditation proposal so that the learning curve of the surgeon, who is starting his foray into robotic surgery, is a satisfactory experience for him, and the patient is offered the greatest security from the stage of the curve of learning.

#### **9.5 Program information data log**

Data collection is very important. Collecting, analyzing, and presenting data prospectively to Institutional colleagues, at a minimum, allow objective analysis of results for comparative studies against other approaches, as well as to publish them.
