**5. Thoracic robotic surgery**

*Latest Developments in Medical Robotics Systems*

**4.7 Various procedures in general surgery**

Elective robot-assisted cholecystectomy *is* relatively prevalent in the literature [13]. Multiport robotic cholecystectomy and single-site robotic cholecystectomy are the approach options. Robotic cholecystectomy is safe and effective and serves as an excellent introductory procedure for pediatric surgeons considering the develop-

Splenectomy remains the mainstay of treatment for the sequelae of pediatric hereditary hematologic disorders. These conditions can lead to splenomegaly, medically refractory cytopenias, and dependence on transfusions. Laparoscopic splenectomy is the standard of surgical care. Robot-assisted splenectomy is an option and is associated with a shorter length of hospital stay compared to laparoscopic

There are case reports and series documenting a variety of robotic gynecological surgeries in children with favorable results. Procedures consisted of ovarian cystectomies, oophorectomies for ovarian masses, and salpingo-oophorectomy for gonadal dysgenesis [127]. In addition, robotic resection of mature cystic teratoma and mucinous ovarian tumor. It is an easy and safe technique in selected patients and also for the treatment of complex gynecological diseases [128]. Surgeries in the

pelvis have a reduced field of work and are ideal for the robotic approach.

Achalasia is rare in children. Surgical options include open, laparoscopic, and robotic approaches, and Heller's myotomy remains the treatment of choice. Concomitant partial posterior fundoplication is suggested for all patients. Heller's robotic myotomy for esophageal achalasia in children has been shown to be safe and effective. Both laparoscopic and robotic esophageal myotomy are comparable in their results. However, robotic surgery is superior in terms of avoiding mucosal perforation, this complication occurred in 16% of patients in the laparoscopic

Anorectal pull-through for anorectal malformations, with the robotic technology assists the pediatric surgeon by increasing dexterity and precision of movement. This is important in anorectal malformations surgery, where the dissection of the fistula and the pull-through of the rectum into the muscular complex are crucial to achieve continence in future. RAS permits easier closure of the fistula, improves reconstruction technique, and minimizes trauma to important surrounding structures, providing better visualization of the muscular complex. Robotic anorectal pull-through makes use of fundamental concepts learned from decades of highanorectal malformation open repair, and combines them with modern advances in

ment of a pediatric robotic surgery program, useful for training [125].

*4.7.1 Cholecystectomy*

*4.7.2 Splenectomy*

splenectomy [126].

group [129–131].

*4.7.3 Gynecological surgery*

*4.7.4 Heller's cardiomyotomy for achalasia*

*4.7.5 Management for anorectal malformations*

surgical instrumentation and techniques [132].

**36**

The global experience in thoracoscopic surgery in children is more than 30 years compared to robot-assisted thoracic surgery (RATS). The learning curve of thoracoscopy is longer compared to RAS. Thoracic MIS reduces the risk of thoracic and spinal deformities after lung resection in children. Lobectomy is one of the robotic techniques most frequently performed in children [133].

Early publications on RATS in children reported having performed cardiovascular techniques such as patent ductus arteriosus (PDA) closure and vascular ring section [134, 135]. Le Bret, et al. [134] in 2000, 56 children operated on for PDA surgical closure, 28 cases with thoracoscopy and 28 cases with robotic approach. They used the ZEUS robotic surgical system (Computer Motion, Inc., Goleta, CA. USA). Their results were comparable in both approaches.

Cundy et al. [13], in a systematic search in the literature of reported cases of robotic surgery in children of 2393 procedures, thoracic procedures accounted for 3.2% (77 surgeries and 12 different techniques), and the conversion rate was 10% in thoracic procedures. In this report, the five most frequent RATS procedures are: lobectomy (18), thymectomy (14), benign mass excision (9), diaphragmatic plasty (8), and malignant tumor resection (5).

There are three series reported with a greater number of cases, each with 11 RATS in children (total 33), in order of frequency the procedures include: tumor masses resection (8), lobectomy (7), diaphragmatic plication (4), diaphragmatic plasty (3), esophageal atresia correction (3), bronchogenic cysts resection (3) and unique procedures of segmentectomy, esophageal duplication resection, pleural and lung biopsies, gastric tube/esophagoplasty and Heller myotomy. Overall, there were 6 (18%) conversions to open surgery in neonatal patients and (3) 9% postoperative complications. The neonatal thorax represents the greatest obstacle in the adaptation of the 5 or 8 mm robotic platform instruments [20, 133, 136]. In RATS, children weighing more than 4 kg are more easily treated [15].
