Pediatric Robotic Surgery 981199692X, 9789811996924

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Matthew P. Lungren Michael R.B. Evans Editors

Clinical Medicine Pediatric Robotic Covertemplate Surgery Subtitle for Qiang ClinicalShu Medicine Covers T3_HB Editor Second Edition

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Pediatric Robotic Surgery

Qiang Shu Editor

Pediatric Robotic Surgery

Editor Qiang Shu Cardiac Surgery Children’s Hospital Zhejiang University School of Medicine Hangzhou, China

ISBN 978-981-19-9692-4    ISBN 978-981-19-9693-1 (eBook) https://doi.org/10.1007/978-981-19-9693-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface 1

As a state-of-the-art intelligent minimally invasive technology, the da Vinci surgical system (DVSS) has made a giant leap forward in terms of software and hardware innovations, compared with the traditional laparoscopic technique. Although robotic surgery has been widely used in adult surgery, the use of robotic surgery in the field of pediatric surgery is relatively lagging behind. Recent years have witnessed an increasing number of DVSS installed in pediatric hospitals, which is a clear indication that robotic surgery has been more widely used in pediatric surgery. The combined use of DVSS and traditional laparoscopic techniques has demonstrated advantages in the treatment of pediatric surgical diseases, including the treatment of related diseases in various departments of pediatric surgery. This book falls into five parts. The first part is about the related equipment and installments of DVSS operating room; the second part is about the cooperation of DVSS’s professional nurses during operation; the third part is about the specific procedures and attentions of anesthesiologists before, during, and after DVSS operation; the fourth part is about the standardized resident doctor training of DVSS operation; and the fifth part is about the introduction and operation description of various diseases from all pediatric departments suitable for DVSS operation; among these are pediatric general surgery (choledochal cyst radical mastectomy, Hirschsprung’s disease, spleen and partial splenectomy, mesenteric cyst, Meckel’s diverticulum), neonatal surgery (anoplasty, annular pancreatoduodenal anastomosis, intestinal malrotation correction), cardiothoracic surgery (lobectomy and segmentectomy, esophagoplasty, fundoplication, diaphragmatic plication, patent ductus arteriosus ligation), oncology surgery (ovarian cystectomy, adrenal tumor resection), and urology (pyeloplasty, ureteral bladder reimplantation, ureteral anastomosis, kidney and partial nephrectomy, prostatectomy). The first four parts are introduced to the surgery textbook for the first time. These contents are written in plain language with practical purposes, combined with illustrations in an easy-to-read manner. The fifth part is based on each disease. It elaborates the diagnosis, surgical indications, and surgical procedures for each disease and systematically describes different parts of the surgical technology with real diagrams, which contributes to the prevention and treatment of intraoperative and postoperative complications. It is also companioned with a complete surgery video, which is beneficial to medical students and young pediatric surgeons. By reading this book, team cooperation in surgery will be further improved, so that everyone knows what to do v

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next. The assistant will be familiar with the operation steps, knowing how to cooperate with the surgeon, and the nurse can accurately provide instruments and sutures in time. It is also of high reference value for building a da Vinci’s operating room team in your hospital. Nowadays, the living standards of the whole people have significantly improved, while the well-being of children demands even higher levels. Thus, pediatric surgery requires reasonable standardization. This book, by improving and perfecting the standardization of pediatric da Vinci surgery, provides reference templates and lays foundation for pediatric surgery in times to come. Shusen Zheng, MD Academician of China Academy of Engineering Division of Hepatobiliary Pancreatic Surgery, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine; NHC Key Laboratory of Combined Multi-organ Transplantation, China; Key Laboratory of the diagnosis and treatment of organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), China; Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou 310003, China

Preface 1

Preface 2

With the rapid evolution of surgical robot technology, the da Vinci robotic surgical system has been upgraded to the Xi. Along with the design of robotic surgical instruments becoming more suitable for pediatric patients and a deeper understanding of complex diseases in pediatric surgery, superiorities of robotic surgery for complex pediatric surgical diseases are being increasingly highlighted. The doubts about the contradiction between robotic surgical instruments and the limited surgical space of children are also diminishing, and a revolution in pediatric robotic surgery is quietly underway. In 2002, the first case of pediatric robotic-assisted pyeloplasty was reported in the United States. Since then, robotic surgery has made significant progress in the field of pediatric urology. However, the application of roboticassisted surgery in pediatric general surgery, pediatric cardiothoracic surgery, neonatal surgery, and pediatric oncology surgery has not reached the same level as its application in pediatric urology. Dr. Qiang Shu, the editor of this book, has led the surgical team at Children’s Hospital, Zhejiang University School of Medicine, to systematically evaluate the safety, feasibility, and future applications of robotic surgery in the field of pediatric surgery. They innovatively developed mechanical system layout techniques and a series of surgical procedures, achieving comprehensive coverage of robotic surgery for pediatric diseases in six major systems: general surgery, oncology, neonatal surgery, cardiac surgery, thoracic surgery, and urology. They have also developed a day surgery program for pediatric robotic surgery. While advancing their own team’s development, Children’s Hospital, Zhejiang University School of Medicine, has established the Chinese da Vinci Robot Pediatric Surgery Clinical Training and Demonstration Center, which provides a highlevel platform for training Chinese robotic surgery experts. Dr. Shu’s surgical team has achieved a series of major innovative and revolutionary breakthroughs in pediatric robotic surgery, including various disease types, youngest age, lowest weight, etc. Based on their own experiences, the team finally published this academic monograph on pediatric robotic surgery, which will provide a practical and in-depth guidance to more pediatric surgeons worldwide and promote the development of robotic surgery in pediatric surgery. This book is an extremely practical and highly specialized book on pediatric robotic surgery, with comprehensive and in-depth contents, concise structures, and clear key points, accompanied by rich illustrations. The book starts with the current development status of pediatric robotic surgery, the basic principles and technology of robotic systems, the construction of vii

Preface 2

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robotic operating rooms, and the qualification training for pediatric surgeons. It then provides in-depth descriptions of specific surgical procedures, indications and contraindications, and complications in the six major systems of diseases, providing readers with knowledge and insights in multiple fields. The book also provides schematic diagrams of the surgical procedures and actual surgical case photos and videos, making the whole surgical process visually displayed to the readers. The publication of this book is a milestone in the field of pediatric robotic surgery. I believe it will become a landmark literature in pediatric robotic surgery, which provides rich and valuable resources for medical practitioners, researchers, and students. On the eve of the publication of this book, I am honored to be invited to write the foreword. While reading it, I have felt Dr. Shu and his team’s dedicated pursuits and diligent efforts in professional and excellent surgical skills. Finally, I hope this book will inspire more research and innovation in robotic surgery, cultivate more pediatric robotic surgical teams, and then contribute to the promotion for children’s well-being. Xu Zhang Academician of Chinese Academy of Sciences; Director of the Academy of Urology, Chinese PLA General Hospital, Beijing, China.

Contents

1 Robotic-assisted  Surgery in Pediatrics: Current Applications, Limitations and Prospects ��������������������������������������������������������������   1 Qiang Shu 2 Introduction  of Robot-assisted Surgical Technology: the da Vinci Xi System������������������������������������������������������������������������������������������   7 Kun Zheng and Zhongkuan Lin 3 Robotic  Operating Room Configuration ��������������������������������������  17 Hang Yan Zhao and Chunyan Zhan 4 Pediatric  Anesthesia for Robotic Surgery in Children ����������������  21 Jinjin Huang and Yaoqin Hu 5 Robotic  Resident and Fellow Training ������������������������������������������  29 Qiang Shu and ZongWei Huang 6 Robotic-Assisted  Esophagoplasty for Congenital Esophageal Atresia��������������������������������������������������������������������������  35 Shaotao Tang and Liang Liang 7 Robotic-Assisted Pulmonary Lobectomy��������������������������������������  41 Qiang Shu and Zheng Tan 8 Robotic-Assisted Segmentectomy ��������������������������������������������������  47 Qiang Shu and Zheng Tan 9 Robot-Assisted  Laparoscopic Repair of Hital Hernia������������������  53 Jiangeng Yu and Yue Gao 10 Robotic-Assisted  Plication of Diaphragmatic Eventration����������  61 Zheng Tan and Ting Huang 11 Robotic-Assisted  Ligation of The Patent Ductus Arteriosus��������  67 Liyang Ying and Xiwang Liu 12 Robotic-Assisted  Congenital Choledochal Cyst Radical Surgery��������������������������������������������������������������������������������  75 Zhigang Gao and Duote Cai 13 Robotic-Assisted Splenectomy��������������������������������������������������������  85 Zhigang Gao and Yuebin Zhang

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14 Robotic-assisted Partial Splenectomy��������������������������������������������  95 Zhigang Gao and Yuebin Zhang 15 Robotic-Assisted  Mesenteric Cyst Resection�������������������������������� 103 Zhigang Gao and Di Hu 16 Robotic  System Assisted Soave Procedure for Hirschsprung Disease���������������������������������������������������������������������������������������������� 111 Qingjiang Chen and Wenjuan Luo 17 Robotic-Assisted Anorectoplasty for Congenital Anorectal Malformation������������������������������������������������������������������������������������ 117 Jinfa Tou and Dengming Lai 18 Robotic-Assisted  Duodenoduodenostomy for Duodenal Stenosis and Atresia ������������������������������������������������������������������������ 123 Qingjiang Chen and Ken Chen 19 Robotic-Assisted  Ladd’s Procedure for Congenital Malrotation �������������������������������������������������������������������������������������� 129 Jinfa Tou and Shoujiang Huang 20 R  obotic-Assisted Duodenal Anastomosis for Annular Pancreas�������������������������������������������������������������������������������������������� 135 Jinfa Tou and Chengjie Lv 21 Robotic-Assisted  Intestinal Duplication Resection ���������������������� 141 Zhigang Gao and Yi Jin 22 Robotic-Assisted  Partial Nephrectomy for Duplicated System ���������������������������������������������������������������������������������������������� 149 Chang Tao and Long Sun 23 Robotic-Assisted  Nephrectomy for Dysplasia Kidney������������������ 155 Chang Tao and Long Sun 24 Robotic-Assisted  Pyeloplasty for Ureteropelopic Junction Obstruction ���������������������������������������������������������������������� 161 Chang Tao and Huixia Zhou 25 Robot-Assisted Ureterovesical Replantation �������������������������������� 167 Guangjie Chen and Huixia Zhou 26 Robotic-Assisted  Prostatic Cystectomy and Seminal Reconstruction for Prostatic Utricle Cyst�������������������������������������� 173 Chang Tao and Zheming Xu 27 Robot-Assisted  Ureteroureterostomy for Duplicated Kidneys��������������������������������������������������������������������������������������������� 179 Guangjie Chen and Huixia Zhou 28 Robotic-Assisted Adrenal Tumor Resection���������������������������������� 185 Jinhu Wang and Jiabing Cai

Contents

Contents

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29 Robotic-Assisted Ovarian Tumor Resection���������������������������������� 191 Jinhu Wang and Jiabing Cai 30 Robotic-Assisted  Resection for Mediastinal Tumors�������������������� 195 Zheng Tan and Jian Zhang 31 Complications  of Robotic-Assisted Surgery in Children�������������� 205 Qiang Shu and Shuhao Zhang

Editors and Contributors

About the Editor Qiang Shu  MD, obtained his bachelor’s degree in 1988 and master’s degree in medicine in 1996 from Zhejiang Medical University (now Zhejiang University School of Medicine), Hangzhou, China. He received his doctoral degree in 1999 at the University of Bonn, Germany. He completed his residency training in pediatric surgery and fellowship training in pediatric cardiothoracic surgery in Children’s Hospital, Zhejiang University School of Medicine, where he became a chief surgeon in 2004 and professor of pediatrics in 2006. He is now the dean of School of Pediatrics, Zhejiang University School of Medicine, and the Director of the Heart Center of Children’s Hospital, Zhejiang University School of Medicine. To date, he as the corresponding author and coauthor published more than 240 peer-reviewed articles and edited 14 books. He also received many research grants and awards in recognition of his contributions to the advanced development in the field of pediatrics and surgery. Qiang Shu is an Editor-in-Chief of World Journal of Pediatrics and World Journal of Pediatric Surgery; he is also an editorial board member of Chinese Medical Journal, Journal of Clinical Pediatrics, and Chinese Journal of Pediatric Surgery and a regular reviewer of many international leading journals in pediatrics and surgery. He is the Vice Chairman of Pediatric Surgery Society of Chinese Medical Association, Pediatric Professional Teaching Guidance Sub-committee of Chinese Medical Association, High Education Steering Committee of Ministry of Education, and Chinese Society for the Prevention and Control of Birth Defect. He is also the Vice Director of Cardiothoracic Surgery Group of Paediatric Surgery Society, Chinese Medical Association. Qiang Shu is an active member of Paediatric Surgeons Branch Standing Committee, Chinese Medical Association, Women and Children’s Healthcare Branch Standing Committee, China International Exchange and Promotion Association for Medical and Health Care, Congenital Heart Disease Professional Committee, and National Cardiovascular Expert Committee.

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Associate Editors

Zhigang Gao  Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Shaotao Tang  Department of Paediatric Surgery, Xiehe Hospital Affiliated to Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China Huixia Zhou  Department of Urology, Bayi Children’s Hospital Affiliated of the Seventh Medical Center of PLA General Hospital, Beijing, China

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Contributors

Duote  Cai  Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Jiabin Cai  Department of Oncology Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Guangjie  Chen Department of Pediatric Urology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Ken  Chen  Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Qingjiang  Chen Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Yue  Gao Department of Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Jinjin Huang  Department of Anaesthesiology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Shoujiang  Huang Department of Neonatal Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Ting Huang  Department of Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Zongwei  Huang Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Di  Hu Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Yaoqin Hu  Department of Anaesthesiology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Yi  Jin Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Dengming  Lai Department of Neonatal Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Liang Liang  Department of Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China xvii

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Zhongkuan Lin  Department of Clinical Engineering, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Xiwang  Liu Department of Cardiovascular Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Wenjuan  Luo Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Chengjie Lv  Department of Neonatal Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Long Sun  Department of Pediatric Urology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Zheng Tan  Department of Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Chang Tao  Department of Pediatric Urology, Children’s Hospital, Zhejiang University School of Medicine, HangzhouChina Jinfa  Tou  Department of Neonatal Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Jinhu  Wang Department of Oncology Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Zheming  Xu Department of Pediatric Urology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Liyang  Ying  Department of Cardiovascular Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Jiangen Yu  Department of Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Chunyan Zhan  Department of Pediatric Surgery Room, Children’s Hospital, Zhejiang University School of Medicine, HangzhouChina Jian Zhang  Department of Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, ,Hangzhou China Shuhao  Zhang Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Yuebin  Zhang Department of General Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Hangyan Zhao  Department of Pediatric Surgery Room, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China Kun  Zheng Department of Clinical Engineering, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China

Contributors

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Robotic-assisted Surgery in Pediatrics: Current Applications, Limitations and Prospects Qiang Shu

Robot surgical system is currently widely used all over the world. The use of robotic-assisted surgery has also been increasingly introduced in pediatric surgery. Comparing with conventional minimally invasive techniques, the main advantages of robotic-assisted surgery are its dexterity and 3D visualization leading advance to more complex technical areas [1]. Da Vinci robot system is the most successful and widely used surgical system. To date, this da Vinci robot system has undergone four generations. The first generation (da Vinci Standard Surgical System) was commercialized in 1999, the second (da Vinci S Surgical System) and the third generations (da Vinci Si Surgical System) were commercialized in 2006 and 2009, respectively. The fourth generation is the da Vinci Xi Surgical System, which came into the market in 2014. Up to 2019, there are 5582 da Vinci surgical system worldwide and 81 of those are in China. In terms of the number of da Vinci robotic surgeries, gynecological surgery ranks followed by urological surgery and general surgery. In China, urological surgery accounts for about 43% of the total number of da Vinci robotic surgeries and general surgery accounts for about

Q. Shu (*) Department of Cardiac and Thoracic Surgery, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

33%, followed by gynecological surgery and cardiothoracic surgery. With successive optimization and improvement of robotic surgical instruments and deepening of understanding of complex congenital malformations in children, the use of roboticassisted surgery has achieved great success in complex reconstructive surgeries such as radical choledochal cyst resection and ureteral replantation. However, the large surgical instruments, high costs, and special pathophysiological status of pediatric patients have limited its wide application in young patients. The main reason of limited use in children may be smaller volume of pediatric patients eligible for robotic procedures which may lead to increased costs for children’s hospitals [2, 3]. Therefore, the use of roboticassisted surgery has been increased more slowly in pediatrics than in the adult population [4]. Herein, we review the current applications, limitations and prospects of da Vinci robot system in pediatric surgery.

1.1 Current Applications of Robot Surgical System in Pediatric Surgery Robot surgical system has been widely used in pediatric surgery, including urinary, general, cardiothoracic and oncological surgery. Procedures in pediatric robotic urology mainly include pyeloplasty, complete or partial nephrec-

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_1

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tomy, ureteral reimplantation, and cystoplasty. Among them, robotic-assisted pyeloplasty is the most commonly. Its feasibility, safety and effectiveness have been demonstrated to be comparable to open or laparoscopic robotic surgery for children [4–6]. The number of robot-assisted ureteral reimplantation has been increased from less than 1% in 2000–2012 to 6% in 2016 [7]. In addition, the surgical success rate was increased and even reached 100% in hospitals in China. The robot-assisted nephroureterectomy, ranks third in urological surgery volume, although the operation time is increased significantly due to the robotic installation time. However, with the assistance of the amplification of the da Vinci 3D surgical field and flexible robotic arms, it is still advantageous in reducing postoperative complications and increasing surgical success rate. In pediatric general surgery, the application of robotic surgery is not popular yet when compared to pediatric urology. Among applications, robot-­ assisted fundoplication is the most common general surgery in children, especially for children with a history of gastrostomy, adhesions caused by previous abdominal surgery, initial fundoplication failure and combined neurological impairment [8]. Due to the high cost of robotic surgery, the rationality of its application in simple fundoplication remains to be questioned. However, for choledochal cyst radical surgery, which requires fine anatomy and a large number of sutures in a narrow anatomical space, robotic surgery has its own advantages in cyst dissection and choledochojejunostomy. A large number of cases under robotic treatment of choledochal cysts have been reported, and the incidence of surgical complications and postoperative recovery time are significantly decreased compared to traditional laparoscopic surgery. In addition, robot-assisted treatment of Hirschsprung’s disease and anal atresia has also been carried out. Owe to robotic 3D surgical field with flexible robotic arms, surgeon’s satisfaction has been significantly improved. Nevertheless, the long-term follow-up study on intestinal function for patients with both megacolon and anal atresia is still lacking. Therefore, the effectiveness, safety, and repeatability of robotic-assisted surgery for compli-

Q. Shu

cated intestinal malformation require further investigation. There are many complications and trauma after thoracotomy in children, including scoliosis, shoulder muscle weakness, and chest wall deformity. Thus, minimally invasive surgery may become inevitable for cardiothoracic surgery. However, robotic cardiothoracic surgery started relatively late. The following factors may limit the extensive development of robotic-assisted cardiothoracic surgery: small thoracic with “concentrated” large vessels and vital organs, less cardiothoracic reconstruction surgery, needs and less well trained cardiothoracic surgeons [9]. At present, robotic-assisted cardiothoracic surgery mainly includes lobectomy, mediastinal tumor resection, and patent ductus arteriosus (PDA) ligation. Though the surgical duration of robotic surgery for pediatric PDA was significantly increased. However, intraoperative manipulation around the aorta, subclavian artery, ductus arteriosu, or ligaments become more delicate and safe [10]. Tang et al. completed the first robotic-assisted surgery for type I esophageal atresia correction in China, the young patient recovered well postoperatively (not published case). Overall, the conversion of robotic surgery was significantly lower than conventional thoracoscopic surgery, with technical and safety advantages, it is likely that more and more robotic-assisted precise surgeries will be performed for the lung, heart tissues and large vessels in the young. Indeed, many scholars believe that it is safe and feasible for robot-­assisted pulmonary surgery, and even superior to thoracoscopic surgery. However, the long-term efficacy of robotic-assisted pulmonary surgery over traditional thoracotomy and thoracoscopic surgery still needs to be determined through multicenter, large sample and prospective study [11].

1.2 Limitations of Using Robot Surgical System in Pediatric Surgery With the introduction of robot surgical system into more and more children’s hospitals, robotic surgery has gradually broken barriers for its

1  Robotic-assisted Surgery in Pediatrics: Current Applications, Limitations and Prospects

more applications. However, the special pathophysiological status of children compared with adults also limits the extensive development of robotic surgery. First, the narrow lacunar operating space of children is its greatest limitation. Robot surgical instruments are large, and the 8-mm-diameter trocar is too large for children’s intercostal space and thorax, especially for infants younger than 1 year old. The size of the trocar, in turn, directly affects the size of the surgical instrument, resulting in a very limited choice of 5  mm instruments. In addition to dimensional differences, there are many differences in design of 5 mm and 8 mm instruments. Devices in size of 5 mm are smaller with their joint motion mechanism different from that of 8 mm devices; and a larger curve radius is needed to make a motion similar to that of an 8  mm instrument. In addition, the 5 mm device options are limited and the mechanical motion is less precise. Second, the da Vinci robot instructions for two trocar distances are at least 5 cm to avoid robotic arm collisions. But due to the small body surface area of the child, da Vinci surgery of trocar location in children is more special. We should ensure that no collision occurs when the smaller thoracic or abdominal cavity simultaneously accommodates the lens, robotic arms, and trocar. Meanwhile, the use of the fourth arm is limited. Third, infant airways are more vulnerable to pneumoperitoneum than adults, with reduced airway compliance and increased airway pressure. Especially for infants weighing less than 10  kg, pressures exceeding 9  mmHg have significant effects on respiratory mechanics and hemodynamics [12]. While insufficient clinical experience can significantly prolong robotic surgery time, which further aggravates the negative physiological effects of CO2. In addition, inflation can increase vagal tone, leading to bradycardia and reducing ventricular preload, thus endangering infants whose cardiac system is not yet mature [13]. Fourth, children have limited abdominal inflation and pressure, and children weighing 10 kg have abdominal inflation of less than 1  L, which reduces the operable space of robotic devices to some extent, and the propor-

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tion of spleen and liver in the abdominal cavity of infants is relative bigger to that of adults, thus further limiting the working space [14].

1.3 Prospects of Robot Surgical System in Pediatric Surgery 1.3.1 Robotic Surgery Under the 5G Era The maturity of robotic surgery technology and the refinement of robotic surgical instruments make it increasingly used in pediatric surgery; and the comprehensive coverage of 5G network lays a solid foundation for robotic telemedicine. Studies have shown that delays of around 200 ms can be fatal for complex and delicate procedures. But the peak theoretical transmission speed of 5G network is 10 Gb per second, which is faster than the transmission speed of the 4G network hundred times, fast 5G network, therefore, significantly promote the development of telemedicine showcase. The design of da Vinci robot system is on the basis of the concept of remote operation. Thus, telemedicine will be performed in the 5G era. The remote operation with a low delay will break through the space and geographical restrictions to the greatest extent and will facilitate the subsidence of robotic surgical techniques and operating experience as high-end non-­material medical resources to primary hospitals [15]. In 2019, Beijing Jishuitan Hospital took the lead in conducting spinal internal fixation surgery for five cases through remote manipulation of robots with the help of 5G network, which makes patients from low socioeconomic regions who access the top medical resources in China. The impact of 5G technology on medical care is enormous and far-reaching, and with the help of 5G medical care, medical resources can be shared and used by more people. With the establishment of two children’s national medical centers and five children’s regional medical centers in China, more children in remote areas can access to highquality medical care and will get more benefits from robotic surgery technology.

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1.3.2 The Future of Single-Port Robotic Surgery in Pediatric Surgery

1.3.3 Development of Pediatric Surgery Under Artificial Intelligence

In recent years, increased demands for minimally invasive surgery, prompting surgeons continuously explore innovation in pursuing smaller and less incisional surgical methods, such as transumbilical single-­port laparoscopic radical resection of intestinal duplication and transaxillary small incision atrial septal defect repair. Due to the limited flexibility and field of view of traditional laparoscopic instruments, after losing the “operation triangle,” device collision is prone to happen in single-port laparoscopic surgery, thus limiting the application of single-port laparoscopic surgery. The flexible robotic arm design of the da Vinci robot system and the better threedimensional surgical field will solve this technical barrier. Robotic-assisted surgery has clear advantages for complex reconstructive surgery in children, such as radical choledochal cyst surgery, ureteral reimplantation, and radical megacolon surgery. However, robotic-assisted laparoscopic surgery has more puncture holes than traditional laparoscopy. With the further pursuit of minimally invasive and esthetic by doctors and patients, robotic surgery has gradually moved to a single port. Currently, single-port robotic surgery is primarily used in adults, including gynecology, urology, general surgery and thoracic surgery. Single-port laparoscopic robot-assisted renal transplantation has also been reported [16]. In the field of pediatric surgery, single-port da Vinci surgery has been used gradually. In 2015, 16 cases of single-port robotic-assisted cholecystectomy was reported [17]. Sung and colleagues completed the first single-port robot-assisted pyeloplasty in who successfully completed anatomy, anastomosis, and antegrade indwelling of a ureteral stent [18]. Therefore, single-port robotic surgery can reduce the difficulty of surgery and meet the need for one step minimally invasive and cosmetic surgery. For children, single-port robotic surgery is not far off.

Thanks to the evolution of information technologies such as the internet, big data, and cloud computing, the rapid development of artificial intelligence (AI) technology represented by deep learning has even surpassed humans in terms of images, speech, and text recognition. In recent years, it has gradual penetration into medical care field. Surgical robot is an important part of clinical adjuvant therapy, of which the da Vinci robot is representative. In addition, there are robotic frameless stereotactic surgical assistive systems (robotized stereotactic assistant, ROSA), robotic surgery system (transoral robotic surgery, TORS) and more. De Benedictis et  al. [19] reported surgical treatment of 116 children with ROSA surgery, including epilepsy, brain tumors, and hydrocephalus. The overall procedural success rate was 97.7%. TORS [20] was widely used in head and neck surgery. The treatment of glottic stenosis, laryngeal fissure, cleft palate, thyroglossal duct cyst, and other diseases in children with TORS is associated with less trauma, lower recurrence rate, and better outcomes than traditional surgical methods. The application of AI in the medical field is still in its infancy, and it mainly relies on the surgeon to control the robot on the operating table to complete the operation. With the continuous accumulation and innovation of technology and the continuous improvement of existing algorithms and instruments, AI can help to solve palliative pediatric surgery status quo of uneven distribution of medical resources and improve childish diagnostic efficiency in a simple, low-risk, repeatable, and efficient manner. In conclusion, robot surgical system is a safe, feasible, and promising new technology in pediatric surgery and has obvious advantages for complex gastrointestinal surgery and organ reconstruction surgery. Although robot surgical system still have many defects, including high costs, lack of tactile feedback

1  Robotic-assisted Surgery in Pediatrics: Current Applications, Limitations and Prospects

and too relatively larg surgical instruments for children. Therefore, further developments in the robot surgical system are required, and indications for its use in pediatric surgery are still under investigation. Robotic-assisted surgery is undoubtedly a promising technology and will be used more widely in future.

References 1. Matson A, Sinha CK, Haddad M. Robotic Pediatric Surgery. In: Sinha CK, Davenport M, editors. Handbook of Pediatric Surgery. Cham(CH): Springer; 2022. p. 569–75. 2. Denning NL, Kallis MP, Prince JM. Pediatric Robotic Surgery. Surg Clin North Am. 2020;100:431–43. 3. Bergholz R, Botden S, Verweij J, et al. Evaluation of a new robotic-assisted laparoscopic surgical system for procedures in small cavities. J Robot Surg. 2020;14:191–7. 4. Boscarelli A, Giglione E, Caputo MR, et al. Roboticassisted surgery in pediatrics: what is evidence-based?a literature review. Transl Pediatr. 2023;12:271–9. 5. Esposito C, Masieri L, Castagnetti M, et al. Robotassisted vs laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO): technical considerations and results. J Pediatr Urol. 2019;15:667.e1–e8. 6. Lenfant L, Wilson CA, Sawczyn G, Aminsharifi A, et al. Single-port robot-assisted dismembered pyeloplasty with mini-pfannenstiel or peri-umbilical access: initial experience in a single center. Urology. 2020;143:147–52. 7. Baek M, Koh CJ. Lessons learned over a decade of pediatric robotic ureteral reimplantation. Investig Clin Urol. 2017;58:3–11. 8. Chaussy Y, Becmeur F, Lardy H, et al. Robot-assisted surgery: current status evaluation in abdominal and urological pediatric surgery. J Laparoendosc Adv Surg Tech A. 2013;23:530–8.

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9. Nakamura H, Taniguchi Y. Robot-assisted thoracoscopic surgery: current status and prospects. Gen Thorac Cardiovasc Surg. 2013;61:127–32. 10. Suematsu Y, Mora BN, Mihaljevic T, et al. Totally endoscopic robotic-assisted repair of patent ductus arteriosus and vascular ring in children. Ann Thorac Surg. 2005;80:2309–13. 11. Adams RD, Bolton WD, Stephenson JE, et al. Initial multicenter community robotic lobectomy experience: comparisons to a national database. Ann Thorac Surg. 2014;97:1893–8; discussion 1899–900. 12. Muñoz CJ, Nguyen HT, Houck CS. Robotic surgery and anesthesia for pediatric urologic procedures. Curr Opin Anaesthesiol. 2016;29:337–44. 13. Barbosa JA, Barayan G, Gridley CM, et al. Parent and patient perceptions of robotic vs open urological surgery scars in children. J Urol. 2013;190:244–50. 14. Villanueva J, Killian M, Chaudhry R. Robotic Urologic Surgery in the Infant: a Review. Curr Urol Rep. 2019;20:35. 15. Xu JM, Chang WJ, Jian M. Updates and prospect of da Vinci robotic surgical system in radical resection of rectal cancer. Chin J Oper Proc Gen Surg (Electronic Edition). 2020,14:9–12 (in Chinese). 16. Spinoit AF, Moreels N, Raes A, et al. Single-setting robot-assisted kidney transplantation consecutive to single-port laparoscopic nephrectomy in a child and robot-assisted living-related donor nephrectomy: initial Ghent experience. J Pediatr Urol. 2019;15:578–9. 17. Jones VS. Robotic-assisted single-site cholecystectomy in children. J Pediatr Surg. 2015;50:1842–5. 18. Kang SK, Jang WS, Kim SW, et al. Robot-assisted laparoscopic single-port pyeloplasty using the da Vinci SP® system: initial experience with a pediatric patient. J Pediatr Urol. 2019;15:576–7. 19. De Benedictis A, Trezza A, Carai A, Genovese E, Procaccini E, Messina R, et al. Robot-assisted procedures in pediatric neurosurgery. Neurosurg Focus. 2017;42:E7. 20. Khan K, Dobbs T, Swan MC, Weinstein GS, Goodacre TE. Trans-oral robotic cleft surgery (TORCS) for palate and posterior pharyngeal wall reconstruction: A feasibility study. J Plast Reconstr Aesthet Surg. 2016;69:97–100.

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Introduction of Robot-assisted Surgical Technology: the da Vinci Xi System Kun Zheng and Zhongkuan Lin

2.1 The Main Components and Characteristics of the da Vinci Xi System Surgical robots are an example of one of the most cutting-edge technologies that combines medicine, mechanics, electronics, and computer science [1]. The application of robotic technology to minimally invasive surgery is a major innovation in this field [2]. It not only expands the surgical capabilities of doctors, improves the accuracy and consistency of surgery, and shortens surgical procedure duration but also broadens the scope of application of minimally invasive surgery [3–5]. Robot systems have the advantages of extremely high operation accuracy, strong flexibility, and excellent repeatability and are much less affected by operator physiological factors, such as fatigue and emotion [6]. It has been shown to improve surgical outcomes in the medical literature [7, 8]. The da Vinci surgical robot system is currently the most widely used advanced surgical platform system in the world. Its tremor filtering and motion reduction system can guarantee surgical accuracy up to the submillimeter level [9]. Another important feature is the alleviation of anxiety about

K. Zheng (*) · Z. Lin Department of Clinical Engineering, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]; [email protected]

potential damage to adjacent tissues [10]. Its supporting equipment has seven degrees of freedom, breaking through the limit of the human hand traits and the rotatable wrist range of motion, and can realize flexible operation in narrow anatomical areas as well [11]. The da Vinci Xi series is the flagship device of the fourth-­generation surgical robot developed by Intuitive Surgical Inc [12]. It was cleared through the FDA510 (K) review back in April 2014 [13]. This surgical system can be used on both adult and pediatric patients. Da Vinci surgical robots are widely used in general surgery, urology surgery, thoracic surgery, gynecology surgery, cardiovascular surgery, and head and neck surgery [14]. The operating platform of the robot allows the operator to grasp, cut, dissect, approximate, ligate, cauterize, suture, transport, and place microwave and cryogenic ablation probes endoscopically with precise control of the da Vinci Xi EndoWrist instruments and accessories [6]. The safe use of such a system requires additional training for the surgical team and engineering service providers. The system is considered a major capital investment and requires facility planning both for its installation and support in the surgical area. The main components of the robot system include a surgeon console, a patient operation platform and an image processing platform, which are used together with endoscopes [14, 15], da Vinci Xi EndoWrist instruments, and accessories, as shown in Fig. 2.1.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_2

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a

b

c

d Fig. 2.1  System composition (a) surgeon console, (b) patient surgery platform, (c) image processing platform, (d) typical system and surgeon positions

2.1.1 Surgeon Console The surgeon console is the workstation that allows the surgeon to operate and control the robot system. The surgeon can fully control the operation, video, audio and system settings through a sitting operation. The surgeon console is usually positioned outside the sterile area of the operating room. The product design conforms

to human factors engineering principles, and the surgeon’s position can be adjusted accordingly to promote comfort and minimize fatigue and wear-­ and-­tear on the body during the operation [13, 16]. The surgeon sits by the console, with his or her hands and feet operating the two main controllers and foot pedals, respectively, that enable control of all the needed actions of the instrument and the endoscope. The observation window of

2  Introduction of Robot-assisted Surgical Technology: the da Vinci Xi System

the console provides clear views of the patient’s anatomy and the operating instruments, as well as icons and other user interface functions. The surgeon can view the three-dimensional picture with the naked eye in the observation window. When the surgeon carries out the operation under the observation window, he or she may grasp the manual controller with both hands and control the tip of the instrument in the field of view to operate. During this process, the controller can precisely and flexibly control the da Vinci EndoWrist instruments. The action ratio setting allows the surgeon to adjust the hand-to-instrument motion ratio seamlessly, which translates the surgeon’s hand, wrist, and finger motions with precision, achieving real-time synchronization between the tip of the surgical instrument and the surgeon’s hands [11]. In addition, the multiterminal input display function of the console’s TileProTM provides the whole surgical team with clear presentation of 3D images and other image information of the surgical field, plus the patient’s ECG images and ultrasound images as needed. In addition, according to various clinical needs, the dual-console system can be upgraded, which can not only meet the needs of two surgeons in joint operations but also facilitate the required training and guidance.

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that the system accommodates can be attached to other instrument arms as well. Furthermore, the platform has a built-in voice communication system to facilitate communication among members of the surgical team.

2.1.3 Image Processing Platform The image processing platform is also one of the core components of the robot system, which processes the data and image information. It mainly consists of the electronic system module, the endoscope control module, the video processing module, the VIO dV module, and the vision system module. It generates high-quality video images through advanced processing and control algorithms. The platform is equipped with a high luminance light source and a touchscreen monitor, plus image function capacity for up to four times digital zoom, to achieve surgical visual effects similar to open surgery. If equipped with high-definition fluorescence imaging capability, it can show and evaluate the real-time perfusion of blood vessels, bile ducts, and tissues, which is very helpful for the surgeon to make timely clinical judgment.

2.1.2 Patient Surgery Platform

2.1.4 Endoscope and EndoWrist Instrument

The patient surgery platform is a major operational component of the da Vinci Xi system. It includes four instrument arms and a laser positioning-assisted system. By being positioned next to the patient operating table with its easy placement at any location around the patient, it facilitates flexible surgical layout and increases the movement angle of surgical instruments. The instrument arm can be moved appropriately to a desired position with a greater range of motion to access a significant intraoperative surgical workspace by the rotating adjustable overhead boom and the laser positioning-assisted system. The endoscope and surgical instrument

The function of the da Vinci Xi electronic endoscope is to acquire high-definition (HD) three-­ dimensional (3D) videos from the surgical field. The endoscope has a diameter of 8mm and has two angle options of 0° and 30°. The EndoWrist instrument is a multipurpose swivel wrist surgical instrument used with the system, with a diameter of 8mm and a total length of 53  cm. EndoWrist instruments can be used for endoscopic operations during surgery, providing surgeons with natural flexibility and range of motion. It can achieve grasping, cutting, blunt and sharp peeling, approaching, ligation, electrocautery, suturing and other operations, which can acquire

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high-precision surgical results. During the operation, it is the patient-side assistant who performs the attachment and detachment of the endoscope and the surgical instrument in the sterile area. Meanwhile, the surgeon at the console controls the four arms to manipulate the surgical instruments and the endoscope.

run. Make sure that there is no error code displayed on the monitor of the image processing platform.

2.2 Introduction to the Basic Operation of the Robot System

The integrated cable of the endoscope is connected to the endoscope controller. If the LED next to the connector lights up, the endoscope detected by the system is properly connected, as shown in Fig. 2.3.

2.2.1 System Start-Up Assure that the electric power outlet intended to be used for the robot system has been tested and confirmed appropriately. All system components, namely, the image processing platform, patient operation platform, and surgeon console are connected to AC power accordingly, and each component is connected through cables as well. Press any single power button to power the entire system. The power switch positions are shown in Fig.  2.2. Once powered up, the robotic system will run a self-test first. During that period, all the components will conduct relative activities accordingly, and a ready sound is emitted afterwards once the system self-test has successfully

a

b

2.2.2 Connecting the Endoscope to the Image Processing Platform

2.2.3 Positioning and Docking of the Patient’s Surgical Platform First, the boom and instrument arm were adjusted to place the patient’s surgical platform next to the patient operating table. Subsequently, there are two methods for positioning and docking the patient’s surgical platform. The first choice is to use a Guided Setup. The system will be set up to the preset docking position according to the anatomical part intended to be worked on and the position of the surgical plat-

c

Fig. 2.2  The power switch positions of the surgeon console (a), patient operation platform (b), and image processing platform (c)

2  Introduction of Robot-assisted Surgical Technology: the da Vinci Xi System

a

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b

Fig. 2.3  Endoscope connection. (a) the integrated cable of the endoscope to the endoscope controller; (b) the LED light indicates that the system is connected

a

b

Fig. 2.4  Equipment installation before (a) and after (b). (a) the instrument housing into the sterile adapter; (b) if you hear the completion prompt sound means the device has been installed

form selected from the patient’s surgical platform touch pad. Guided setup is the easiest way to precisely place the patient’s surgical platform. However, if the Guided Setup cannot reach the desired position, by using manual controls, the height of the boom and the extension of the instrument arm can be adjusted to reach the appropriate positioning and surgical movement range.

2.2.4 Equipment Installation First, make sure that the wrist of the instrument is straightened and the jaws are closed, insert the end of the instrument into the sleeve, and press the instrument housing into the sterile adapter. If you hear the completion prompt sound, it means that the device has been installed, as shown in Fig. 2.4.

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Fig. 2.5  Adjust the position of the surgeon console

2.2.5 Adjustment of the Position of the Surgeon Console

2.3 Troubleshooting Common Problems

It is important to match the system’s console position with the dimensions of the surgeon’s body. The seat height, armrest height, height, and slope of the 3D observation window were adjusted, and the depth of the foot switch panel was adjusted by operating the ergonomic control switch, as shown in Fig.  2.5. First, adjust the height of the seat to ensure that the surgeon’s legs can move flexibly; second, adjust the position of the armrest so that the surgeon can rest comfortably on it while relaxing the shoulders; finally, adjust according to the surgeon’s personal preference. The height and slope of the 3D observation window and the depth of the foot switch panel can also be adjusted accordingly.

As described in the previous section, the robot system is a complex integration of many electronical mechanical and software components that have been developed and updated over the past 20 years. The development of this complex system was not without challenges. For example, between 2012 and 2018, the developer issued 25 product recalls of defects. It is important to fully understand the safe use and maintenance of such a system and be able to determine how to respond when a problem arises. Users should have in place a program to follow recall and system performance announcements issued by the vendor or regulatory authority.

2.2.6 System Shutdown Ensure that instruments and endoscopes are removed from the patient’s surgical platform. Use the channel clutch button to move the instrument arm far away from the patient. Move the patient’s operating platform away from the patient operating table. The Stow button on the touch screen of the patient’s surgical platform was used to retract the patient’s surgical platform. Press any power button on the equipment to switch off the system.

2.3.1 System Power Problems When any components of the system cannot start properly or cannot enter an automatic and controlled shutdown procedure, the system may exhibit abnormal behavior. Troubleshooting procedures: 1. Confirm that all the power cords of the surgeon console, patient operation platform, and image processing platform are connected correctly to the dedicated AC power outlets.

2  Introduction of Robot-assisted Surgical Technology: the da Vinci Xi System

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instrument arm LED indicator will light up in amber, and a related prompt message will be displayed on the screen. In such cases, pressing the port clutch button of the arm can release the additional force that may be applied to the patient.

2.3.3 The System Does Not Respond If the system does not respond or work properly, the problem must be investigated immediately according to the protocol with troubleshooting of the fault’s reason by the following methods:

Fig. 2.6  EPO switch

2. Confirm that the power switches on the surgeon console, patient operation platform, and image processing platform are set to the on position. 3. Check if the Emergency Power Off (EPO) button on the patient’s surgical platform has been pressed. Once it is pressed, it needs to be pressed again to reset the EPO button. The EPO switch is shown in Fig. 2.6. 4. Check if the blue system cable between the patient’s operating platform, the surgeon console and other core equipment is con­ nected appropriately.

2.3.2 Accidental Movement When the instrument arm is overloaded, it may cause accidental movement. Various factors can contribute to this problem, including applying excessive force to the patient and interfering with the patient’s surgical platform components. If the system detects any movement, the corresponding

(1) Check the information displayed on the screen to determine whether the system is performing a task. (2) Press the emergency stop button on the control panel of the patient’s operating platform or the surgeon console. (3) Press the fault recovery button on the touch pad or touch screen to confirm proper system functioning. (4) Press any power button on the device to restart the system. (5) If the system cannot be restarted, you need to mandatory shut down and then press any power button to start again . (6) If the problem persists, contact the vendor for further assistance.

2.4 Preventive Maintenance Preventive maintenance (PM) is an important measure to ensure that the robot system is in a safe and optimal working condition. Clinical engineers and manufacturers regularly maintain the system. The specific maintenance tasks are shown in Table 2.1. PM should be carried out at least once every half year during normal system operation and also required after troubleshooting, component or part replacement.

K. Zheng and Z. Lin

14 Table 2.1  Preventive maintenance items and contents Maintenance item Preliminary inspection

Equipment function check

Service mode function test

Electrical safety test Other tests

Content (a) Appearance inspection of the equipment (b) Inspection of the connection and condition of each power cord (c) Inspection of the connection between the components (d) Inspection of the data transmission fiber (e) Calibration of time (a) Drive check (b) Battery status check (c) Touch screen function check (d) Robot arm movement range check (e) Surgeon side console zero motion check (f) Surgeon side console movement and brake function check (g) Vision cart display support arm check (h) Trolley filter cleaning check (i) HRSV video check (j) SSC touch screen function check (k) PSC touch screen function check (l) VSC touch screen function check (m) VSC video system function check (n) Check system log (a) SUJ-Z count (b) USM sensor range detection (c) USM braking performance detection (d) USM motion detection of each node (e) USM motion resistance detection (f) Carriage Strength detection (g) USM level detection (h) USM motion range detection (i) SSC control arm function detection (j) Voice communication function detection (k) System log processing (l) Maintenance count reset (a) Ground resistance test (b) Leakage current test Check system software compatibility

References 1. Wang W, Wang WD, Yan ZY, et al. Development review of laparoscopic surgical robotic. CN Med Devices. 2014;29:5–10. (In Chinese). 2. Ghani RK, Trinh Q, Sammon J, et al. Robot-assisted urological surgery: Current status and future perspectives. Arab J Urol. 2012;10:17–22. 3. Norasi H, Tetteh E, Law KE, et al. Intraoperative workload during robotic radical prostatectomy: Comparison between multi-port da Vinci Xi and single port da Vinci SP robots. Appl Ergon. 2022;104:103826. 4. Moschovas MC, Bhat S, Sandri M, Rogers T, Onol F, Mazzone E, Roof S, Mottrie A, Patel V. Comparing the Approach to Radical Prostatectomy Using the Multiport da Vinci Xi and da Vinci SP Robots: A Propensity Score Analysis of Perioperative Outcomes. Eur Urol. 2021;79:393–404. 5. Wang RS, Ambani SN. Robotic Surgery Training: Current Trends and Future Directions. Urol Clin North Am. 2021;48:137–46. 6. Kallingal GJ, Parekh DJ. Rise of robotics in urologic surgery: current status and future directions. Expert Rev Med Devices. 2013;10:287–9. 7. Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC. Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems. Eur Urol. 2021;79:676–83. 8. Panteleimonitis S, Pickering O, Ahmad M, et al. Robotic rectal cancer surgery: Results from a European multicentre case series of 240 resections and comparative analysis between cases performed with the da Vinci Si and Xi systems. Laparoscopic, Endoscopic and Robotic Surgery. 2020;3:6–11. 9. Yang LS, Hou ZS, Tang W, et al. Development of Surgical Robots in Recent Years. Zhongguo Yiliao Qixie Zazhi. 2023;47:1–12. (In Chinese) 10. Hong W, Jin L. Overview of the Development of Spatial Positioning Accuracy Testing Technology for Surgical Robots. Zhongguo Yi Liao Qi Xie Za Zhi. 2023;47:32–7. (In Chinese) 11. Ahmad A, Ahmad ZF, Carleton JD, et al. Robotic surgery: current perceptions and the clinical evidence. Surg Endosc. 2017; 31:255–63. 12. Liu H, Xu M, Liu R, et al. The art of robotic colonic resection: a review of progress in the past 5 years. Updates Surg. 2021;73:1037–48. 13. Robotics Business Review. Intuitive Surgical Receives FDA Approval for New da Vinci Xi. 2014. https://www.roboticsbusinessreview.com/health-

2  Introduction of Robot-assisted Surgical Technology: the da Vinci Xi System medical/intuitive_surgical_receives_fda_approval_ for_new_da_vinci_xi/. Accessed 1 Aug 2023. 14. Wang G, Zeng Y, Sheng X. Robotic Surgery and Nursing. 1st ed. Springer Singapore; 2021. 15. Intuitive Surgical Inc. da Vinci Xi Surgical System. https://www.intuitive.com/en-us/prod-

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ucts-and-services/da-vinci. Accessed 1 Aug 2023. 16. Catchpole K, Bisantz A, Hallbeck SM, et al. Human factors in robotic assisted surgery: Lessons from studies ‘in the Wild’. Appl Ergon. 2019;78:270–6.

3

Robotic Operating Room Configuration Hang Yan Zhao and Chunyan Zhan

3.1 Robotic Operating Room Configuration The area of the da Vinci Robotic Operating Room is recommended to be approximately 60 m2 to easily move the equipment flexibly. In the overall layout, fully consider the use of doors, power sockets and overhead structures. The doctor’s console is fixed on the wall outside the central area of the operating room, ensuring that the surgeon can look directly at the operating area and communicate with the assistant. The patient’s surgical platform is placed on the principle of ensuring the largest patient-side contact area [1]. The da Vinci Xi system supports 2700 patient contact areas, which can be placed anywhere around the patient. According to our experience, placing the patient’s surgical platform on the right side of the patient can meet most operations [2]. For surgery where the target anatomical site is not in the midline, such as kidney surgery, the patient’s operating platform should be placed on the side of the target anatomical site. The image processing platform is placed on the side of the end of the operating bed to ensure that the operator of the patient operat-

H. Y. Zhao (*) · C. Zhan Department of Pediatric Surgery Room, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

ing platform can see the image processing platform components and touch screen and fix the equipment compatible insufflator, energy platform, electric knife, and other equipment in the image processing platform host, which not only saves space but also reduces repeated movement and connection of equipment. Display equipment is installed on the mobile arm or wall to facilitate the operator of the patient’s surgical platform to obtain image information from multiple angles. In the limited operating room space, reasonably adjust the spatial layout of the power supply, air source, various information interfaces and medical equipment to reduce the interference of equipment layout on laminar flow, ensure the safety of the operating environment and improve the work efficiency of relevant personnel and patient satisfaction [1].

3.2 System Cable Management 1. The system cable is 20 m long, and the cable core is optical fiber. Take care to avoid trampling and bending the cable. The minimum safe bending radius is 2.54 cm, which can be wiped with a soft cloth [1]. 2. During the operation, the cable was placed between the shaft of the endoscope and the arm of the instrument, and the cable of the endoscope was handled carefully during the operation to avoid severe bending or kinking [3].

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_3

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3.3 Endoscope Management 1. The distal end of the endoscope may reach a high temperature of 50–55  °C during use. When the endoscope controller is turned on, avoid contact with skin, tissues, cloth dressings, etc., to prevent skin burns. 2. When the endoscope lens is connected to the system and emits light, avoid looking directly at it. 3. When the endoscope is fogging, immerse the lens end in 50  °C warm water for 10  s (the temperature does not exceed 55  °C, and the time does not exceed 15 s). 4. Lay a sterile table to place the 3D endoscope camera separately, connect it to the endoscope controller 30  min in advance to preheat it, place it between the image processing platform and the end of the operating table, cover it with sterile towels, and leave the surroundings empty to avoid pollution [4].

3.4 Endo Wrist Device Management 1. According to the needs of specialist surgery and the usage habits of surgeons, the special equipment is configured as a package of specialist surgery equipment. Instruments that are not commonly used or of variable frequency are sterilized separately for easy turnover. EndoWrist instruments are programmed to be used a predetermined number of times. At the same time, attention should be given to the limitation of the maximum number of sterilizations of the instruments to avoid the possibility of not being used after sterilization [4]. 2. Establish equipment use files to record equipment name, use date, use status, repair application, and other information for easy traceability. 3. Disposal after use: When cleaning the instrument during the operation, the scrub nurse uses moist gauze to wipe off the blood on the tip and surface of the instrument. During the operation, the tip of the instrument was kept free of blood scabs and tissue attachment.

H. Y. Zhao and C. Zhan

After the operation, the instrument should be pre-­treated in time and placed properly for transportation. The scrub nurse and the nurse in the supply room handed over face-to-face and handed over detailed information on the instrument such as the name, quantity, use status, and completeness. After sterilization is completed, the instruments are placed in a dedicated rack for storage [5].

3.5 Intraoperative Control and Instrument Arm Management According to the age of the child, the pneumoperitoneum pressure is maintained at 6–10 mmHg, the flow rate is 2–4 L/min, and the single-bipolar coagulation is maintained at 15–20. Children’s abdomen operation space is limited, and the distance between the holes is closer than that of adults [6]. To ensure the maximum reach and minimum arm interference, the instrument arms should be arranged in parallel to maintain a punch distance of the mechanical arms, and attention should be given to the operating conditions to avoid equipment collisions. When replacing the operating forceps, ensure that the front joints remain straight to prevent shifting of the tip of the operating forceps and damaging the tissue when the operating forceps enter for the second time. At the same time, attention should be given to the gap between the child and the distance between the robotic arm and the child’s body to avoid squeezing. After the operation, remove the robotic arm, remove the sterile protective cover, and retract the robotic arm to the smallest extent [7].

3.6 Personnel Management and Training 3.6.1 Da Vinci Operating Room Personnel Management Strictly controlling the entry and exit of personnel, except for the surgeon, anesthesiologist, and nurse of this surgery, the rest of the staff are not

3  Robotic Operating Room Configuration

allowed to enter the robot operating room to visit. The instrument is hung with eye-catching signs to avoid accidental damage or collisions caused by unqualified personnel [1].

3.6.2 Establish da Vinci Surgical Medical Team The da Vinci robotic surgery medical team was established before the operation, and nurses who had rich experience in specialist open surgery and proficient in cooperation with laparoscopic surgery were selected to participate in the professional training of the da Vinci robotic surgery system [8]. Before the operation, the team conducts preoperative simulation training, sets up various simulation scenes of robotic surgery, and repeats the practice, so that the nurses can achieve the team skills required for the work, and obtain professional certificates after the assessment [9].

3.6.3 Nurse Training The da Vinci Surgical Nursing Specialist Group, which is jointly trained by nurses with professional certificates and equipment engineers, was established to provide standardized and staged training for new nurses in the specialist group. Establish a training package including theoretical training, operational training, and simulation training, and modularize the training content according to the training period [10]. The training content includes the knowledge of the robotic surgery system, which includes the performance of robotic surgery equipment, use procedures, operating methods, equipment names, uses, disassembly and cleaning, installation methods, daily maintenance, fault identification and preliminary. After completing all the content of the training package, the theory and operation assessment will be carried out, and then the next stage of simulation training can be entered after passing the assessment. Simulation training is mainly to simulate the operation site, use similar equipment to increase its realism, and simulate many special situations that may occur during the

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o­ peration, which helps to improve the learning effect. Its practice content includes preoperative preparation, space layout, placement of the surgical position, layout of the surgical hole, and placement of the bedside arm system. Only after completing all training content and passing the assessment can the nurse serve as a robotic surgery nurse. Finish the special operation cooperation manual used as daily training, including pathophysiology, article preparation, anesthesia methods, surgical positions, surgical platform paths, surgical procedures, precautions, and personnel station maps [11].

3.7 Position Placement of Pediatric Robotic Surgery 1. Supine position: When the newborn is placed in the posture, the overall body of the child should be raised by 10–15 cm to increase the operating space of the robotic arm and avoid collisions between the robotic arm and the operating table. (a) The child is placed in the supine position with the head high, and the restraint belt is used to properly fix the child, paste a film sticker on the bone carina position bone of the child, place a silicone head ring under the head with cloth glue, and place a home-made water bag on the body with gloves on the limbs to prevent pressure ulcers. Properly arrange venous access, urinary catheters, zinc wire, etc., to prevent skin damage. It is suitable for the radical treatment of choledochal cysts, malrotation of the intestine, circular pancreas, etc. (b) The child is placed in the supine position with the head low, the chest is lined with cotton pads and fixed with cloth tape, shoulder pads are placed under the shoulders on both sides to prevent the patient from sliding down when the head is low and the feet are high or the patient’s position changes or accidents, placed under the head circle, the limbs are put into the water bag, and the lower limbs are fixed

H. Y. Zhao and C. Zhan

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with restraint straps. For urology patients, the hips are raised, the head is lowered in the supine position, and the knees are fixed with cloth glue lined with cotton pads. It is suitable for anal atresia, megacolon, ovarian cysts, vesicoureteral replantation, prostate cysts, etc. 2. Lateral position: (a) General thoracic surgery: The child is lying on the contralateral side at 90°, with a head circle under the head, and a semicircular soft cushion under the armpit to ensure that the gap between the side ribs of the patient is enlarged. The surgical site is exposed and the patient’s blood vessels and nerves are not compressed. In addition, place two U-shaped silicone pads was placed on the abdomen and back to fix the child. The upper limb of the contralateral side is stretched out 90°, and the restraint belt is fixed stably. The iliac area is reinforced with cloth glue. A soft pillow was placed between the lower limbs, straightening the lower limbs of the contralateral side, and flexing the lower limbs of the affected side 90°. Water bags were placed between the feet. Suitability for lobectomy, mediastinal tumor, PDA ligation, etc [12]. (b) Urology: The child is lying on the contralateral side at 60°, close to the bedside of the contralateral side, expanding the operating space of the robotic arm. The head ring is placed under the head, and a U-shaped silicone was placed on the back for fixation with wide tape. A soft pillow was placed between the lower limbs, the lower limb of the contralateral side was straightened, the lower limb of the affected side was extended, and water bags were placed on the feet. Attentions should be given to the use of soft pads to

protect the skin of the patient’s vulnerable parts and keep the joints in a functional position. Suitability for renal pelvic ureteral anastomosis, nephrectomy, adrenal tumors, and etc.

References 1. Zeng J.  Design of the compound operating room with da Vinic robotic surgical system. China Medical Devices. 2016;31:121–3. in Chinese) 2. Giedelman C, Covas Moschovas M, Bhat S, et al. Establishing a successful robotic surgery program and improving operating room efficiency: literature review and our experience report. J Robot Surg. 2021;15:435–42. 3. Lenihan JP Jr. How to set up a robotic-assisted laparoscopic surgery center and training of staff. Best Pract Res Clin Obstet Gynaecol. 2017;45:19–31. 4. Larkins K, Mohamed JE, Mohan H, et al. How I Do It: Structured Narration for Cognitive Simulationbased Training in Robotic Surgery. J Surg Educ. 2023;80:624–8. 5. Jin Y, Zhang Y, Cai D, et al. Robot-Assisted Resection of Intestinal Duplication in Children. J Laparoendosc Adv Surg Tech A Part. 2022;32:1288–92. 6. Suo J, Hua R, Li N, et al. Cleaning and sterilization management of Da Vinci robot surgical instruments. Chinese J Disinfect. 2017;34:97–9. 7. Zhang H, Zeng Z, Cheng G, et al. Scientific management of the introduction of Da Vinci surgical robot into the use process. Beijing Biomedical Engineering. 2021;40:101–4. 8. Wu K, Zhang X. Application value of specialist group management in Da Vinci robot surgical instrument management. Medical Equipment. 2019;32:61–2. 9. Wei A, Li S, Pei H, et al. Application of fine management in Da Vinci robot surgical instrument management. J Modern Med Health. 2021;37:345–7. 10. Yu X, He M. Application of modular training model in coordination training for robotic surgery. Chinese J Robot Surg. 2022;3:217–23. 11. Shen X, Shi Z, Zhou Y, Yang J. Training of operating room nurses over Da Vinci robot surgery based on checklist management. J Nurses Sci. 2022,37:34–6. 12. Tan B, Guo D, Tang L, et al. A comparative study of two kinds of posture placement by robot-assisted laparscopic radical prostatectomy. J Nurses Train. 2019;34:1043–5.

4

Pediatric Anesthesia for Robotic Surgery in Children Jinjin Huang and Yaoqin Hu

Along with the rapid development of minimally invasive techniques, laparoscopy and thoracoscopy have become increasingly mature and are widely used in pediatric surgeries. Robotic surgery is the result of transformation in the minimally invasive surgical evolution [1]. Currently, the use of robotic platforms is widely accepted in many adult surgeries, especially urologic and gynecologic operations. The use of robotic surgery in pediatric patients is almost a decade later than in adults. Due to the limitations of equipment and technology, the application of robotic surgery in pediatrics lags behind that in adults. The advantages of robotic-assisted surgery (RAS) include smaller surgical incisions, improved precision, improved accuracy of the movements, less pain, and shorter hospital stays. The limitations of RAS may be the size of robot, the size of the patients, the cost, and so on. Therefore, all these factors may result in more complicated anesthetic management, particularly in younger children, such as neonates and infants. It is necessary to acquire proficiency in the pathological and physiological changes asso-

ciated with pneumoperitoneum/pneumothorax, and be aware of the potential complications, so that we can provide safer and more effective anesthesia for pediatric patients undergoing robotic surgery. In addition, we should pay more attention to the influence of patients’ position, lengths of operating time, loss of water, and so on (Fig. 4.1).

Fig. 4.1  Robot arm

J. Huang (*) · Y. Hu Department of Anaesthesiology, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_4

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4.1 Robotic-Assisted Thoracoscopic Surgery Robotic approaches have been used in many chest surgeries, including surgeries for congenital diaphragmatic hernia, esophageal atresia, mediastinal cysts, diaphragmatic hernia, pulmonary lobectomy, esophageal cysts, and patent ductus arteriosus [2–6], with outstanding shortterm outcomes. The concerns and key points of anesthesia were have changed equally since the development of technology. Compared with minimally invasive surgery performed in other regions of the body, robotic-assisted thoracoscopic surgery (RATS) is full of different challenges. Specific anesthetic considerations for RATS includes the size of the robotic surgery device, which may limit the ability of anesthesiologist to access the patients, the patient positions, and the absorption of CO2, which insufflates in the thorax [7]. RATS may require the anesthetist to use the one-­lung ventilation (OLV) technique to provide satisfactory visualization for surgeon. The lungs of infants are softer and easier to compress than those of adults. Moreover, the residual volume is larger and nearly equal to the functional residual capacity (FRC) in young children. Therefore, if the healthy lung is only ventilated, even in tidal breathing, lung compliance will decrease, and airway closure will increase. For the pediatric population, the intercostal space and thoracic cavity are much smaller than those in adults, and lung isolation techniques are also not as mature as

J. Huang and Y. Hu

those in adults. Before the robot is docked, bronchofiberscope should be used to confirm the optimal position of the endotracheal tube. During the period of one-­ lung ventilation, pressure-controlled ventilation may provide superior serum oxygen tension and reduced peak airway pressures compared rather than volume-controlled ventilation [8]. Patient positioning plays an important role in the surgery. The position of RATS is lateral, similar to the position of VATS, which limits the ability of anesthetist to access to the patient’s arms and face. Therefore, the anesthesiology team should ensure that patients are visible and accessible. Additionally, robotic surgery has the risk that robotic arms may injure the patients, with additional potential for facial injuries [9], and we should check patients’ facial frequently. Infant has small thoracic size. During RATS, the hydrostatic pressure gradient between dependent and nondependent lungs will decrease, which will inhibit hypoxic pulmonary vasoconstriction. Therefore, infants in the lateral position during one-lung ventilation(OLV) will be more susceptible to hypoxia [10]. The surgeon insufflates CO2 into the thorax to obtain a wider visualization. However, systemic absorption of carbon dioxide(CO2), which insufflates into the intrapleural cavity, may lead to hypercarbia [11]. The shift of intrathoracic structures will lead to hemodynamic effects. Therefore, maintain the flow rates and pressure as low as possible when infusing carbon dioxide into the chest (Fig. 4.2) [12].

4  Pediatric Anesthesia for Robotic Surgery in Children

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b

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c

d Fig. 4.2  The child patient needs to undergo single-lung ventilation. (a) fiber bronchoscopy view of the tracheal bifurcation and carina; (b) fiber bronchoscopy left main

4.2 Robotic-Assisted Urologic Surgery Pediatric urological surgery is one of the most common surgeries that employs robotic assistance in children. Pyeloplasty, surgery for treating vesicouretric reflux, nephrectomy, and heminephrectomy are the most commonly performed operations. The concerns about anesthesia in robotic-assisted urologic surgery are patient positioning, pathophysiological changes in the pneumoperitoneum, and absorption of CO2. In general, patients with congenital malformation of the urogenital system often undergo minimally invasive surgery. Those patients are always associated with heart mal-

bronchus occlusion procedure; (c) image of trachea bifurcation under fiberoptic bronchoscope; (d) ventilator parameters during sing

formations [13]. Therefore urological conditions are always a signal to rule out congenital heart disease. Those patients concerns about renal insufficiency, anemia, electrolyte imbalance, metabolic problems, and hypertension. In pediatric patients, a pneumoperitoneum pressure of 4–12 mmHg is usually enough to explore the surgical area and provide an adequate surgical field of vision, because prepubertal children have softer abdominal walls and smaller peritoneal cavities than adults [14]. In addition, because of the increasing intraperitoneal pressure, the diaphragm will be elevated. Therefore, the functional residual capacity and lung compliance will decline, airway resistance and physiological dead space will increase, and V/Q will mismatch [13].

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Position has different effects on the circulatory system, including cardiac output and blood pressure. The head-up position will reduce venous return of the heart blood volume and cardiac filling pressure. Additionally, some urological surgeries require lithotomy, in the lateral or prone position, which will result in potential nerve injuries. In addition, the steep Trendelenburg position will reduce lung compliance and induce inspiratory pressure increases, which increase the risk of barotrauma in patients. In several cystoscopy and prostate surgeries that require the use of irrigation solution, it may be difficult to estimate blood loss and increase the risk of a reduction in body temperature. Children have a larger body surface area to mass ratio and thinner subcutaneous fat, which will make them more prone to lose heat. We can use warming blanket, infusion warming, and forced air warmers to avoid hypothermia. The insuffing fluid should be warmed, and the flow velocity should be less than 2 L/min [15].

4.3 Robotic-Assisted General Surgery The applications of robotic-assisted general surgery include colectomy [16], fundoplication, and so on. RAS(robotic-assisted surgery) requires carbon dioxide insufflation into the abdomen to provide effective visualization. Meanwhile some patients may need a reverse or steep Trendelenburg position. The pneumoperitoneum will increase intra-­ abdominal pressure (IAP). Increased IAP may affect the circulatory and respiratory systems. When carbon dioxide is insufflated in the abdominal cavity, the diaphragm is shifted to the cephalic side. This will potentially influence the position of tracheal intubation, so anesthetists should assess the bilateral breath sounds frequently, especially in young children who have lower mainstem bronchi length. All these factors may lead to several influences on the respiratory system, including decreased functional residual capacity, lower lung compliance, and high airway

J. Huang and Y. Hu

resistance. Therefore, it will change the ventilation/ perfusion (V/Q) ratio and increase dead space ventilation, which can result in hypoxemia and hypercarbia. Position and CO2 absorption may influence the circulatory system, including the increased systemic vascular resistance, higher pulmonary vascular resistance, and decreased cardiac index [7]. The pneumoperitoneum and reverse-Trendelenburg position may lead to an increase in stroke volume variation (SVV), MSFP and central venous pressure (CVP) and a decrease in the microcirculatory perfusion index [17]. In addition, with the increase in IAP levels, the inferior vena cava may be compressed, resulting in a reduction in venous return ,which can lead to decreased cardiac output and hypotension. In healthy pediatric patients, these changes can be compensated for a limited time and can easily offset by changes in ventilator parameters [18, 19]. However, in patients with pre-­existing myocardial function injury, the impact may be magnified. Anesthetists should pay more attention to patients with congenital heart disease (CHD ).

4.4 Robotic-Assisted Cardiac surgery Currently, several cardiac operations also use robotic surgical systems, such as patent ductus arteriosus closure, atrial septal defect closure, ASD closure [20], and mitral valve replacement [5, 21– 24]. Patients undergoing robotic cardiac surgery need to be selected, especially in totally endoscopic robotic surgery. Factors limiting the RACS include the size of thorax and the distance between the mediastinum and anterolateral chest wall. Anesthetists should pay more attention to assessing whether the patient can tolerate the effects of pneumothorax on respiration and circulation and have a longer operation time compared to traditional surgery. The plan for the induction of anesthesia is similar to the open procedure. Intraoperative monitoring included invasive blood pressure, pulse oximetry, EtCO2, central venous pres-

4  Pediatric Anesthesia for Robotic Surgery in Children

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patient positioning, such as Trendelenburg and lithotomy, pneumoperitoneum, and prevention of its associated complications [27].

4.6 Neonatal Robotic Surgery

Fig. 4.3  PDA ligation assisted by robot

sure, and ECG.  After the induction of anesthesia, some surgeries need one-lung ventilation; in some research, a left-sided double-­lumen endotracheal tube (DLETT) is preferred for mitral valve replacement [25]. The influences of OLV are the same as those of RATS.  In robotic surgeries, transesophageal echocardiography(TEE) was routinely checked, and the probe was placed through the surgeries. The process of placing a special cannula for extracorporeal circulation and cardioplegia is the same as in traditional cardiac surgery. Patients are always in lateral decubitus to meet the needs of surgery, and anesthetists should understand the effect of the patients’ position, OLV, and surgical manipulation. In the same time, every staff member should be trained to be able to quickly remove the robotic arms from the patient so that to convert to an open sternotomy (Fig. 4.3).

4.5 Robotic-Assisted Surgery in Pediatric Gynecology In the field of pediatric gynecology, the use of robotic-assisted surgery is not as wide as in other departments . The use of robotic surgeries includes ovarian cystectomy, exploration for ­suspected malformation, and oophorectomy for gonadal dysgenesis [20, 26]. During surgery, the anesthetic considerations include the influence of

The physiology of preterm and term neonates is quite different from that of adults, and the function of every system has not developed completely. Neonates have a fast respiratory rate of approximately 40 cpm at rest. In neonates, the thorax is cylindrical, the intercostal muscles are weak, and breathing mainly depends on the action of the diaphragm [28, 29]. However, the diaphragm of neonates is prone to fatigue. Additionally, the respiratory control system is immature in neonates, and the ventilation response when suffering hypercapnia and hypoxia is incomplete [30]. In awake neonates, functional residual capacity (FRC) is similar to that in adults, but alveolar ventilation is doubled. The heart rate of neonates fluctuates over a wide range, ranging from 90 to 160 bpm, and cardiac output is exquisitely heartrate dependent. Therefore, the neonate does not improve cardiac output by increasing heart rate or adjusting total peripheral vascular resistance. Circulation in the neonate is similar to the situation comparable to compensated shock in adults. The peripheral vascular resistance of neonates is high and cardiac output is mainly distributed in vital organs, such as the brain and heart. In addition, in neonates, the function of the thermal regulating center is imperfect, the surface area is lager, the layer of insulating subcutaneous fat is thinner, and skin keratinization is lower. These factors may result in susceptibility to perioperative hypothermia in neonates. The considerations of neonatal robotic surgery [31]: 1. The size of the surgical robot 2. Patients size: smaller cavities leading to decreased workplace size 3. The time of docking the robot 4. The influence of pneumoperitoneum/pneumothorax

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The main influence of robot-assisted abdominal surgery is the pneumoperitoneum. During surgery, because of CO2 insufflation, with the increase in IAP, respiratory function and pulmonary mechanics will be affected. Additionally, because of the pneumoperitoneum, the diaphragm is pushed cephalad, which may reduce respiratory compliance and functional residual capacity [11]. Thus, it can cause atelectasis, which may potentially result from hypoxemia due to the neonate’s low closing volume. Headdown tilt positioning can also aggravate the loss of FRC [32]. As CO2 is absorbed, the risk of hypercarbia is higher in younger children than in older children. The pneumoperitoneum might further deteriorate V/Q mismatch. During surgery, it is necessary to limit the IAP to under 6 mmHg in neonates [33] and apply an appropriate PEEP.  For the sake of protecting neonates from intraoperative hypothermia, there are several simple measures such as raising the operating room temperature to 28 °C or 30 °C, using a warming blanket, warming the solution for surgical sterilization, and administering warm infusion solutions and blood [34].

References 1. Shen LT, Tou J. Application and prospects of robotic surgery in children: a scoping review. World J Pediatr Surg. 2022;5:e000482. 2. Ballouhey Q, Villemagne T, Cros J, et al. Assessment of paediatric thoracic robotic surgery. Interact Cardiovasc Thorac Surg. 2014;20:300–3. 3. Obasi PC, Hebra A, Varela JC. Excision of esophageal duplication cysts with robotic-assisted thoracoscopic surgery. JSLS. 2011;15:244–7. 4. Meehan JJ. Robotic surgery in small children: is there room for this? J Laparoendosc Adv Surg Tech A. 2009;19:707–12. 5. Suematsu Y, Mora BN, Mihaljevic T, et al.  Totally endoscopic robotic-assisted repair of patent ductus arteriosus and vascular ring in children. Ann Thorac Surg. 2005;80:2309–13. 6. Anderberg M, Kockum CC, Arnbjornsson E. Morgagni hernia repair in a small child using da Vinci robotic instruments – a case report. Eur J Pediatr Surg. 2008;19:110–12.

J. Huang and Y. Hu 7. Wakimoto M, Michalsky M, Nafiu O, et al. Anesthetic implications of robotic-assisted surgery in pediatric patients. Robot Surg. 2021;8:9–19. 8. Hammer GB. Single-lung ventilation in infants and children. Paediatr Anaesth. 2004;14:98–102. 9. Mukhtar AM, Obayah GM, Elmasry A, et al. The therapeutic potential of intraoperative hypercapnea during video‐assisted thoracoscopy in pediatric patients. Anesth Analg. 2008;106:84–8. 10. Sauvat F, Michel JL, Benachi A, et al. Management of asymptomatic neonatal cystic adenomatoid malformations. J Pediatr Surg. 2003;38:548–52. 11. Mukhtar AM, Obayah GM, Elmasry A, et al.  The therapeutic potential of intraoperative hypercapnia during video-assisted thoracoscopy in pediatric patients. Anesth Analg. 2008;106: 84–8. 12. Geraci Travis C, Prabhu S, Brent L, et al. Intraoperative anesthetic and surgical concerns for robotic thoracic surgery. Thorac Surg Clin. 2020;30:293–304. 13. Means LJ, Green MC, Bilal R.  Anesthesia for minimally invasive surgery. Semin Pediatr Surg. 2004;13:181–7. 14. De Waal EE, Kalkman CJ.  Haemodynamic changes during low-pressure carbon dioxide pneumoperitoneum in young children. Paediatr Anaesth. 2003;13:18–25. 15. Hammer G, Hall S, Davis PJ.  Anesthesia for general abdominal, thoracic, urologic, and bariatric surgery. Smith’s anesthesia for infants and children, vol. 2006. 7th ed. Pennsylvania: Elsevier Inc; 2006. p. 686–8. 16. Xie X, Li Y, Li K, et al. Total robot-assisted choledochal cyst excision using da Vinci surgical system in pediatrics: Report of 10 cases. J Pediatr Surg. 2021;56:553–8. 17. He H, Gruartmoner G, Ince Y, et al. Effect of pneumoperitoneum and steep reverse-Trendelenburg position on mean systemic filling pressure, venous return, and microcirculation during esophagectomy. J Thorac Dis. 2018;10:3399–408. 18. Neira VM, Kovesi T, Guerra L, et al. The impact of pneumoperitoneum and Trendelenburg positioning on respiratory system mechanics during laparoscopic pelvic surgery in children: a prospective observational study. Can J Anesth. 2015;62:798–806. 19. Kalfa N, Allal H, Raux O, et  al. Tolerance of laparoscopy and thoracoscopy in neonates. Pediatrics. 2005;116:e785–91. 20. Pelizzo G, Nakib G, Calcaterra V. Pediatric and adolescent gynecology: Treatment perspectives in minimally invasive surgery. Pediatr Rep. 2019;11:8029. 21. Onan B, Aydin U, Kadirogullari E, et al. Totally endoscopic robotic-assisted cardiac surgery in children. Artif Organs. 2019;43:342–49.

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22. Cannon Jeremy W, Howe Robert D, Dupont Pierre E, et al. Application of robotics in congenital cardiac surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2003;6:72–83. 23. Ümit GA, Şahin Ş, Egemen E, et  al. Feasibility of robotic-assisted atrial septal defect repair in a 6-year-­ old patient. Int J Med Robot. 2021; 17:e2185. 24. Le Bret E, Papadatos S, Folliguet T, et al. Interruption of patent ductus arteriosus in children: robotically assisted versus videothoracoscopic surgery. J Thorac Cardiovasc Surg. 2002;123: 973–6. 25. Rehfeldt KH, Andre JV, Ritter MJ. Anesthetic considerations in robotic mitral valve surgery. Ann Cardiothorac Surg. 2017;6:47–53. 26. Nakib G, Calcaterra V, Scorletti F, et al. Robotic assisted surgery in pediatric gynecology: promising innovation in mini invasive surgical procedures. J Pediatr Adolesc Gynecol. 2013;26: e5–7. 27. Mishra P, Gupta B, Nath A. Anesthetic considerations and goals in robotic pediatric surgery: a narrative review. J Anesth. 2020;34:286–93.

28. Jin Y, Chen Q, Zhang Y, et al. Robot-assisted resection of choledochal cysts in children weighing less than 6 kg. Br J Surg. 2023;110:267–8. 29. Jin Y, Zhang Y, Cai D, et al. Robot-assisted resection of intestinal duplication in children. J Laparoendosc Adv Surg Tech A. 2022;32:1288–92. 30. Carroll JL, Agarwal A. Development of ventilatory control in infants. Paediatr Respir Rev. 2010;11:199–207. 31. Bergholz R, Botden S, Verweij J, et al. Evaluation of a new robotic-assisted laparoscopic surgical system for procedures in small cavities. J Robot Surg. 2020;14:191–7. 32. Regli A, Habre W, Saudan S, et al. Impact of Trendelenburg positioning on functional residual capacity and ventilation homogeneity in anesthetized children. Anesthesia. 2007;62:451–5. 33. Truchon R. Anesthetic considerations for laparoscopic surgery in neonates and infants: a practical review. Best Pract Res Clin Anesthesiol. 2004;18:343–55. 34. Hillier SC, Krishna G, Brasoveanu E. Neonatal anesthesia. Semin Pediatr Surg. 2004;13:142–51.

5

Robotic Resident and Fellow Training Qiang Shu and ZongWei Huang

With the continuous development and progress of medical technology, minimally invasive surgery has become a major trend in the development of surgical procedures. Clinical surgery is also gradually changing from traditional open surgery to minimally invasive surgery. In the field of minimally invasive surgery, surgical techniques have evolved again from general laparoscopic techniques to robotic surgical systems. This shows that medical technology can be described as rapidly changing. In Europe and the United States, robotic surgery has been widely popularized. In recent years, an increasing number of hospitals in China have started to apply robotic surgery technology. In China, the installed base of da Vinci robots and the number of surgeries are also increasing year by year. While robotic surgery presents opportunities for modern medicine, it also presents challenges. In particular, learning and training in robotic surgery is a daunting and extremely important task. In recent years, there has been a large body of literature reporting a high incidence of compliQ. Shu Department of Cardiac and Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected] Z. Huang (*) Department of General Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

cations associated with robotic surgery. For example, in 2013, the U.S.  Food and Drug Administration (FDA) reported 3697 adverse events of robotic surgery. In summary, the causes were mainly due to inadequate training of the robotic system [1]. Therefore, in the process of standardized training in robotic surgery, it is particularly important to ensure the safety of patients’ lives and improve the skill level and expertise of surgeons. The Society of American Gastroenterology Surgery (SAGES) and the Minimally Invasive Robotic Association (MIRA) state that surgeons must undergo specialized training before using robotic surgery. Only after rigorous training and passing an examination can a surgeon perform robotic surgery [2].

5.1 The Current State of Robotics Training Today, international training programs in robotic surgery are primarily provided by the U.S. Food and Drug Administration (FDA), which has authorized the da Vinci robot manufacturer, Intuitive Surgical, to provide training certification for surgeons using the system. The company’s professional technicians usually conduct this training. The training aims to provide the participants with the basic skills to operate the da Vinci robot through standardized training. In addition, the basic skills training curriculum (BSTC) and the fundamental skills of robotic surgery (FSRS)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_5

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can establish standards for the curriculum of robotic surgery training [3, 4]. To standardize the curriculum and certification of robotic surgeons, in 2013, 14 international surgical society organizations worked together to develop the Fundamentals of Robotic Surgery (FRS) training standard [5]. The criteria indicate that the safe performance of robotic surgery is the essential skill that surgeons need to master. However, both the developers and raters of the current training program are drawn from robotic surgery certification bodies. Due to the lack of a third-party organization to determine the rating results, there is a possibility of unclear or somewhat subjective scoring criteria. Intuitive Surgical’s robotics training standards divide training into preclinical and clinical phase training. Preclinical training consists of three courses: an e-learning course, a live simulation course, and an animal experiment course. After that, they needed to enter the clinical period training, go through the process of surgical observation, serve as the first assistant of surgery, operate under the supervision of senior doctors, and complete 15 cases of robotic surgery within 3 months before they could officially obtain the qualification certificate of da Vinci surgery robotic surgery issued by Intuitive Surgical, Inc., authorized by the National Health Planning Commission. When the da Vinci robot was first introduced, most of the robotic surgery training for domestic and foreign surgeons had to be conducted at the Jockey Club Minimally Invasive Surgery Training Centre at the Chinese University of Hong Kong. Courses at this training center included operating room layout, surgical system preparation, patient position placement, surgical operation pathways, and robotic surgery application skills [6]. With the establishment of the da Vinci International Training Center at the General Hospital of the Chinese People’s Liberation Army in Beijing and the da Vinci International Training Center at Shanghai Changhai Hospital, these two training centers are gradually becoming the main training bases for robotic surgery in China. In addition, a robotic training simulation center based on a Mimic simulator was established in Tianjin,

Q. Shu and Z. Huang

which has actively explored the systematization and localization of robotic surgery training. At present, the installed volume of da Vinci robots and surgical procedures in China is increasing rapidly. However, the training system for robotic surgery still needs to be improved, and the standardization of robotic training is lagging behind hardware construction.

5.2 Preclinical Training 5.2.1 Online Learning Courses In robotic surgery training, the first step is to learn the theoretical knowledge and understand the basic knowledge of the development history of robots, machine models, operation principles, machine structure, names, and performance of each component, so that trainees can fully realize the advantages of robotic surgery systems. Theoretical knowledge of robotics is the foundation of the training course, and this phase of the course can be learned through online platforms. Currently, the main online learning platforms are Intuitive Surgical and FRS.  Intuitive Surgical’s online learning courses focus on robot structure and operational features, while FRS’s online learning courses focus on robot surgery theory and anatomy. One of them, the online learning platform of Intuitive Surgical (https://www.davincisurgerycommunity.com), grants the robotics theory course using a learning program that categorizes and registers different models of robots and health care workers with different roles in the operating room. The training and assessment of online learning ensure that each participant has acquired basic theoretical knowledge by the time he/she starts performing robotic surgery [7].

5.2.2 On-Site Simulation Courses Due to the high cost of robotic surgical systems and the fact that training in robotic operation is constrained by the time of clinical application, it is unlikely that the skills of robotic surgery can be

5  Robotic Resident and Fellow Training

acquired directly through the learning of clinical surgery. Thus the robotic surgery simulator has become an important tool for surgeon training, providing trainees with a training environment similar to that of robotic surgery through simulation on an operating table. It also allows for the development of simulation training programs and provides multiple training modules. Leading surgeons and training experts design the training content of the simulator based on what is needed for real robotic surgery operations. The training generally includes the operation of the surgeon’s console system, coordination training, moving the collar, electrocoagulation hemostasis training, clamping, cutting, vascular separation, suturing, and knotting training [8]. The current use of the more mature DVSS simulator, which is integrated like a backpack on the back of the da Vinci robotic surgeon console, enables the application of simulation training procedures directly to the da Vinci. A professional scoring system designed to assess the operator’s mastery can be used during robotic surgery simulator training. The operator needs to successfully pass a training program before moving on to the next program, thus continuously improving operational skills. The use of the simulator allows the surgeon to master robotic surgery more intuitively, improves operator coordination, and compensates for the lack of tactile feedback during robot operation. Related studies have shown that the operating and surgical skills of the lead surgeon improve significantly after training in a simulation course, a course that bridges the gap between basic training and practical clinical application [9].

5.2.3 Animal Experimentation Course Although the robotic simulator is important for the mastery of basic surgical movements and for the improvement of operational proficiency, it is not fully equivalent to the operation of a real machine. After completing simulator training, the next step requires physical operation on a real da Vinci robot. The training molds generally have simulated organ materials, tissue vessels, training

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collars, and so on. Operators can gradually master the use of common robotic surgery instruments and basic operation skills from easy to difficult. After mastering the basic skills of physical manipulation, the entire surgical steps are finally simulated and trained on live animals. Live animals are generally chosen from experimental live pigs because their anatomy is close to human anatomy. This part of the training requires special robots and corresponding animal feeding facilities, and the corresponding training costs are high. During training, the entire surgical operation can be performed on live pigs, from the installation of the robotic arm and the placement of the trocar at the puncture hole. Live animal training can experience operation techniques such as freeing, resection, hemostasis, ligation, and suturing of living tissues. Preclinical training such as gallbladder removal, freeing, transection and reconstruction of the ureter, dissection of the hilar vessels and nephrectomy, intestinal resection, and intestinal anastomosis can be accomplished [10]. The animal experimentation course at Changhai Hospital Training Center in China includes training and assessment in lens and instrument manipulation, tissue suturing, electrical energy use, blunt separation exercises, vascular freeing and ligation, and specialty project exercises [11].

5.3 Clinical Period Training After completing the basic training and assessment in the preclinical period, we will enter the learning and training phase of the clinical period. There are generally two options for the clinical phase of training. In accordance with the DVSS training requirements, the supervised training of the clinical phase can be started within the trainee’s hospital if the surgeon already has a surgeon in his or her medical institution who is skilled in performing robotic surgery. However, most hospitals in China are currently using the DVSS system for the first time, and the surgeons in training are at institutions where robotic surgery is not yet routinely performed, so they need to go to medical institutions that are already equipped to

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p­ erform robotic surgery to observe and learn the surgery and receive supervisory training. Surgical observation is a very important part of the primary stage of clinical phase supervisory training. On-site observation of surgery can make trainees familiar with the entire surgical operation process. Through the operation and explanation of the attending surgeon, they can understand the details, precautions, and surgical techniques in surgery and lay the foundation for them to carry out robotic surgery. After observing a large number of robotic surgeries, the trained physicians gradually began to act as surgical first assistants. After having some experience in robotic surgery as first assistants, they started to operate under the guidance of robotic supervising experts to complete gallbladder resection, gastrointestinal anastomosis, biliary-intestinal anastomosis, partial hepatectomy, and so on. They are gradually able to carry out robotic surgical procedures in conventional specialties independently. During this period, expert supervisors adjusted the trainees’ surgical operations in a timely manner and monitored the trainees’ performance during critical intraoperative operations. They are able to perform the operations effectively while ensuring the safety of patients’ lives, avoiding surgeons from performing operations blindly before mastering the operating skills, and improving the surgeons’ operating level. Currently, during clinical training, trainees are required to lead 15 da Vinci robotic surgeries within 3  months of clinical completion after going through the process of surgical observation, serving as the first assistant to the surgery, and leading the surgery under the supervision of a senior physician before they are officially certified by the National Health Planning Commission to perform da Vinci robotic surgery authorized by Intuitive Surgical, Inc., in the United States [12].

5.4 Training of the Surgical Nurse Team Robotic surgical systems are much more cumbersome than typical laparoscopic surgical systems and require good coordination between nursing

staff and surgeons during surgery. Surgical nurses can only form tacit cooperation with the surgeon if they are systematically trained and familiar with the surgical steps. Good nursing cooperation can significantly shorten the operation time and provide a guarantee for the safety and successful completion of the operation. Therefore, prior to performing robotic surgery, the nursing team also needs training related to robotic surgery. The training of the surgical nurses and the surgeons can be done simultaneously, or the nursing team can be trained separately. A surgical nurse team needs at least two groups of nurses to be trained, and after training out one group, new members should be reasonably arranged to be trained so that the two groups can easily change shifts with each other. Changhai Hospital of the Second Military Medical University has carried out the construction of a nursing team for robotic-­assisted radical prostate cancer surgery and trained the nursing staff who need this surgical team. The training includes four steps: theoretical learning, simulation, on-site teaching, and centralized reinforcement. A “ladder” training system was eventually formed from the initial dedicated learning, expanding the training scale in the middle of the training period and quality control at the end of the training period. After such systematic training, the preoperative preparation time for robotic surgery was significantly reduced, and the professional level of the nursing staff was improved [13].

5.5 Conclusion Robotic surgery is currently the development direction of minimally invasive surgery technology, and it has become a mainstream surgical technique in Europe and America. At present, robotic surgery in China is in a rapid development stage. In the future, this technology will also become the development trend of surgery. However, launching a robotic surgery program comes with a huge financial investment. Irregular operation damages the equipment and affects the safety of the procedure, and the physicians involved need to undergo rigorous and ­standardized training to master robotic surgery

5  Robotic Resident and Fellow Training

techniques. There will also be an increasing demand for robotic surgery training courses in the industry today, making it imperative to plan and design robotic surgery training programs. Due to the complexity of robotic surgery techniques and the long learning curve, traditional laparoscopic surgery training methods are no longer able to meet today’s training needs. Therefore, exploring standardized, safe, and effective training methods for robotic surgery can promote the rapid and smooth development of robotic surgery. The current step-­by-­step training approach of web-based theoretical learning, simulator trainer module operation, robot physical operation practice, and robot animal live surgery training not only avoids the tedium of previous surgical teaching training but also increases the operator’s interest in robotic surgery. Through different stages of progressive and cross-training, a foundation can be laid for the practical clinical application of robots for surgery, which facilitates the diffusion of robotic surgery techniques.

References 1. Alemzadeh H, Raman J, Leveson N, et  al. Adverse events in robotic surgery a retrospective study of 14 years of FDA data. PLoS One. 2016;11:e0151470. 2. Herron DM, Marohn M. SAGES-MIRA robotic surgery consensus group. A consensus document on robotic surgery. Surg Endosc. 2008;22:313–25.

33 3. Foell K, Finelli A, Yasufuku K, et al. Robotic surgery basic skills training: evaluation of a pilot multidisciplinary simulation-based curricIllum. Can Urol Assoc J. 2013;7:430–4. 4. Stegemann AP, Ahmed K, Syed JR, et al. Fundamental skills of robotic surgery: a multi-institutional randomized controlled trial for validation of a simulation-­ based curricIllum. Urology. 2013;81:767–74. 5. Smith R, Patel V, Satava R. Fundamentals of robotic surgery: a course of basic robotic surgery skills based upon a 14 society consensus template of outcomes measures and curriculum development. Int J Med Robot. 2014;10:379–84. 6. Le HM, Do TN, Phee SJ.  A survey on actuators driven surgical robots. Sensor Actuat A-Phys. 2016;2016:323–54. 7. Intuitive Surgical da Vinci community. 2015. http:// www.davincisurgerycommunity.com. Accessed 15 Jun 2016. 8. Alzahrani T, Haddad R, Alkhayal A, et al. Validation of the da Vinci surgical skill simulator across three surgical disciplines:a pilot study. Can Urol Assec J. 2013;7:E520–9. 9. Bric JD, Lumbard DC, Frelich MJ, et al. Current state of virtual reality simulation in robotic surgery training: a review. Surg Endosc. 2016;30:2169–78. 10. Ping H, Qiu Z, Zhang X.  Exploration on standardization training of robotic-assisted surgery in China. Chin Med Rec. 2018;19:97–9. 11. Li J, Liu Y. Construction of the Da Vinci Surgical robot international training center. Hospital administration. J Chin People’s Liberat. 2017;24:1156–8. 12. Zheng H, Cheng J.  Standardized training in robotic surgery in urology and andrology. Natl J Androl. 2020;26:751–8. 13. Shen Q, Yang B, Wang Y, et  al. Construction and training of robot-assisted laparoscopic prostatectomy nursing team. Nursing J Chin People’s Liberation Army. 2014;31:58–60.

6

Robotic-Assisted Esophagoplasty for Congenital Esophageal Atresia Shaotao Tang and Liang Liang

6.1 Introduction Pediatric esophagoplasty is mainly performed for esophageal anastomosis in neonates with congenital esophageal atresia (EA). This chapter mainly describes the procedures of robotassisted thoracoscopic esophageal anastomosis and tracheoesophageal fistula repair. To date, fewer than ten cases of roboticassisted thoracoscopic esophageal surgery have been reported worldwide. In 2009, Meehan et al. [1] reported the first case of robotic-assisted thoracoscopic surgery (RATS) for congenital esophageal atresia with tracheoesophageal fistula, but the recurrent esophagotracheal fistula was repaired again 2 weeks after the operation. In 2015, Ballouhey et al. [2] reported three cases of RATS for congenital esophageal atresia with tracheoesophageal atresia, but two cases were converted. Because of the size of the instruments of the robotic system, it is unlikely to be mainstream for esophageal anastomosis in newborns. Meehan

S. Tang Department of Paediatric Surgery, Xiehe Hospital Affiliated to Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China L. Liang (*) Department of Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

[3] demonstrated that the weight of neonates (usually under 3 kg), the deficient intercostal space for robotic 8.5 mm scope and small working space for articulating robotic instruments were the main disadvantages of carrying out the procedure. Recently, Tang et al. [4, 5] reported the first case of RATS for esophageal atresia without tracheoesophageal atresia in China and later one case of RATS for esophageal atresia with tracheoesophageal atresia that was successfully operated in on in 2020.

6.2 Indications and Contraindications Surgical indications include congenital esophageal atresia with esophagotracheal fistula and congenital esophageal cyst. Due to the small number of cases, there is no unified conclusion on the choice of the minimum age of robotic chest surgery. It is relatively difficult to perform robot-assisted thoracoscopic esophageal atresia anastomosis for newborns. At present, there is no unified standard for surgical indications and contraindications, and the operation mainly depends on the proficiency of robot surgery in clinical units. According to our experience, it is difficult for children weighing less than 5 kg to receive an 8 mm robotic endoscopic system because of the intercostal space, so caution should be taken when choosing robotic surgery for newborns.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_6

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6.3 Preoperative Preparation

6.3.3 Equipment Preparation

6.3.1 Preoperative Examination

General robot systems, bipolar electrocoagulation, Maryland forceps, Cadiere forceps, etc. Other special instruments can be adjusted according to the surgeon’s habits.

Routine examination of blood and body fluids, such as routine blood tests, liver and kidney function, and blood coagulation function, is necessary. Contrast esophagography (Fig. 6.1) is an examination item that must be completed before operation. Other examinations include chest X-ray, electrocardiogram and echocardiography to determine whether there are other systemic malformations, such as congenital heart disease and congenital anal atresia.

6.4 Position and Docking 6.4.1 Surgical Position Usually, the patient is placed in a left recumbent with 45° forward tilt, and the right upper limb is fixed on the side of the head (Fig. 6.2).

6.3.2 Patient Preparation

6.4.2 Layout of Operation Ports

Children should be treated with fasting and fluid replacement before surgery.

The ports were asymmetrically placed as described below: (1) 12  mm 30° camera in the fifth intercostal space (ICS) on the right midaxillary line, CO2 gas was introduced at a pressure of 6 mmHg; (2) anterior arm through the third ICS on the right midaxillary line with a distance of 3  cm from the camera port; (3) posterior arm through the seventh ICS on the posterior axillary line with a distance of 5 cm from the camera port, respectively; (4) auxiliary trocar (3  mm) was placed in the sixth ICS of the anterior axillary line. The robot completes the docking from the back of the child (Fig. 6.3).

Fig. 6.1  Contrast esophagography of EA before the operation

Fig. 6.2  Surgical position and layout of Trocarthe trocar

6  Robotic-Assisted Esophagoplasty for Congenital Esophageal Atresia

a

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b

Fig. 6.3  The layout of the Trocar for da Vinci and the position for docking. (a) Position of docking; (b) layout of Trocar

6.5 Surgical Procedures After routine surgical area disinfection, lay disposable sterile sheets. The ports were placed as described above. Bipolar electrocoagulation severed azygos vein, explored the thoracic cavity, and evaluated the distance between the proximal esophageal blind end and distal tracheoesophageal fistula (or distal esophageal blind end). An electric hook and Maryland forceps were used to peel off the proximal and distal ends of the esophagus and retain the

periesophageal blood supply as much as possible. The tracheoesophageal fistula was exposed, and the tracheoesophageal fistula was cut off by double suture with 5-0 prolene suture. The posterior wall of the esophagus was anastomosed intermittently with 5-0 absorbable sutures, the nasogastric tube was placed into the gastric cavity through the anastomosis, and then the anterior wall of the esophagus was anastomosed intermittently with 5-0 absorbable sutures. The chest drainage tube was placed, and the skin was sutured (Fig. 6.4).

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a

b

c

d

Fig. 6.4  The surgical steps of the surgery. (a) Open the proximal esophagus; (b) dissociate the distal esophagus; (c) suture the posterior wall; (d) suture the anterior wall

6.6 Technical Points and Skills

6.7 Postoperative Complications

Because of the narrow intercostal space and thoracic volume, it is difficult to insert 12 mm trocar, and the distance between the port holes is small, so the manipulator easily collides inside and outside the thoracic cavity, which will increase the difficulty of the operation. To solve the above problems, the sequential expansion method can be used to place trocar [4, 5]: first, 3 mm trocar, then 5 mm trocar, and then 8 mm or 12 mm trocar, to gradually increase the intercostal space. In addition, the asymmetrical layout trocar makes the distance between the anterior arm port (or posterior arm port) and camera port different (3  cm and 5  cm respectively), which breaks through the limit of the intercostal space and chest space, and avoids collision of the manipulator.

Postoperative complications are similar to traditional video-assisted thoracoscopic surgery, including anastomotic leak, anastomotic stricture, recurrence of tracheoesophageal fistula, and pleural effusion. Anastomotic leakage is the most common complication after esophageal atresia, and the current incidence of anastomotic leakage is 15% to 20% [6–8]. The main causes of anastomotic leakage may be poor local blood supply of the anastomotic site, infection or poor nutritional status of the children affecting local tissue healing. Therefore, injury of large nutrient vessels should be avoided during the operation. In the robot system, the exposure to the blood vessels in the esophageal wall will be clearer due to the magni-

6  Robotic-Assisted Esophagoplasty for Congenital Esophageal Atresia

fication of the field of vision, and it is easier to retain the small blood vessels. When anastomotic leakage occurs after surgery, routine management measures include continued fasting, adequate thoracic drainage, use of broad-spectrum antibiotics, use of proton pump inhibitors and total parenteral nutrition support.

6.8 Comparisons with Conventional Thoracoscopic Surgery Because the da Vinci robot is a high-resolution 3D lens, the visual field is magnified by 10–15 times, which provides the operator with a three-­ dimensional high-definition image, which makes the tissue structure around the esophageal atresia and esophagotracheal fistula clearer, reduces the damage to the blood supply around the esophagus, and makes the process of esophageal anastomosis more accurate. At the same time, the robot has a simulated wrist manipulator with a flutter filtering function, which is more stable and flexible than the traditional video-assisted thoracoscope, and provides satisfactory ergonomic experience for operators and assistants. Therefore, it is feasible for pediatricians with rich experience in open surgery and skilled operation of robotic surgery and anesthesiologists to complete RATS in EA together [9]. Because the robot system needs a certain amount of space between the manipulators, children who are too young may be unable to operate because of the interference between the manipulators in the small chest cavity. Therefore, it

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greatly limits the application of robotic surgery in low-age, low-weight infants. Robotic surgery cannot be performed if preoperative pulmonary infection leads to severe chest adhesion or if the child is unable to tolerate artificial pneumothorax. In addition, some experts have raised the problem that robot surgery takes a relatively long operation time.

References 1. Meehan JJ. Robotic surgery in small children: is there room for this? J Laparoendosc Adv Surg Tech A. 2009;19:707–12. 2. Ballouhey Q, Villemagne T, Cros J, et al. Assessment of paediatric thoracic robotic surgery. Interact Cardiovasc Thorac Surg. 2015;20:300–3. 3. Mattioli G, Petralia P. Pediatric Robotic Surgery. Cham: Springer International Publishing. 2017. 4. Cao G, Zhang Q, Zhou Y, et  al. Robotic thoracoscopic surgery for esophageal atresia: the first case report in China. Chin J Minim Invasive Surg. 2021;11:1026–8. 5. Wang Y, Tang ST, Cao GQ, et al. Robot-assisted thoracoscopic surgery on type III esophageal atresia: the first case report in China. Chinese Journal of Robotic Surgery. 2022;3:423–7. 6. Upadhyaya VD, Gangopadhyaya AN, Gupta DK, et  al. Prognosis of congenital tracheoesophageal fistula with esophageal atresia on the basis of gap length. Pediatr Surg Int. 2007;23:767–71. 7. Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest. 2004;126:915–25. 8. Askarpour S, Peyvasteh M, Javaherizadeh H, et  al. Evaluation of risk factors affecting anastomotic leakage after repair of esophageal atresia. Arq Bras Cir Dig. 2015;28:161–2. 9. Pierre AF, Thomas B, Aurelien B, et al. The potential and the limitations of esophageal robotic surgery in children. Eur J Pediatr Surg, 2020;32:170–6.

7

Robotic-Assisted Pulmonary Lobectomy Qiang Shu and Zheng Tan

7.1 Introduction In 2000, Rothenberg [1] described thoracoscopic lobectomy for children for the first time in the literature. In recent years, thoracoscopic lobectomy has been gradually carried out all over the world [2]. According to literature reports, thoracoscopic assisted lobectomy still has certain limitations, such as two-dimensional plane images seen during the solo operation, limited operation space, and fatigue of the solo surgeon caused by too long of an operation time [3, 4]. Da Vinci’s robot-assisted surgical system solves these problems perfectly. In 2008, Meehan first reported the application of robot-assisted lobectomy, believing that this method has advantages such as more

Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­9693-­1_7. Q. Shu Department of Cardiac and Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected] Z. Tan (*) Department of Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

accurate blood vessel separation and a clearer visual field in 3D imaging surgery [5]. The Children’s Hospital affiliated to Zhejiang University introduced da Vinci Xi in April 2020 performed the first robot-assisted thoracoscopic mediastinum tumor resection in May 2020, and completed 115 pediatric thoracic surgeries by the end of March 2021, including 85 pediatric

7.2 Indications and Contraindications Robotic indications for lobectomy can be compared to the thoracoscopic indications for lobectomy. Including congenital pulmonary airway malformation, isolated lung, lobar emphysema, and so on. However, considering the requirements of hole spacing between robotic arms, robotic surgery is not recommended for children of too young age at present. According to the experience of our center, children older than 6 months can complete the operation. However, if the operation is to be smooth, children over 8 months are generally recommended. The larger the relative chest space, the larger the spacing of holes can be. Contraindications: diffuse lesions in both lungs. Severe cardiopulmonary failure or other conditions requiring priority. Severe thoracic deformity.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_7

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7.3 Preoperative Preparation The time of fasting and water prohibition before operation was the same as that of routine general anesthesia. Intraoperative one-lung ventilation is generally recommended, and a bronchial plugging device can be used routinely to block bronchial ventilation on the diseased side by filling the balloon. However, due to the small diameter of children’s bronchial tubes, it is sometimes difficult to place the appropriate plugging device, or when the blockage balloon easily slides to the main airway after the placement of the plugging device, resulting in obstruction of ventilation, selective endobronchial intubation can also be considered, and endotracheal intubation can be directly inserted into the healthy side of the bronchus. Regardless of what method is used to achieve single-lung ventilation, it is generally recommended to use bronchofibroscopy with close observation of changes in airway pressure, airway carbon dioxide waveform, and arterial oxygen saturation (SpO2) to prevent catheter or occluded displacement. Other preoperative preparations included the establishment of central venous access, catheterization with invasive arterial pressure, and indwelling catheterization. Attention should be given to sputum aspiration at any time during the operation, and arterial blood gas analysis should be monitored when necessary.

7.4 Position and Docking Healthy side decubitus position, double upper limb flexion, pillow, underarm cushion pillow to make the torso slightly folded knife position, so that the intercostal space is passively widened.

Q. Shu and Z. Tan

Due to the small space of children’s chest, the hole position should be as low as possible to ensure that the range of motion of the lens and instruments can cover the whole chest, and the auxiliary hole position should also be as low as possible to avoid interference with the mechanical arms. Generally, the three-arm method is adopted. The location of the cannula varies slightly depending on the location of the lobectomy and is generally as follows: Into the lens aperture generally obtained after axillary line 8 or 9 rib poke card, put between 8  mm diameter (lower lobe resection card can be done between the ninth floor or a 10th rib, on the middle of the rib resection can be relatively high 1, 2) into the lens confirmation is located in the chest cavity and external artificial pneumothorax (general pressure for 6 mmHg), makes the diaphragm down further to provide more 5 breast space. For the left and right instrument holes, 8 mm stamp cards are usually inserted in the 6th intercostal space between the anterior axillary line and the midclavicular line and the 8th intercostal space between the subscapular line. Ensure that there is a sufficient distance (approximately 4–8  cm) between the two instrument holes and the lens inlet holes, so that each mechanical arm does not interfere with each other during operation. It is mainly used for intraoperative use of attractor, auxiliary hole clamp apparatus and equipment, general with the door to the lungs for the principle, take the axillary midline and axillary 7 rib poke card in 5 mm clearance between the front (e.g., intraoperative use endoscopic cutting anastomat can extend the 5 mm incision and poke into 12 mm), assistant in children with ventral auxiliary operation, each robot manipulator is in the head side of the children (Fig. 7.1).

7  Robotic-Assisted Pulmonary Lobectomy

Fig. 7.1 Conventional perforation in lobectomy. C: observation hole, A: auxiliary hole, 2: robot arm No. 2, 3: robot arm No. 3

7.5 Surgical Steps The surgical area was routinely sterilized, and a disposable sterile sheet was laid out. A poke card was inserted into the incision at the marked

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p­ osition and then sent into the lens. After probing the chest cavity without extensive adhesion, CO2 was added to ensure a clear visual field and accelerate the removal of residual gas in the lung (the pressure was generally 6  mmHg). Two instrument arm stamp cards and auxiliary hole stamp cards were inserted into the incision under the guidance of endoscope. Push the bedside operation arm system (generally placed on the right side of the child, at a 90° angle with the longitudinal axis of the child) and connect the stamp card. The right arm was connected with a Maryland bipolar claw, and the left arm was connected with a pericardial claw (Cadiere claw). The surgeon performs the operation in front of the console with a three-dimensional visual field. Generally, the robot uses three arms (one lens arm and two instrument arms), makes full use of the assistant through the auxiliary mouth to complete pulling, clamping, closing operation, etc., and uses fewer robot instruments to save costs. The procedure for anatomic lobectomy was the same as that for open lobectomy. The routine is AVB, treating the pulmonary artery first, then the pulmonary veins, then the bronchi. However, in the case of lobed dysplasia, where the artery is difficult to expose, the pulmonary veins can be dealt with first, then the bronchus, and finally the pulmonary artery. Determine the procedure according to the specific situation. Here is an example of anatomic excision of the lower lobe of the left lung (Fig. 7.2).

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a

b

c

d

e

f

Fig. 7.2  Example of anatomic excision of the lower lobe of the left lung. (a) Dissociation of lower pulmonary ligaments; (b) dissection of the pulmonary artery; (c) ligation of the lower pulmonary artery; (d) dissection of inferior of

g the pulmonary vein; (e) ligation of inferior pulmonary vein; (f) dissection of lower pulmonary bronchi; (g) suture bronchial stump

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7.6

Technical Points and Skills

The thoracic space in pediatric patients is relatively small, which limits the placement of operating and observation ports. It may not be possible to create a straight line arrangement of ports, so it is important to choose the maximum distance between ports to avoid interference between robotic arms. For patients with a sequestered lung, there may be abnormal collateral blood supply. In such cases, the operating ports on the side closer to the spine should be placed downward as much as possible to prevent difficulties during the procedure. For patients with a well-vascularized sequestered lung, gentle traction should be applied to avoid bleeding that may obstruct the view. During dissection of the pulmonary veins, caution should be exercised, as the vessel walls are relatively thin, especially when separating them from the posterior wall, to prevent damage to the blood vessels. For proximal segment ligation of the pulmonary artery and pulmonary vein, it is recommended to perform at least two ligations to prevent slippage and major bleeding. After bronchus division, it is advisable to perform continuous absorbable suture with at least one stitch to minimize the risk of suture line detachment and pneumothorax.

7.7 Postoperative Complications 1. Pneumothorax: if there is continuous gas leakage from the closed thoracic drainage tube after surgery, it can be temporarily observed; small alveolar gas leakage can heal by itself; if there is a continuous large amount of gas leakage, bronchopleural fistula should be considered, and timely surgical treatment should be performed. 2. Atelectasis, contusion caused by pull-clamp on lung tissue during operation, and atelectasis caused by obstruction of bronchial

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s­ecretions after operation are also common. Postoperative physical therapy can be strengthened for children and supplemented by atomization to help discharge sputum. 3. Bleeding: if a large amount of bright red fluid continues to be extracted from the drainage tube, the possibility of postoperative bleeding should be considered. 4. Residual lesions: due to the large scope of lesions in some CPAM cases, unclear boundaries, and ease of pushing the normal lung tissue, residual lesions may occur after lung segment or wedge resection and other lung preservation operations [6–8]. In Stanton’s report, 15% (9/60) of patients developed residual lesions after pulmonary segmental resection [8]. In Johnson’s report, 6.6% of patients underwent lung preservation surgery and underwent secondary surgical resection due to residual lesions [6]. When performing segmentary resection or irregular resection, the surgeon should strictly grasp the indications of surgery, accurately judge the scope of the lesion, clarify the involvement of the lesion, and make a careful decision in combination with intraoperative lesion exploration to avoid residual lesions. When residual lesions are found during postoperative follow-up, according to current literature reports, most authors choose to rescease the lesions, and the specific surgical method depends on the residual lesions [7, 8]. With respect to the timing of reoperation, there are few reports about it in the literature, and Fascetti et al. believed that for residual cases, resurgical resection should be performed about 5 months after surgery [7].

7.8 Comparisons with Conventional Thoracoscopic Surgery Compared with traditional laparoscopic thoracic surgery, the robotic surgical system has unique advantages: (1) clear and accurate three-­ dimensional vision. The common cavity mirror

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for two-dimensional plane vision, two-dimensional view cannot accurately position the distance, and the robot’s vision for three-­dimensional vision simulates human eyes, seeing more clearly, more accurately positioning the distance; (2) intelligent action: the operator of hand and wrist action can be converted into real-time accurate mechanical action, and action height simulation coincides with surgery; (3) motion correction and shake filtering function: the surgical instruments that can turn the wrist can bend and rotate far more than the limit of the hand. Shiver filtering and intuitive movement allow the physician to operate steadily and naturally; (4) remote control: the operator does not need to go on the operating table, save space, avoid crowding between the main knife and the assistant, and avoid obstruction of the surgical field of view; (5) suitable for pediatric surgery: Compared with adults, the pediatric body cavity space is small, and traditional surgical operations are limited. The progress of endoscopic surgery has gradually solved this problem, but there are still shortcomings in the accurate operation of localized lesions. Fine operation in a limited space can reduce the side injury of the operation, improve the curative effect and minimize the pain of children [5]; (6) reduce surgeon fatigue: compared with traditional surgery and endoscopic surgery, a good three-dimensional field of vision and simplified

coordination, ergonomic design of the doctor’s operation table can minimize the fatigue and physical injury of the doctor.

References 1. Rothenberg SS. Thoracoscopic lung resection in children. J Pediatr Surg. 2000;35:271–4. 2. Tan Z, Li JH, Liang L, et al. Thoracoscopic lobectomy in infants and children. Chin J Thorac Cardiovasc Surg. 2017;33:490–2. 3. Kolvenbach R, Schwierz E, Wasilljew S, et al. Total laparoscopically and robotically assisted aortic aneurysm surgery: a critical evaluation. J Vasc Surg. 2004;39:771–6. 4. Cook RC, Nifong LW, Enterkin JE, et al. Significant reduction in annuloplasty operative time with the use of nitinol clips in robotically assisted mitral valve repair. J Thorac Cardiovasc Surg. 2007;133:1264–7. 5. Meehan JJ, Phearman L, Sandler A. Robotic pulmonary resections in children: series report and introduction of a new robotic instrument. J Laparoendosc Adv Surg Tech A. 2008;18:293–5. 6. Johnson SM, Grace N, Edwards MJ, et al.  Thoracoscopic segmentectomy for treatment of congenital lung malformations. J Pediatr Surg. 2011;46:2265–9. 7. Fascetti-Leon F, Gobbi D, Pavia SV, et  al. Sparing-­ lung surgery for the treatment of congenital lung malformations. J Pediatr Surg. 2013;48:1476–80. 8. Stanton M, Njere I, Ade-Ajayi N, et al.  Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg. 2009;44:1027–33.

8

Robotic-Assisted Segmentectomy Qiang Shu and Zheng Tan

8.1 Introduction At present, with the widespread use of prenatal ultrasound screening, the diagnosis rate of congenital pulmonary diseases in infants and children has greatly increased [1]. Although these lesions rarely affect pregnancy or postnatal growth, pediatric surgeons are now faced with advising families on prenatal and postnatal issues and whether to operate [1–3]. While many of these lesions were previously diagnosed after patients developed symptoms from infections or other problems, most are now diagnosed before birth, and many babies are asymptomatic. The traditional view of surgical treatment is to remove the entire diseased lung at diagnosis, but some centers use a more conservative approach, believing that these lesions do not pose longterm risks, and therefore choose to retain the Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­9693-­1_8. Q. Shu Department of Cardiac and Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected] Z. Tan (*) Department of Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

affected lung [4, 5]. To achieve a balance between removing diseased lung tissue and preserving as much normal lung tissue as possible, we began to attempt anatomical segment resection in children. With the improvement of anesthesia and thoracoscopic techniques, an increasing number of cases have been reported in pediatric thoracoscopic anatomical lobectomy. Most surgeons agree on the benefits of thoracoscopic surgery over traditional thoracotomy, including less pain, shorter hospital stay, better cosmetic results, and reduced long-­term morbidity, including reduced chest wall deformities [6–8]. However, the diseases that require lobectomy in children are mostly benign diseases, such as congenital pulmonary airway malformation (CPAM), intralobular isolated lung, and bronchial atresia. It is necessary to retain as much healthy lung tissue as possible and improve postoperative lung function. However, compared with lobectomy, the anatomical structure of the pulmonary segment is more distal to the bronchus and blood vessels, with more branches, and the adjacents between pulmonary arteries and veins and bronchus are more complex, with large individual differences and variations, which brings great difficulties to accurate pulmonary segment resection. Therefore, the current anatomical pulmonary segmentectomy mainly takes the basal segment, dorsal segment, and lingual segment of the lower lobe of both lungs [9, 10]. The anatomy of this kind of pulmonary segment is similar to that of

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the fusing lung lobe, and the surgical technique is similar to that of lobectomy or wedge resection. Compared with thoracoscopy, the Da Vinci robot has clearer vision and more flexible operation, so it has greater advantages in performing complex operations.

8.2 Indications and Contraindications Indications for robotic pulmonary segmentectomy can be compared to the indications for thoracoscopic pulmonary segmentectomy which include congenital pulmonary airway malformation, isolated lung, lobar emphysema ,and so on. However, considering the requirements of hole spacing between robotic arms, robotic surgery is not recommended for children of too young age at present. According to the experience of our center, children older than 6  months can complete the operation. However, if the operation is to be smooth, children over 8 months are generally recommended. The larger the relative chest space, the larger the spacing of holes can be. Contraindications: diffuse lesions in both lungs. Severe cardiopulmonary failure, or other conditions requiring priority. Severe thoracic deformity.

8.3 Preoperative Preparation The time of fasting and water prohibition before operation was the same as that of routine general anesthesia. Intraoperative one-lung ventilation is generally recommended, and a bronchial plugging device can be used routinely to block bronchial ventilation on the diseased side by filling the balloon. However, due to the small diameter of children’s bronchial tubes, it is sometimes difficult to place the appropriate plugging device, or when the blockage balloon easily slides to the main airway after the placement of the plugging device, resulting in obstruction of ventilation, selective endobronchial intubation can also be considered, and endotracheal intubation can be directly inserted into the healthy side of the bronchus. Regardless of what method is used to

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achieve single-lung ventilation, it is generally recommended to use bronchofibroscopy with close observation of changes in airway pressure, airway carbon dioxide waveform, and arterial oxygen saturation (SpO2) to prevent catheter or occluded displacement. Other preoperative preparations included the establishment of central venous access, catheterization with invasive arterial pressure, and indwelling catheterization. Attention should be given to sputum aspiration at any time during the operation, and arterial blood gas analysis should be monitored when necessary.

8.4 Position and Docking Healthy side decubitus position, double upper limb flexion, pillow, underarm cushion pillow to make the torso slightly folded knife position, so that the intercostal space is passively widened. Due to the small space of children’s chest, the hole position should be as low as possible to ensure that the range of motion of the lens and instruments can cover the whole chest, and the auxiliary hole position should also be as low as possible to avoid interference with the mechanical arms. Generally, the three-arm method is adopted. The location of the cannula varies slightly depending on the location of the lobectomy and is generally as follows: Into the lens aperture generally obtained after axillary line 8 or 9 rib poke card, put between 8  mm diameter (lower lobe resection card can be done between the ninth floor and a tenth rib, on the middle of the rib resection can be relatively high 1, 2) into the lens confirmation is located in the chest cavity and external artificial pneumothorax (general pressure for 6  mmHg), makes the diaphragm down further to provide more 5 breast space. For the left and right instrument holes, 8 mm stamp cards are usually inserted in the sixth intercostal space between the anterior axillary line and the midclavicular line and the eighth intercostal space between the subscapular line. Ensure that there is a sufficient distance (approximately 4–8  cm) between the two instrument holes and the lens inlet holes, so that each mechanical arm does not interfere with each other during operation. It is mainly used for intraoperative use of attractor,

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a

b

c

d

Fig. 8.1  3D reconstruction to determine the lung segment occupied by the lesion (a-d)

auxiliary hole clamp apparatus and equipment, general with the door to the lungs for the principle, take the axillary midline and axillary 7 rib poke card in 5 mm clearance between the front (e.g., intraoperative use endoscopic cutting anastomat can extend the 5 mm incision and poke into 12 mm), assistant in children with ventral auxiliary operation, each robot manipulator is in the head side of the children (Fig. 8.1).

8.5 Surgical Steps The surgical area was routinely sterilized, and a disposable sterile sheet was laid out. A poke card was inserted into the incision at the marked position and then sent into the lens. After probing the chest cavity without extensive adhesion, CO2 was added to ensure a clear visual field and accelerate the removal of residual gas in the lung (the pressure was generally 6  mmHg). Two instrument arm stamp cards and auxiliary hole stamp cards were inserted into the incision under the guidance of the endoscope. Push the bedside opera-

tion arm system (generally placed on the right side of the child, at a 90° angle with the longitudinal axis of the child) and connect the stamp card. The right arm was connected with a Maryland bipolar claw, and the left arm was connected with a pericardial claw (Cadiere’s claw). The surgeon performs the operation in front of the console with a three-dimensional visual field. Generally, the robot uses three arms (one lens arm and two instrument arms), makes full use of the assistant through the auxiliary mouth to complete pulling, clamping, closing operation, etc., and uses fewer robot instruments to save costs. According to the anatomical marks displayed in preoperative 3D-CTBA images, the vessels and bronchus of the target segment were dissected in order from shallow to deep (Fig. 8.2). Small branches of pulmonary arteries and veins can be cut off by electrocoagulation or ultrasonic knife, and large branches can be cut off by ultrasonic knife after medium hemlock clamp. The bronchus of the pulmonary segment was cut off with a large Hem lock clamp and then cut off with an ultrasound knife or a linear cutting

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a

b

c

d

e

f

Fig. 8.2  Dissection of the vessels and bronchus of the target segment. (a, b) According to the 3D reconstructed arterial images, the target segment arteries were determined by intraoperative comparison; (c, d) according to

the 3D reconstructed vein image, the target vein was determined during the operation; (e, f) according to 3D reconstructed bronchial images, the target segment bronchus was resected by intraoperative comparison

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s­ tapler. The intersegmental plane was determined by the extent of the inflatenation and collapse junction between the lung segments or after arterial ischemia, and the intersegmental plane was separated by electrocoagulation with a linear cutter or an ultrasound knife.

8.6

Technical Points and Skills

The thoracic space in pediatric patients is relatively small, which limits the placement of operating and observation ports. It may not be possible to create a straight line arrangement of ports, so it is important to choose the maximum distance between ports to avoid interference between robotic arms. For patients with a sequestered lung, there may be abnormal collateral blood supply. In such cases, the operating ports on the side closer to the spine should be placed downward as much as possible to prevent difficulties during the procedure. For patients with a well-vascularized sequestered lung, gentle traction should be applied to avoid bleeding that may obstruct the view. During dissection of the pulmonary veins, caution should be exercised, as the vessel walls are relatively thin, especially when separating them from the posterior wall, to prevent damage to the blood vessels. For proximal segment ligation of the pulmonary artery and pulmonary vein, it is recommended to perform at least two ligations to prevent slippage and major bleeding. After bronchus division, it is advisable to perform continuous absorbable suture with at least one stitch to minimize the risk of suture line detachment and pneumothorax.

8.7 Post-operative Complications 1. Pneumothorax: if there is continuous gas leakage from the closed thoracic drainage tube after surgery, it can be temporarily

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observed; small alveolar gas leakage can heal by itself; if there is a continuous large amount of gas leakage, bronchopleural fistula should be considered, and timely surgical treatment should be performed. 2. Atelectasis, contusion caused by pull clamp on lung tissue during operation, and atelectasis caused by obstruction of bronchial secretions after operation are also common. Postoperative physical therapy can be strengthened for children and supplemented by atomization to help discharge sputum. 3. Bleeding: if a large amount of bright red fluid continues to be extracted from the drainage tube, the possibility of postoperative bleeding should be considered. 4. Residual lesions: due to the large scope of lesions in some CPAM cases, unclear boundaries and ease of pushing normal lung tissue, residual lesions may occur after lung segment or wedge resection and other lung preservation operations [11–13]. In Stanton’s report, 15% (9/60) of patients developed residual lesions after pulmonary segmental resection [13]. In Johnson’s report, 6.6% of patients underwent lung preservation surgery and underwent secondary surgical resection due to residual lesions [11]. When performing segmentary resection or irregular resection, the surgeon should strictly grasp the indications of surgery, accurately judge the scope of the lesion, clarify the involvement of the lesion, and make a careful decision in combination with intraoperative lesion exploration to avoid residual lesions. When residual lesions are found during postoperative follow-up, according to current literature reports, most authors choose to rescease the lesions, and the specific surgical method depends on the residual lesions [12, 13]. With respect to the timing of reoperation, there are few reports about it in the literature, and Fascetti et al believed that for residual cases, resurgical resection should be performed approximately 5 months after surgery [12].

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8.8 Comparisons with Conventional Thoracoscopic Surgery

References

1. Adzick NS, Harrison MR, Crombleholme TM, et al. Fetal lung lesions: management and outcome. Am J Obstet Gynecol. 1998;179:884–9. Compared with traditional laparoscopic thoracic 2. Lakhoo K.  Management of congenital cystic adenomatous malformations of the lung. Arch Dis Child surgery, the robotic surgical system has unique advantages: (1) clear and accurate three-­ Fetal Neonatal Ed. 2009;94:F73–6. 3. Khosa JK, Leong SL, Borzi PA.  Congenital cysdimensional vision. The common cavity mirror for tic adenomatoid malformation of the lung: inditwo-dimensional plane vision, a two-dimensional cations and timing of surgery. Pediatr Surg Int. 2004;20:505–8. view cannot accurately position the distance, and 4. Yan-Sin Lo A, Jones S.  Lack of consensus among the robot’s vision for three-­ dimensional vision Canadian pediatric surgeons regarding the managesimulates human eyes, seeing more clearly, more ment of congenital cystic adenomatoid malformation accurately positioning the distance; (2) intelligent of the lung. J Pediatr Surg. 2008;43:797–9. 5. Wong A, Vieten D, Singh S, et  al. Long-term outaction: the operator of hand and wrist action can come of asymptomatic patients with congenital be converted into real-time accurate mechanical cystic adenomatoid malformation. Pediatr Surg Int. action, and action height simulation coincides 2009;25:479–85. with surgery; (3) motion correction and shake fil6. Vu LT, Farmer DL, Nobuhara KK, et al. Thoracoscopic versus open resection for congenital cystic adenotering function: the surgical instruments that can matoid malformations of the lung. J Pediatr Surg. turn the wrist can bend and rotate far more than the 2008;43:35–9. limit of the hand. Shiver filtering and intuitive 7. Rothenberg SS. First decades experience with thoramovement allow the physician to operate steadily coscopic lobectomy in infants and children. J Pediatr Surg. 2008;43:40–5. and naturally; (4) remote control: the operator 8. Rothenberg SS, Kuenzler K, Middlesworth W, et al. does not need to go on the operating table, save Thoracoscopic lobectomy in infants less than 10  kg space, avoid crowding between the main knife and with prenatally diagnosed cystic lung disease. J Laproendosc Adv Surg Tech A. 2011;21:181–4. the assistant, and avoid obstruction of the surgical 9. Yang CF, D’Amico TA.  Thoracoscopic segfield of view; (5) suitable for pediatric surgery: mentectomy for lung cancer. Ann Thorac Surg. Compared with adults, the pediatric body cavity 2012;94:668–81. space is small, and traditional surgical operations 10. Okada M, Tsutani Y, Ikeda T, et  al. Radical hybrid video-assisted thoracic segmentectomy: long-term are limited. The progress of endoscopic surgery results of minimally invasive anatomical sublobar has gradually solved this problem, but there are resection for treating lung cancer. Interact Cardiovasc still shortcomings in the accurate operation of Thorac Surg. 2012;14:5–11. localized lesions. Fine operation in a limited space 11. Johnson SM, Grace N, Edwards MJ, et al.  Thoracoscopic segmentectomy for treatment can reduce the side injury of the operation, improve of congenital lung malformations. J Pediatr Surg. the curative effect, and minimize the pain of chil2011;46:2265–9. dren [2]; (6) reduce surgeon fatigue: Compared 12. Fascetti-Leon F, Gobbi D, Pavia SV, et  al. Sparing-­ with traditional surgery and endoscopic surgery, a lung surgery for the treatment of congenital lung malformations. J Pediatr Surg. 2013;48:1476–80. good three-dimensional field of vision and simpli13. Stanton M, Njere I, Ade-Ajayi N, et al.  Systematic fied coordination, ergonomic design of the docreview and meta-analysis of the postnatal managetor’s operation table can minimize the fatigue and ment of congenital cystic lung lesions. J Pediatr Surg. physical injury of the doctor. 2009;44:1027–33.

9

Robot-Assisted Laparoscopic Repair of Hital Hernia Jiangeng Yu and Yue Gao

9.1 Introduction Hiatal hernia (HH) refers to the abdominal segment of esophagus, gastric fundus, and even the whole stomach and part of abdominal organs herniated into the mediastinum through the abnormally wide esophageal hiatus, which is mainly caused by congenital developmental abnormality of the diaphragm and can lead to gastroesophageal reflux. The prevalence rate of Chinese population is 3.3%. There are more females than males, which are common in the elderly. HH can be divided into sliding type, para-esophageal type, mixed type, and giant esophageal hiatal hernia according to the location of hiatal defect and the number of herniated tissues [1]. Most of the esophageal hiatal hernia in children is mixed type, most of the stomach or the whole stomach is herniated into the mediastinum, and the herniSupplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­9693-­1_9. J. Yu (*) Department of Cardiac and Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected] Y. Gao Department of Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

ated stomach is at risk of torsion, incarceration, or strangulation; other organs in the abdominal cavity can also be herniated into the mediastinum. Gastroesophageal reflux disease (GERD) refers to the reflux of gastric contents to the esophagus and even the oropharynx, causing a series of symptoms and complications inside and outside the esophagus. GERD is a common concomitant symptom of HH. The prevalence of HH with GERD in Western countries is as high as 10–20% [2]. With the increase of abdominal pressure, the abdominal segment of esophagus, cardia, and gastric fundus entered the mediastinum, resulting in recurrent vomiting, upper gastrointestinal bleeding, retrosternal pain, dysphagia, and other symptoms. The gold standard of diagnosis of HH is upper gastrointestinal radiography, and gastroscopy or CT can be used as auxiliary examination. Children less than 1 year old with sliding hiatal hernia can be treated conservatively, including medicine, posture, diet, and so on. Para-hiatal hernia, mixed and giant hiatal hernia, and sliding hiatal hernia with obvious symptoms and ineffective conservative treatment all need surgical treatment. The purpose of the operation is to restore the anatomical position of the esophagus and stomach, repair the esophageal hiatus, and establish an anti-reflux structure [3]. The surgical methods of HH include traditional open surgery and laparoscopic surgery. Laparoscopic surgery has the advantages of safety, less pain and less scar, so it has gradually become the standard operation of HH, and its

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safety and effectiveness have been widely veri- 9.3 Preoperative Preparation fied [4–6]. However, the laparoscopic system still has some shortcomings, such as unstable imag- Children with routine fasting, dehydration and ing system, 2D imaging field of vision, limited electrolyte disorders, anemia, and malnutrition movement of instruments, poor ergonomics, and should be corrected before operation. so on. In recent years, robot-assisted laparoscopic Antibiotics are routinely administered half an surgery has more obvious advantages because of hour before surgery. Preoperative placement of its three-dimensional images, ultra-high-­gastric tube and catheter can reduce the volume definition surgical field of vision, and flexible of stomach and bladder. Preoperative femoral surgical instruments, which overcome the limita- vein catheterization will facilitate a large amount tion of two-dimensional vision and degree of of fluid replacement during and after operation. freedom of laparoscopic surgery [7]. The mode of anesthesia is endotracheal intubation intravenous inhalation combined anesthesia.

9.2 Indications and Contraindications

Indications: (1) HH with complications, such as severe esophagitis, ulcer, bleeding, stricture, organ incarceration, and so on; (2) paraesophageal hernia and giant hiatal hernia; (3) no obvious improvement after medical treatment; (4) acute gastrointestinal volvulus incarceration is an indication of emergency operation [3]. In theory, all children who can undergo laparoscopic surgery can be operated by robot, but considering that there is a certain distance between the robotic arms, the children who are too young and underweight may not operated by robot because of the narrow operating space. However, the age limit can also be reduced appropriately according to the surgical proficiency of the surgeon. Contraindications: premature infants or newborns with poor tolerance; complicated with other severe congenital malformations, cardiopulmonary dysfunction; severe pulmonary infection; patients with a history of abdominal surgery and severe abdominal adhesions [3]. However, with the continuous maturity of surgery and anesthesia techniques, the indications of laparoscopic surgery in children are constantly expanding, and some previous contraindications no longer exist.

9.4 Position and Docking The patient was placed in a supine position before the surgery. The robot arm and assistant are located on the right side of the child, the instrument nurse stands on the left side of the child, and the anesthesiologist is located on the head end of the child. The 8  mm trocar was inserted into the skin of the umbilical margin of the child to establish the observation hole, the lens was connected to explore the abdominal cavity, and the pneumoperitoneum (6–8 mmHg) was established. Under the direct view of the lens, the 8  mm trocar was placed as the robot operation hole at the incision under the rib edge of the left and right midline of the clavicle, and the 5  mm trocar was placed as the auxiliary hole at the 2 cm incision on the right side of the flat umbilical cord (Fig.  9.1). After the robot system is ready, the manipulator is connected to the trocar respectively to release the tension between the trocar and the abdominal wall. The left-hand robot arm was implanted with Maryland bipolar separation forceps and the right-hand robot arm was implanted with ultrasonic knife.

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9.5 Surgical Steps

Fig. 9.1  The trocar positions of da Vinci robotic surgical system

First pass the abdominal from the left subcostal arch with 2-0 nonabsorbable thread, pick up the liver, pass from the falciform ligament of the liver, and thread out from the right abdominal wall with the assistant from both ends of the tight thread on the outer abdominal wall, suspend the liver, and fully expose the esophageal cardia region (Fig. 9.2a), then the operator and assistant assist in bringing the gastric and lower esophageal segments herniated into the thoracic cavity to the abdominal cavity. At least the abdominal segment esophagus 3  cm in length was maintained. The phrenoesophageal and hepatogastric ligaments were dissected free with a scalpel to expose the lower esophagus and cardia and covered free along the upper cardia with the perito-

a

b

c

d

e

f

Fig. 9.2  da Vinci robotic surgical system repair of paraesophageal hiatus hernia in infants and children. (a) Suspend the liver to expose the esophageal-cardia areas; (b) fully expose both diaphragmatic feet; (c) the tightness of the

closed hernia hole was detected by the suction device; (d) the right side of the abdominal esophagus is fixed to the diaphragm; (e) the top side of the abdominal esophagus is fixed to the diaphragm; (f) fundoplication (Nissen procedure)

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neum or hernia sac between the lower esophagus and cardia until the lower esophagus and fundus were no longer pulled into the mediastinum. Care was taken to avoid excessive depth of dissociation and to adequately protect vagal branches and esophageal muscularis. The left and right hemidiaphragmatic feet were freed, a cuff was bypassed from the back of the esophagus and elicited from the left hemidiaphragm, and the assistant fully exposed the bilateral hemidiaphragmatic feet by grasping the cuff with an accessory hole and pulling the lower esophagus downward (Fig. 9.2b). The mechanical arm of the right hand replaced the needle holder, 2-0 nonabsorbable thread was interrupted and sutured three to four times to reconstruct the esophageal hiatus, and the assistant needle holder was placed at the esophageal hiatus after suturing, so that it could pass smoothly through the suction apparatus (Fig. 9.2c). The ventral esophagus was preserved for more than 2 cm, and the esophagus was fixed with the diaphragmatic crus on both sides (Fig. 9.2d, e). The master knife was assisted by an assistant to wrap the gastric fundus around the lower esophageal segment 360° posterior to the esophagus with 2-0 nonabsorbable sutures with three needles (Nissen fundoplication, Fig. 9.2f). After exploration of the abdominal cavity no active bleeding, abdominal wall puncture point no bleeding, withdraw the robot system, close the abdomen. There is no need to place abdominal drainage tube.

9.6 Technical Points and Skills When treating pediatric HH with da Vinci robotic surgery system, due to the frequent separation and cutting of tissue, the left arm is connected with Maryland bipolar separation forceps and the right arm is connected with ultrasonic knife. Maryland bipolar separation forceps can pull blunt tissue and perform electrocoagulation. Ultrasonic knife can quickly cut tissue and perform electrocoagulation to reduce the interference of bleeding to the visual field. When dissociating the adhesive tissue around the lower segment of the esophagus, we should pay atten-

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tion that the separation depth should not be too deep, we can remove part of the hernia sac to avoid blocking the field of vision, but it is not necessary to completely dissociate and remove the hernia sac to avoid damage to the esophageal wall, vagus nerve, and mediastinal pleura. When the hernia is tightened, the last needle should be closely coordinated with the assistant, and it is appropriate for the assistant to hold the attractor or clamp to pass smoothly. Overloosening can easily lead to esophageal hiatal hernia recurrence and esophageal stricture, so experienced physicians should be used as assistants. At the same time, because the chief surgeon is far away from the operating table, the assistant should be prepared for thoracotomy or laparotomy at any time, such as massive bleeding during the operation, no visual field, or unable to find the location of the bleeding. The assistant must quickly complete emergency operations such as withdrawal from the robot, thoracotomy, laparotomy, and so on. According to the guidelines for the diagnosis and treatment of HH issued by the American Association of Gastrointestinal Endoscopic Surgeons in 2013, for some patients with HH of type I and II, the clinical symptoms are more likely to be caused by reflux, and anti-reflux surgery is more effective than herniorrhaphy [8]. Some scholars have proposed that the mode of operation should be selected according to the preoperative clinical symptoms and examination results of gastroesophageal reflux and its degree [9]. At present, the main anti-reflux procedures include Nissen’s operation, touch’s operation, or Thal’s operation, but the choice of anti-reflux operation is still controversial [10–13]. It has been reported that the three procedures are safe and effective. Nissen is a widely accepted gastric fundoplication, but the incidence of postoperative esophageal and cardiac stricture is higher than that of other surgical methods. Some studies have found that although the incidence of dysphagia after Toupet fundoplication decreased significantly in the short term, the difference decreased significantly with the prolongation of postoperative recovery period, and there was no significant statistical difference in the long-term effect. Our view is that according to the degree of

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dissociation of the gastric body during the operation, we choose the anti-reflux operation, the gastric body wrapping the esophagus is more relaxed, we choose Nissen, and when the gastric body wraps the esophagus more tightly, we choose Toupet. In Nissen operation, 1–2 needles should be fixed to the anterior wall of the esophagus to prevent the folded cardia from sliding up and down along the esophagus and cardia when the gastric fundus is wrapped around the esophagus. If vagus nerve injury is suspected during operation, pyloroplasty can be performed at the same time to prevent postoperative gastric dilatation and disturbance of gastric emptying.

operative recurrence and gastroesophageal reflux: too short abdominal esophagus, partial gastric fundus folding, and not tight enough esophageal hiatus may cause postoperative gastroesophageal reflux, which can be relieved with growth and development, and a few need reoperation [3]. The postoperative recurrence rate of esophageal hiatal hernia is 0.98%–4%, and recurrent surgery can also be performed under laparoscopy [14].

9.7 Post-Operation Complications

Since the first laparoscopic anti-gastroesophageal reflux surgery was completed by Bammer et al. in 1991, it has been widely accepted by surgeons and patients [9] and has become the standard procedure for the treatment of pediatric HH [15]. Laparoscopic surgery has obvious advantages over open surgery in postoperative infection, incidence of small intestinal obstruction, hospital stay, fasting time, dry retching, and so on. However, the operation time and postoperative recurrence rate were higher than those of open surgery (the difference was not statistically significant). However, laparoscopic surgery also has some shortcomings, such as two-dimensional visual field, poor sense of space, insufficient operational stability and accuracy due to the amplification of instrument angle and natural tremor, and the greater risk of accidental injury. In addition, the doctor’s learning curve is longer [16]. In recent years, Leonardo da Vinci robotic surgery system has been more and more used in the field of minimally invasive surgery. In 2004, Hanly et  al. reported robot-assisted HH repair and Nissen fundoplication for the first time [17]. Subsequently, more and more studies have confirmed that robotic HH surgery has the advantages of safety and effectiveness, less trauma, rapid postoperative recovery, and low recurrence rate [18–20]. Tian Wen et al. successfully implemented the first robotic HH operation in China in 2015 [21]. da Vinci robot system has the advantages of high-definition three-dimensional imag-

Patients with hiatal hernia routinely fasted for 2–3 days after operation, and were treated with intravenous fluid replacement at the same time. After anal exhaust and defecation, they ate gradually. It was necessary to observe whether there were symptoms of dysphagia and vagus nerve injury after eating. The common complications after robotic esophageal hiatal hernia surgery include: (1) esophageal injury: esophageal perforation caused by excessive deep injury to the esophageal wall during the operation, which can be repaired under microscope if it is found in time during the operation, and severe esophageal injury needs to be repaired by open surgery in time; (2) vagus nerve injury: dissociation too close to the side of the esophagus may lead to vagus nerve injury. If it is suspected that vagus nerve injury should be performed with pyloroplasty, it is necessary to prolong the indwelling time of gastric tube and fasting time after operation; (3) dysphagia: it may be caused by tissue edema at the gastroesophageal junction, which is usually relieved within a few days to weeks after operation, or dysphagia caused by esophageal stricture caused by esophageal hiatus suture or gastric fundus bypass. If this happens, you can try to dilate the esophagus by balloon, but if the dilatation is ineffective, you need another operation to relieve the esophageal stricture; (4) post-

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ing vision, 7-degree-of-freedom movement of the wrist of the manipulator, tremor filtering, and more reasonable ergonomic design [22]. It has achieved good therapeutic results in the fields of general surgery, obstetrics and gynecology, urology, cardiovascular surgery, thoracic surgery, and so on. However, Leonardo da Vinci robot surgery is mainly concentrated in general hospitals, and it is seldom used in the field of pediatric surgery [23–25]. At present, there is no report of Leonardo da Vinci robot surgery system in the treatment of esophageal hiatal hernia in children. The ­temperature of Leonardo da Vinci robot lens is about 50 °C, which makes the operation field not easy to blur, the smoke produced by electrocoagulation interferes with the field of vision very little, and shortens the time of operation. Moreover, the chief surgeon can adjust the lens independently to avoid the prolongation of operation time and the increase of operation risk caused by uncoordinated cooperation with assistants and improper operation. The 3D imaging system makes it possible to provide ultra-highdefinition vision, and the surgical field has a three-dimensional sense of hierarchy, which makes some fine anatomical structures clearer, especially when separating the tissue structures around the esophageal wall, it can clearly distinguish the vagus nerve and short gastric vessels, reduce the chance of accidental injury, avoid gastroparesis caused by vagus nerve injury, and contribute to the rapid recovery of gastric function after operation. The closed Leonardo da Vinci robot surgery system has obvious advantages in suture, its robotic arm system has high degree of freedom and accurate positioning, and can be sutured and knotted from different angles, which makes the suture and knotting in the narrow space easier to operate and more safe, shorten the operation time, and improve the quality of the operation.

References 1. Kavic SM, Segan RD, George IM, et al. Classification of hiatal hernias using dynamic three-dimensional reconstruction. Surg Innov. 2006;13:49–52.

J. Yu and Y. Gao 2. Siegal SR, Dolan JP, Hunter JG.  Modern diagnosis and treatment of hiatal hernias. Langenbeck's Arch Surg. 2017;402:1145–51. 3. Minimally invasive surgery group of pediatric surgery branch of Chinese Medical Association. Thoracic and cardiac surgery group of pediatric surgery branch of Chinese Medical Association expert consensus on laparoscopic procedures for hiatal hernia in children. Chin J Pediatr Surg. 2021;42:1–6. 4. Tan Z, Li J, Liang L, et al. Short term efficacy of laparoscopic Nissen and Toupet surgery in the treatment of esophageal hiatal hernia in children. Chin J Pediatr Surg. 2016;37:742–5. 5. Cheng C, Wu Y. Advances of laparoscopic fundoplication for children with congenital esophageal hiatal hernia. J Clin Pediatr Surg. 2019;18:1067–71. 6. Lobe TE. The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children. Surg Endosc. 2007;21:167–74. 7. Mertens AC, Tolboom RC, Zavrtanik H, et  al. Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high- volume center. Surg Endosc. 2019;33:2152–61. 8. Zhang C, Li J, Ke L, et  al. Interpretation of 2013 American Association of Gastrointestinal Endoscopic Surgeons guidelines for the diagnosis and treatment of esophageal hiatal hernia (I). Chin J Gastroesophageal Reflux Dis. 2015;2:6–9. 9. Lobe TE, Schropp KP, Lunsford K.  Laparoscopic Nissen fundoplication in childhood. J Pediatr Surg. 1993;28:358–61. 10. Fontaumard E, Espalieu P, Boulez J.  Laparoscopic Nissen-Rossetti fundoplication. First results. Surg Endosc. 1995;9:869–73. 11. Ashcraft KW, Goodwin CD, Amoury RW, et al. Thal fundoplication: a simple and safe operative treatment for gastroesophageal reflux. J Pediatr Surg. 1978;13:643–7. 12. Horvath KD, Jobe BA, Herron DM, et al. Laparoscopic Toupet fundoplication is an inadequate procedure for patients with severe reflux disease. J Gastrointest Surg. 1999;3:583–91. 13. Su F, Zhang C, Ke L, et  al. Efficacy comparison of laparoscopic Nissen, Toupet and dor fundoplication in the treatment of hiatal hernia complicated with gastroesophageal reflux disease. Zhonghua Wei Chang Wai Ke Za Zhi. 2016;19:1014–20. 14. Stefanidis D, Hope WW, Kohn GP, et al. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010;24:2647–69. 15. Garvey EM, Ostlie DJ.  Hiatal and paraesophageal hernia repair in pediatric patients. Semin Pediatr Surg. 2017;26:61–6. 16. Soliman BG, Nguyen DT, Chan EY, et  al. Robotassisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair. Surg Endosc. 2020;34:2495–502. 17. Hanly EJ, Talamini MA. Robotic abdominal surgery. Am J Surg. 2004;188:19S–26S.

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18. Vasudevan V, Reusche R, Nelson E, et  al. Robotic paraesophageal hernia repair: a single-center experience and systematic review. J Robot Surg. 2018;12:81–6. 19. Brenkman HJ, Parry K, van Hillegersberg R, et  al. Robot-assisted laparoscopic hiatal hernia repair: promising anatomical and functional results. J Laparoendosc Adv Surg Tech A. 2016;26:465–9. 20. Tolboom RC, Broeders IA, Draaisma WA.  Robotassisted laparoscopic hiatal hernia and antireflux surgery. J Surg Oncol. 2015;112:266–70. 21. Tian W, Xi H, Wei B, et  al. Robotic-assisted repair of esophageal hiatal hernia combined with fundoplication: a report of two cases. Chin J Pract Surg. 2015;35:519–21.

22. O'Connor SC, Mallard M, Desai SS, et  al. Robotic versus laparoscopic approach to hiatal hernia repair: results after 7 years of robotic experience. Am Surg. 2020;86:1083–7. 23. Meng H, Wang X, Xu S, et al. Selection of the surgical incisions in general thoracic surgery with da Vinci robotic surgical system: experience from 661 serial cases. Clin J Med Offic. 2016;44:556–62. 24. Wang Y, Tang S. Application of da Vinci robotic system for pediatric mediasinal tumors: a case report. J Clin Pediatr Surg. 2017;16:518–20. 25. Cundy TP, Harling L, Marcus HJ, et  al. Meta analysis of robot-assisted versus conventional laparoscopic fundoplication in children. J Pediatr Surg. 2014;49:646–52.

Robotic-Assisted Plication of Diaphragmatic Eventration

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Zheng Tan and Ting Huang

10.1 Introduction Diaphragmatic eventration (DE) is a congenital anomaly and is caused by diaphragmatic abnormalities or partial diaphragms due to phrenic nerve palsy. The incidence rate of congenital diaphragmatic eventration is about 0.05%, it is more common in males than in females [1]. Early diagnosis and repair of the diaphragm can prevent gastrointestinal disorders, reduce recurrent respiratory tract infections, and improve quality of life [2, 3]. Thoracoscopic diaphragmatic folding is a classic operation for the treatment of diaphragmatic eventration [4]. In recent years, with the rapid development of robot technology, many studies have reported that robotic-assisted surgeries are safe and feasible for pediatric cases. However, very few pediatric thoracic robotic cases have been described, and most roboticassisted surgery in children is urological surgery [5, 6]. No pediatric robotic-assisted diaphragmatic surgery has been reported.

Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­9693-­1_10. Z. Tan (*) · T. Huang Department of Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]; [email protected]

In our center, we successfully operated on four cases of robotic-assisted thoracoscopic diaphragmatic folding. This chapter mainly shares and summarizes the experience of robotic-­ assisted thoracoscopic diaphragmatic folding.

10.2 Indications and Contraindications Robotic-assisted thoracoscopic surgery (RAT) has certain advantages. Almost all the indications and contraindications are consistent with thoracoscopic surgery. Due to our experience, we recommend that the patient should be at least 7 months old or weigh at least 8 kg, but the operation requirements of pediatric RATs are clear, strict, and objective. The indications and certain conditions are affected by the accumulation of personal RAT experience and grasp the impact of the scope of indications. Indications: (1) relative to the normal position, the diaphragm moved upward to more than 3 ribs; (2) the inflated diaphragm causes obvious compression on the affected side of the lung, and there are obvious respiratory distress symptoms such as shortness of breath and asthma; (3) frequent pulmonary infection, hypoxemia and even abnormal respiratory movement; (4) conservative treatment was ineffective. During the follow-up, the diaphragm continued to lift, and the became worse; worsened; (5) accompanied by gastrointestinal obstruction symptoms such as gastric volvulus or acute intestinal obstruction; (6) newborns and

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_10

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infants with respiratory distress, repeated episodes of hypoxia or inability to evacuate the ventilator [7]. Contraindications: (1) abnormal coagulation function and bleeding tendency; (2) severe infection; (3) systemic organ failure and unstable vital signs unable to tolerate the operation; (4) diagnosed with neuromuscular disease; (5) weight less than 8 kg or age less than 6 months, for children with these relative contraindications, a careful preoperative discussion by experienced clinicians is required to assess the suitability of da Vinci surgery.

10.3 Preoperative Preparation First, related examinations are consummated, and the diagnosis is confirmed. The preoperative preparation of Da Vinci-assisted thoracoscopic diaphragmatic folding includes gastrointestinal preparation, psychological preparation, and blood preparation. Intestinal preparation included eating digestible food, preoperative enema, preoperative fasting for 8 hours and being water-free for 2 hours before surgery. Appropriate fluid replacement was performed before the operation. On the day of the operation, a glycerine enema can be given according to defecation and abdominal distention, and gastrointestinal decompression can be carried out before the operation. Psychological preparation includes preoperative doctor–patient communication and nursing education so that the guardian can understand the operation process, possible complications and perioperative preventive measures to reduce the anxiety of the family and children. For blood preparation, with the maturity of diaphragmatic folding in recent years, intraoperative blood transfusion is rarely needed. However, due to the risk of injury to large blood vessels, heart and lung in the chest, red blood cells and plasma still need to be prepared routinely before operation. Diaphragmatic folding surgery is a type I incision that generally does not require the use of antibiotics before the operation. For children with infection, relevant antibiotics can be used according to the pathogen, and surgical treatment can be carried out after the inflammation is controlled.

Z. Tan and T. Huang

10.4 Position and Docking The patient was placed in a lateral position, with the affected side upward and the head low feet at a high tilt (approximately 10-20°) (Fig.  10.1). The ports were asymmetrically placed as described below: (1) 8 mm 30-degree camera in the 3th intercostal space (ICS) on the midaxillary line connect to the arm 2; (2) arm 1 connect with the trocar through the fifth ICS on the preaxillaris line with the distance 5-6 cm with camera port, sometimes the port may be lateral 1 cm the preaxillaris line; (3) arm 3 through the seventh ICS on the posterior axillary line with the distance of 5-6 cm with camera port, also the port can be lateral 1-2 cm the posterior axillary line, respectively; (4) auxiliary Trocar (5 mm) was placed at the fourth intercostal level between the axillary midline and the clavicular midline. Due to the small chest space of children, to achieve sufficient distance, the robot operation holes are not in line with the camera hole. We should keep the distance more than 3 cm between the robot operation hole and

Fig. 10.1  The layout of the trocar for da Vinci diaphragmatic folding surgery. Points 1, 2 and 3 are the positions of DaVinci Trocar holes, and point 4 is the auxiliary hole. Line a: the midaxillary line; line b: the preaxillaris line; line c: the posterior axillary line; star mark: surface projection of the surgical area

10  Robotic-Assisted Plication of Diaphragmatic Eventration

the camera hole to avoid collision and damage of the robotic arm. The specific port position will be appropriately adjusted according to the actual situation. Docking: (1) adjust the child’s position to head down and foot up (note: this step is important, and the patient’s position cannot be adjusted after installation unless a da Vinci eleven integrated operating table is configured); (2) establish pneumothorax by means of the Da Vinci trocar; (3) set the main machine “pelvic surgery” mode, leaving arm 4 empty and arm 2 attached to a camera trocar, determine the operative field using the main view lens, and press the “aim” button to adjust the other robotic arms; (4) arm 1 and arm 3 were attached to the trocar at points 2 and 3, respectively. The instrument was mounted under the supervision of

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a main viewer; (5) put the needle holder and gripper into trocar 1 and trocar 3, respectively.

10.5 Surgical Steps Endotracheal intubation under fiberoptic guidance allows one-lung ventilation to be achieved. Carbon dioxide (CO2) was insufflated into the chest to maintain positive pressure, and the lung collapsed. If one-lung ventilation is not tolerated, we choose two-lung ventilation, but the pressure will be increased. After the reduction was completed, the redundant diaphragm was pulled plicated. Then, it was sutured intermittently with 2-0 nonabsorbable suture (Fig. 10.2). A chest tube was always placed and then removed after 1-3 days.

D

E

F

G

Fig. 10.2  The redundant diaphragm was pulled plicated, then sutured intermittently with 2-0 non-absorbable suture (a–d)

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10.6 Technical Points and Skills The narrow intercostal space and thoracic cavity make the distance between the port holes small, so the manipulator easily collides inside and outside the thoracic cavity, which increases the difficulty of the operation. We used the sequential expansion method to place the trocar: first, a 5 mm trocar was placed, and then an 8 mm trocar was placed to gradually increase the intercostal space. The asymmetrically layout trocar makes the distance between the anterior arm port (or posterior arm port) and camera port different, which breaks through the limit of the intercostal space and chest space and avoids collision with the manipulator. Due to the lack of force feedback and the absence of instruments specifically for younger children, clinicians need to pay attention to the following points: (1) body position (Nonda Vinci integrated surgical bed): The body position should be head-low and foot-high, with the foot side elevated by approximately 10°-20° to prevent the robot arms from squeezing the head and shoulder of the patient. The 30° camera was turned upward while suturing the edge of the diaphragm. The ordinary bed height must be adjusted before docking; (2) reduced grasping and pulling of the diaphragm; (3) choose an appropriate hole position and the depth of trocar into the patient.

10.7 Postoperative Complications Almost all complications are similar to those of traditional thoracoscopic surgery, including pleural effusion, palindromia, tissue and organ bleeding, pneumothorax, chylothorax, atelectasis, and

Z. Tan and T. Huang

lung injury, especially in newborns and young infants. The tissues and organs of newborns and infants are fragile, which easily causes unnecessary damage during the operation. In the initial period, robot installation always takes a long time, which causes hypercapnia and increases the risk of anesthesia [8, 9].

10.8 Comparisons with Conventional Thoracoscopic Surgery The robot has a wider visual angle and a 3-D visual field, which increased magnification and sharpness, greatly increasing the surgical accuracy and reducing tissue damage. Its design is ergonomic, so the operator can work in a relaxed environment, reduce fatigue and concentrate more [10]. However, it also has limitations: lack of tactile feedback, nonbedside operation and limited working space due to the large size of the instrument, especially for small infants. The RATS approach offers an easier learning curve option for minimally invasive diaphragm plication [11]. Future studies are needed to judge the benefits of the RATS approach in children.

10.9 Case Presentations and Video A boy 11 months, 9.5 kg, a right diaphragm elevation was found for 2 months. For robotic-assisted diaphragmatic folding, the setup time was 20 mins, and the operation time was 45 mins. The chest tube was removed 30 hours after the operation. The postoperative hospital stay was 4 days (Fig. 10.3).

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Fig. 10.3  Right diaphragm elevation

References 1. Deslauriers J. Eventration of the diaphragm. Chest Surg Clin N Am. 1998:8:315–30. 2. Özkan S, YaziciÜ, Aydin E, et al. Is surgical plication necessary in diaphragm eventration? Asian J Surg. 2016;39:59–65. 3. Ouyang H, Wu XC, Ding S, et al. Diaphragm plication for the treatment of diaphragmatic paralysis

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in infants after surgical correction for congenital heart diseases. Chin J Clin Thorac Cardiovasc Surg. 2014;21:220–223. 4. Liu JB, Yan XG, Chen G, et al. Comparative study of open and thoracoscopic repair for congenital diaphragmatic eventration in children. Chin J Pediatr Surg. 2014;35:39–42. 5. Fuchs ME, DaJusta DG. Robotics in pediatric urology. Int Braz J Urol. 2020;46:322–7. 6. Ferrero PA, Blanc T, Binet A, et al. The potential and the limitations of esophageal robotic surgery in children. Eur J Pediatr Surg. 2022;32:170–6. 7. Section of Endoscopic Surgery, Branch of Pediatric Surgery, Chinese Medical Association. National consensus in China on surgery for diaphragmatic eventration in children. Section of Cardiothoracic Surgery. Chin J Pediatr Surg. 2018;39:645–9. 8. Bishay M, Giacomello L, Retrosi G, et al. Hypercapnia and acidosis during open and thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia: results of a pilot randomized controlled trial. Annals of Surgery, 2013;258: 895–900. 9. Bishay M, Giacomello L, Retrosi G, et al. Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia in infants. J Pediatr Surg. 2011;46: 47–51. 10. Al-Bassam A. Robotic-assisted surgery in children: advantages and limitations. J Robotic Surg. 2010;4:19–22. 11. Stuart CM, Wojcik BM, Gergen AK, et al. A comparison of short‑term outcomes following robotic‑assisted vs. open transthoracic diaphragm plication. J Robot Surg. 2023;17(4):1787–96.

Robotic-Assisted Ligation of The Patent Ductus Arteriosus

11

Liyang Ying and Xiwang Liu

11.1 Introduction Patent ductus arteriosus (PDA) is a common congenital cardiac anomaly. Without treatment, PDA leads to an increase in continuous pulmonary blood flow and left ventricular preload. It is necessary to treat PDA through surgical intervention [1]. With advances in surgical techniques and perioperative management strategies over the past decades, minimally invasive endoscopic surgery has been extensively developed in all disciplines. Endoscopic technology reduced the incidence of complications after the operation and the length of hospital stay. Recently, robotic-assisted surgery systems have helped to overcome the limitations of conventional endoscopic tools [2]. Robotic surgery for PDA closure with robotically assisted instrumentation provides accurate Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­9693-­1_11. L. Ying (*) Department of Cardiovascular Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected] X. Liu Department of Cardiac and Thoracic Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: [email protected]

three-dimensional vision, intelligent tremor filtering, and motion correction [3]. The recent use of robotic surgical assistance was technically feasible in pediatric patients [4]. Compared with traditional thoracoscopic surgery, new-generation Da Vinci robot-assisted thoracoscopic surgery excels in procedures in the small chest of children. This makes it possible for Da Vinci robots to be widely used in children’s surgery. Areas that are more easily reached with the newest generation robotic articulations, such as the foramen of Bochdalek. This is the most important factor for PDA closure in children [5]. Robot-assisted surgery has been proven to be superior to traditional surgery, even to the thoracoscopic approach for PDA closure [6, 7]. The current diameter of the robotic system trocar limits the progress of its application in children. There are still some limitations for PDA closure by the robotically assisted surgical system in children. Undoubtedly, robotic surgery will prevail with technological improvements in children in the future.

11.2 Indications and Contraindications Indications: age  >1  year old, weight  >10  kg, tubular PDA. Contraindications: age