Robot-Assisted Surgery: Current Status Evaluation in Abdominal and Urological Pediatric Surgery

Abstract

Purpose:

The last two decades have witnessed a dramatic development of minimally invasive surgery (MIS). Robotic-assisted surgery is currently the latest step in the evolution of MIS. MIS was initially developed for adult surgery, but its use has progressively been extended to pediatrics. As for all new technologies, an objective evaluation is essential to adopt the robot in the practice of pediatrics.

Materials and Methods:

This article reviews the spectrum of evidence regarding the feasibility, safety, benefits, and limitations of abdominal and urological robot-assisted surgery in children. This analysis was performed using the PubMed database, using key words such as “robot,” “robotic surgery,” “robot-assisted,” “da Vinci,” and “computer-enhanced surgery” combined with “child,” “children,” “infants,” and “pediatric.”

Results:

In total, 88 studies met the selection criteria for our review. Only 10 studies comparing robotic surgery with open or conventional laparoscopic surgery are available for abdominal or urological pediatric procedures. Fundoplication for gastroesophageal reflux and pyeloplasty for hydronephrosis represent the most frequent procedures performed with robotic assistance in children.

Conclusions:

Robotic surgery is suitable in the pediatric practice, which necessitates fine dissections and sutures in narrow anatomical spaces. The initial results of robotic surgery in the field of pediatrics are encouraging. Further prospective and comparative studies, especially between robotic and laparoscopic approaches, are required to confirm these preliminary results.

Introduction

The last two decades have witnessed a prodigious development of minimally invasive surgery (MIS) and especially in the field of laparoscopic surgery. Undoubtedly, the advantages of MIS are reduced postoperative discomfort and morbidity, decreased hospital stay, faster recovery, and improved cosmetic results.

However, there are several limitations in the use of conventional laparoscopic surgery, such as two-dimensional view of the surgical field with loss of depth perception, counterintuitive movements with rigid and nonarticulated instruments, loss of eye–hand coordination, and nonergonomic position for the surgeon.

Robotic surgery was developed to relieve these drawbacks. Indeed, robotic surgery is a new technology that offers three-dimensional visualization, articulated instruments with seven degrees of freedom, intuitive movements, tremor filtering, motion scaling, complete camera control, and ergonomic position for the surgeon. This method was initially developed for adult surgery, but its use has been progressively extended to the field of pediatrics. There are currently more than 1840 operational master–slave robots installed in the world.

As for all new technologies, an objective evaluation is essential with the need to respond to several questions: Is the technology feasible? Is the technology safe? Is the technology efficient? Does it bring about benefits compared with current technology? What are the procedures derived from most benefits of robotic assistance?

Materials and Methods

Our literature analysis was performed using the PubMed database, using the key words “robot,” “robotic surgery,” “robot-assisted,” “da Vinci,” and “computer-enhanced surgery” combined with “child,” “children,” “infants,” and “pediatric.” We selected only publications in English, and we deliberately limited the results to abdominal and urological surgery.

We could not achieve an analysis according to evidence-based medicine criteria because of the absence of large series and/or randomized studies.

Results

In total, 88 studies met the selection criteria for our review.

The initial reports were experimental animal studies. These studies described the feasibility of several procedures such as entero-enterostomy, hepaticojejunostomy, portoenterostomy, esophago-esophagostomy, or ureteral reimplantation on piglets.^1–7

Case reports and small series are then reported by pioneers in pediatric robotic surgery beginning in 2001.^{5,8–22,49–56}

A current synthesis of abdominal and urological procedures performed with robotic system in children is reported in Table 1.

Table 1.

Pediatric Robotic-Assisted Procedures Reported in Children

Surgery	Procedure
Abdominal	• Fundoplication
	• Cholecystectomy
	• Kasai portoenterostomy
	• Choledochal cyst resection
	• Congenital diaphragmatic hernia
	• Hiatal hernia
	• Heller myotomy
	• Esophageal leiomyoma
	• Esophageal duplication
	• Esophageal atresia
	• Duodenal atresia
	• Pyloroplasty
	• Gastric duplication
	• Appendectomy
	• Meckel diverticle resection
	• Bowel resection
	• Hemicolectomy
	• Total proctocolectomy
	• Anorectal malformation repair
	• Rectal prolapse
	• Abdominal lymphangioma
	• Pancreatic tumor
	• Neuroblastoma
	• Splenectomy
	• Sympathectomy
	• Liver cyst excision
Urologic	• Pyeloplasty
	• Nephrectomy
	• Ureteral reimplantation
	• Appendicovesicostomy
	• Ileocystoplasty
	• Orchidopexy
	• Bladder neck surgery
	• Bladder diverticulum resection
	• Adrenalectomy
	• Ovarian cyst excision
	• Ovarian teratoma
	• Gonadoblastoma
	• Hysterectomy
	• Pelvic organ prolapse
	• Inguinal hernia repair
	• Prostatic utricle excision
	• Müllerian duct remnants
	• Varicocele correction
	• Urachal cyst excision

To date, only 10 studies comparing robotic surgery with open or conventional laparoscopic surgery are available for abdominal or urological pediatric procedures.^{13,29–31,64–67,77,78} For these studies, the level of evidence is specified according to the Oxford Centre for Evidence-Based Medicine.

Abdominal surgery^23–47

Gastric fundoplication

Laparoscopic fundoplication has become the gold standard for the surgical management of gastroesophageal reflux disease in children. Laparoscopic fundoplication allows shorter length of hospital stay, reduced postoperative pain, and faster recovery.^23–25

Fundoplication is one of the most common procedures performed robotically in children. The first case report was published by Meininger et al.⁸ in 2001. The first series demonstrate the feasibility, safety, and efficiency of robotic procedure with good results.^14,15,26,27

In 2010, Margaron et al.²⁸ presented a series of 15 children with neurological impairment and previous gastrostomy who underwent robot-assisted Nissen fundoplication. The authors asserted that robot-assisted laparoscopic Nissen fundoplication is a safe and effective operation for children with existing gastrostomy, particularly those who are neurologically impaired.

Three studies compare robotic fundoplication versus open or conventional laparoscopic fundoplication in children.^29–31 The results are summarized in Table 2.

Table 2.

Comparative Studies Among Robotic, Laparoscopic, and Open Fundoplication in Children

Study, group	n	Type	Mean age (years)	Operating time (minutes)		Length of hospital stay (days)		Conversion	Postoperative complications	Recurrence results (follow-up)
Lehnert et al.²⁹ (2006)
Laparoscopic group	10	Thal	7.6±3.1	128.9±17.4	P=.862	NA		0	0	0 (14 months)
Robotic group	10		11.9±1.4	127.2±24.9		NA		0	0	0 (14 months)
Anderberg et al.³⁰ (2007)
Open group	6	Floppy	4 (1–13)	121±85 (73–215)	P=.03	6.2±0.7	P=.01	0	0	0
Laparoscopic group	6		11 (7–13)	189±13 (140–257)		3.5±0.7		0	0	0
Robotic group	6		7 (2–11)	213±81 (150–285)		4±1.4		0	0	0
Albassam et al.³¹ (2009)
Laparoscopic group	25	Nissen	3.8±3.2 (0.2–12)	193±26.6 (155–288)	P=.334	4.1±1.16	P=.173	2 (8%)	2 (8%)^a	0
Robotic group	25		5.2±3.4 (0.1–12)	186±21.1 (145–259)		4.5±1.08		1 (4%)	2 (8%)^b	0

One delayed gastric emptying and one dysphagia.

Two delayed gastric emptying.

NA, not available.

In a study by Lehnert et al.²⁹ (evidence level III), there were no conversions, no intraoperative complications, and no postoperative complications up to 14 months after surgery. The total operative time was similar in both groups (P=.862). The faster dissection time in the robotically assisted group was counterbalanced by the slower set-up time. The results were limited by a significant age difference between the groups.

In a study by Anderberg et al.³⁰ (evidence level IV), the mean time for the robotic procedure was longer than that of open or laparoscopic surgery (P=.03). However, the operating time for the four latest robotic procedures was similar to the operating time for the laparoscopic technique. The duration of the postoperative use of morphine analgesics and the length of hospital stay were significantly reduced in the robotic and the laparoscopic groups compared with the open group (P=.002 and P=.01, respectively). There was no difference in the short-term clinical outcomes between the groups, with 100% disappearance of reflux symptoms.

In a study by Albassam et al.³¹ (evidence level III), with a larger population, there were no statistical differences between the robotic group and the laparoscopic group regarding operating time, length of hospital stay, or postoperative analgesic requirement (P=.334, P=.173, and P=.76, respectively). Conversion rates, postoperative complications rates, and short-term clinical results were similar in both groups.

In conclusion, robotic-assisted fundoplication is feasible, safe, and efficient in children. The results of robotic surgery are comparable to those of laparoscopic surgery and better than those of open surgery with regard to the use of postoperative analgesics or to length of hospital stay.

Robotic-assisted fundoplication is an alternative to the standard laparoscopic procedure. However, because of expensive robotic procedure cost, its use in gastric fundoplication is rationally questionable. Nevertheless, the robot may be of interest in some procedures such as redo fundoplications or in the most vulnerable children with neurological impairment, for instance.

Hepatobiliary surgery: cholecystecomy

Several studies have revealed the feasibility and the safety of robot-assisted cholecystectomy in children.^{9–12,14,16,17} However, we found no comparative study between robotic versus laparoscopic cholecystectomy in children.

As for many extirpative surgeries, the use of the robot for cholecystectomy is questionable because of the excessive cost of the procedure and the poor clinical benefits expected for the patient. The robot could be more interesting for difficult cholecystectomies (in cholecystitis, for example). In these cases, the robot could facilitate proper identification of anatomical structures and dissection of inflammatory tissues.

Hepatobiliary surgery: choledochal cyst and biliary atresia

The first laparoscopic resection of a congenital choledochal cyst with a Roux-en-Y hepaticojejunostomy was published by Farello et al.³² in 1995. The first laparoscopic porto-enterostomy by the Kasai procedure for the treatment of biliary atresia was reported by Esteves et al.³³ in 2002. Although the laparoscopic approach to the treatment of complex biliary disease is possible, it is technically challenging even in the most expert hands. This difficulty is mainly due to the fine dissection and the many intracorporeal sutures made in a narrow anatomical space.

Some publications have shown the feasibility and the safety of robotic procedure for the treatment of complex hepatobiliary anomalies in children.^{11,17,34–36} Woo et al.³⁴ reported the first successful resection of a choledochal cyst and a Roux-en-Y hepaticojejunostomy performed using a robotic surgical system in a 5-year-old girl. Meehan et al.³⁵ published the first series of two choledochal cyst resections and two Kasai procedures performed by robot-assisted surgery. For these authors, three-dimensional visualization, articulated instruments, and fine-motion filtering were the main advantages of the robotic system. In addition, Dutta et al.,³⁶ Klein et al.,¹¹ and Alqahtaniet al.¹⁷ reported three Kasai procedures, one choledochal cyst resection, and three choledochal cyst resections, respectively.

Robotic surgery may be the minimally invasive solution to complex procedures such as choledochal cyst resection or biliary atresia repair. Indeed, such procedures require fine dissections, numerous suturing, and knot-tying, for which the robot is very helpful.

Additionally, MIS may induce fewer adhesions and an easier dissection if liver transplantation was required following a failed Kasai procedure.³⁵

Robotic surgery seems helpful for many digestive procedures, especially complex procedures. However, the lack of evidence in the current literature necessitates further comparative studies to confirm these preliminary results.

Miscellaneous

These procedures include, for instance, repair of a Bochdalek or a Morgagni congenital diaphragmatic hernia, repair of a congenital paraesophageal hiatal hernia, Heller's cardiomyotomy, repair of a congenital duodenal atresia, repair of an esophageal atresia, and splenectomy.^37–47 These other procedures are reported in Table 1.

Genitourinary tract^48–98

Pyeloplasty

Historically, the gold standard for the treatment of ureteropelvic junction obstruction is the open dismembered pyeloplasty according to the Anderson–Hynes procedure.

Since the first pediatric laparoscopic pyeloplasty published by Peters et al.⁴⁸ in 1995, few series have been reported, confirming the difficulty and the long learning curve of this technique.

Currently, robot-assisted pyeloplasty is the most common operation with robotic assistance in the urological pediatric practice. The surgical approach and technique are dependent on the surgeon's preference and proficiency. As the laparoscopic technique, transperitoneal and retroperitoneal approaches are possible with the robotic system.

In 2004, Olsen and Jorgensen⁵⁸ reported the first series of robot-assisted retroperitoneoscopic pyeloplasty in 15 children. In 2005, Atug et al.⁵⁹ published the first series of robot-assisted transperitoneal pyeloplasty in 7 children. Robotic pyeloplasty is also possible in infants. Kutikov et al.⁶⁰ reported nine successful robotic procedures in infants 5.6 months of age on average. More recently, larger series have been reported, like a study by Olsen et al.⁶¹ with 67 retroperitoneal pyeloplasties and a study by Minnillo et al.⁶² with 155 transperitoneal pyeloplasties. These studies confirmed the feasibility, safety, and efficiency of robot-assisted pyeloplasty in children.^58–63

Currently, there are three pediatric studies^64–66 comparing robotic versus open pyeloplasty and only one pediatric study⁶⁷ comparing robotic versus laparoscopic pyeloplasty. The results are summarized in Table 3.

Table 3.

Comparative Studies Between Open and Robotic Pyeloplasty in Children

Study, group	n	Mean age (years)	Operating time (minutes)		Length of hospital stay (days)		Intraoperative complications	Postoperative complications	Success rate	Follow-up (months)
Yee et al.⁶⁴ (2006)
Open group	8	9.8 (6–15.6)	248 (144–375)	P=.03	3.3 (1–8)	P=.47	0	NA	87.5%	53.2
Robotic group	8	11.5 (6.4–16.5)	363 (255–522)		2.4 (1–5)		1 mechanical failure with robot	NA	100%	14.7
Lee et al.⁶⁵ (2006)
Open group	33	7.6 (0.2–19)	181 (123–308)	P=.031	3.5 (2.7–5)	P<.001	0	0	100%	20
Robotic group	33	7.9 (0.2–19.6)	219 (133–401)		2.3 (0.5–6)		0	1 (3%)^a	94%	10
Sorensen et al.⁶⁶ (2011)
Open group	33	8.2	236 (236±54)	P<.004	NA	P=NS		3 (9%)^b	97%	19
Robotic group	33	9.2	326 (326±77)		2.2		3 mechanical failures with robot	5 (15%)^c	97%	17

Persistent hydronephrosis for missed anterior crossing vessels.

One pyelonephritis, one pain and vomiting, and one stent migration.

One hematuria with clot obstruction of stent and four urine extravasations

NA, not available; NS, not significant.

In a study by Yee et al.⁶⁴ (evidence level IV), the mean operative time was significantly longer in the robotic group (P=.03) compared with the open group. However, this mean operative time was partially affected by 1 case in which a technical problem occurs with the robotic system. The length of hospital stay and the use of pain medication were reduced in the robotic group but not significantly (P=.47 and P=.31, respectively). Complications and success rates were similar in both groups. The success rate was 100% in the robotic group.

In a study by Lee et al.⁶⁵ (evidence level III) conducted in a larger number of patients, the mean operative time was also significantly longer in the robotic group (P=.03). However, the robotic operative times improved with increasing experience and got closer to the open operative times at the end of the study. Length of hospital stay and analgesic requirements were significantly reduced in the robotic group (P<.001 and P=.001, respectively). Although results were comparable in both groups, there was one complication in the robotic group: during a robotic-assisted pyeloplasty using a retroperitoneal approach, anterior crossing vessels were not identified, and re-operation was required.

In a study by Sorensen et al.⁶⁶ (evidence level IV), the mean operative time was also significantly longer in the robotic group (P<.004). However, after 15–20 cases, there was no statistically significant difference in overall operative time for robotic and open pyeloplasty (P=.23). The length of hospital stay was similar in both groups. However, there was a significant decrease in the length of hospital stay with each year of experience. Three conversions to laparoscopic techniques were mentioned in the robotic group because of a technical failure with the robot. Complications and success rates were similar in both groups.

Currently, only one study comparing robotic and laparoscopic pyeloplasty in children is available.⁶⁷ The mean operative time is similar in both groups. However, the results are questionable because only the anastomotic time was performed robotically. Consequently, this study does not take into account the benefits of robotic surgery (three-dimensional visualization, articulated instruments, tremor filtering) in the dissection time. There were two open conversions in the robotic group, including one in a patient with a stone and one due to mechanical failure of the robot. Final success rates were similar in both groups (100%).

In conclusion, pyeloplasty seems to be a good indication for the use of the robot. Indeed, pyeloplasty requires fine dissection and intracorporeal sutures in a narrow anatomical working space. Many recent studies have confirmed the feasibility, safety, and efficiency of robotic procedures in children. The results are comparable in robotic and open groups. In addition, length of hospital stay anduse of analgesics are reduced in the robotic procedure. However, the level of evidence of the available studies is low. Further comparative and prospective studies are now necessary to confirm these preliminary result

Ureteral reimplantation

Ureteral reimplantation is a therapeutic option when a surgical treatment is indicated to correct vesicoureteral reflux (VUR). In 1994, Ehrlich et al.⁷³ published the first laparoscopic correction of VUR in children. Since then, few additional reports have been published in the literature confirming the difficulty of the laparoscopic technique. Robot-assisted surgery could be the minimally invasive solution for the surgical management of VUR.

The first series describe the feasibility of the robotic procedure in children, using an extravesical⁷⁴ or intravesical⁷⁵ approach.

There are three comparative studies^13,77,78 between the conventional open procedure versus the robotic procedure in children. The results are summarized in Table 4.

Table 4.

Comparative Studies Between Open and Robotic Ureteral Reimplantation in Children

	n	Mean age (years)	Operating time (minutes)		Length of hospital stay (days)		Intraoperative complications	Postoperative complications	Success rate	Follow-up (months)
Sorensen et al.¹³ (2010)
Open group	26	8±3.5	236±58	P<.001	2.9±1	P=.31	0	3 (11.5%)^a	92.3%	14
Robotic group	13	8.4±4.1	361±80		2.5±1.5		0	2 (15.4%)^b	84.6%	14
Smith et al.⁷⁷ (2011)
Open group	25	4.2±2.2	165 (116–209)	P<.05	2.1 (1.2–4.2)	P<.001	0	NA	100%	29.1
Robotic group	25	5.7±3.3	185 (117–286)		1.4 (0.6–2.4)		0	3 (12%)^c	97%	16
Marchini et al.⁷⁸ (2011)
Open group IV	22	8.8±4.8	147.5±34.3	P<.001	2.9±1	P=.001	0	12 (54.5%)^d	86.4%	12.1
Robotic group IV	19	9.9±5.2	232.6±37.4		1.8±1.2		0	5 (26.3%)^e	84.2%	19.4
Open group EV	17	6.1±2.7	120±47.5	P<.001	1.7±1	P=1	0	2 (11.8%)^d	94.1%	12.8 months
Robotic group EV	20	8.6±9.1	233.5±60.2		1.7±1		0	4 (20%)^f	100%	12 months

One dehydration, one pyelonephritis, and one wound infection.

One urinoma and one ureteral stenosis.

Voiding difficulty.

Hematuria.

Four bladder leaks and one urinary retention.

Two ureteral leaks and two urinary retentions.

EV, extravesical; IV, intravesical; NA, not available.

In a study by Sorensen et al.¹³ (evidence level IV), the operative time was significantly longer in the robotic group (P<.001). The length of hospital stay was reduced in the robotic group but not significantly (P=.31). Complications and success rates were comparable in both groups (P=.76 and P=.51, respectively).

In a study by Smith et al.⁷⁷ (evidence level III), the operative time was also significantly longer in the robotic group (P<.05). However, the procedures were different in the two groups (extravesical approach for the robotic group and intravesical approach for the open group). The length of hospital stay and use of analgesics were significantly reduced in the robotic group (P<.001). Complications and success rates were similar in both groups.

Marchini et al.⁷⁸ reported the most valuable study (evidence level III). They compared a robotic group with an open group, differentiating extravesical from intravesical approaches in each group. The operative time was significantly longer in the robotic group (P<.001) for extravesical and intravesical approaches. The length of hospital stay was reduced in the robotic group for the intravesical approach (P=.001) but not for the extravesical approach (P=1). A reduction of bladder spasms and hematuria was also identified in the robotic group for the intravesical approach. Complications and success rates were comparable in the two groups.

There is no comparative study between laparoscopic versus robotic ureteral reimplantation in children currently available in the literature.

Robot-assisted ureteral reimplantation seems to be a good alternative in children. This technique provides results similar to those of open surgery with MIS benefits. However, no recommendations can currently be made because of the low level of evidence of studies available in children.

Other procedures: orchidopexy

Najmaldin and Antao¹² reported a case of bilateral orchidopexy with excision of Müllerian remnants using the robotic system.

Currently, it does not appear to be a major benefit over the laparoscopic technique in performing orchidopexy by means of robotic assistance because it does not require any precise suturing.

Other procedures: nephrectomy

In comparison with open nephrectomy, laparoscopic nephrectomy allows for a reduction in the length of hospital stay and use of analgesics.^68,69 Several authors have demonstrated the feasibility of partial and total nephrectomy using the robotic system in children.^{12,13,17,57,70–72} This procedure can be achieved by a transperitoneal or retroperitoneal approach.

Currently, there is no comparative study between robotic versus laparoscopic or open nephrectomy in children.

As for many extirpative surgeries, the use of the robotic system for total nephrectomy is questionable because of the excessive cost of the procedure and the poor benefits expected for the patient. The robotic assistance could be more valuable for partial nephrectomy, which is technically more difficult. Enhanced visualization and surgical dexterity enabled by the robotic system may reduce the risk of remnant pole vascular injury.⁷² Further prospective and comparative studies are necessary to confirm this hypothesis.

Other procedures: complex reconstructive surgery: appendicovesicostomy and augmentation cystoplasty

In 2004, Pedraza et al.⁷⁹ reported the first case of Mitrofanoff appendicovesicostomy performed by robotic surgery in a 7-year-old boy. Storm et al.⁸⁰ published the first short series of three procedures, confirming the feasibility of the technique by robotic surgery. Lendvay et al.⁸¹ reported a case of robotic-assisted Mitrofanoff appendicovesicostomy and antegrade continent enema colon tube creation in a pediatric spina bifida patient. Gundeti et al.⁸² achieved an augmentation ileocystoplasty associated with a Mitrofanoff appendicovesicostomy. Nguyen et al.⁸³ and Gundeti et al.⁸⁴ reported the first series of appendicovesicostomies with hopeful results. However, postoperative complications rates remain high.

The robot is definitely more helpful for complex reconstructive procedures such as appendicovesicostomy or ileocystoplasty. Enhanced visualization and increased dexterity of robotic surgery facilitate fine dissections and sutures in narrow anatomical spaces. Robotic surgery could reduce morbidity among these often multi-operated children. The lack of evidence in the current literature requires comparative studies that are now necessary to assess benefits of robotic surgery in complex reconstructive procedures.

Miscellaneous

Numerous procedures have been performed with the robot in children such as bladder neck sling, adrenalectomy, urachal cyst excision, and ureteroureterostomy for retrocaval ureter correction.^88–97 All such procedures are reported in Table 1.

Conclusions

Robotic-assisted surgery is the new step in the evolution of MIS. In comparison with conventional laparoscopic surgery, robotic-assisted surgery provides numerous benefits, such as magnified three-dimensional visualization, articulated instruments, tremor filtering, motion scaling, or ergonomic position. Robotic surgery is suitable for the practice of pediatrics, which necessitates fine dissections and sutures in narrow anatomical spaces. However, improvements are still possible such as miniaturization of the system and instruments or enhancement of a tactile feedback.

Many studies have been published, but these are often case reports or small series.

Currently, the most frequent procedures performed with robotic assistance in children are fundoplication for gastroesophageal reflux and pyeloplasty for hydronephrosis.

The top of the learning curve is reached after about 10–20 procedures performed for the same pathology. The acquisition of robotic skills is more rapid and less difficult in comparison with laparoscopic skills. Additionally, laparoscopic skills are not absolutely required to use the robot.⁹⁸

The main check to robotic surgery development is the high cost of purchase (approximately 1 million dollars), maintenance (about 10% of purchase cost each year), and consumables (about $2000 per instrument). The cost/benefits ratio remains to be validated.

The initial results of robotic surgery in the field of pediatrics are encouraging. The success rates of robotic procedures seem identical to those ofconventional laparoscopy. However, there is no randomized study currently available for children in the literature. The published studies are essentially studies with an evidence level of III or level IV according to the Oxford Centre for Evidence-Based Medicine.

Further prospective and comparative studies, especially comparisons between robotic and laparoscopic approaches, are necessary to confirm these preliminary results. Economic analyses are also indispensable to ensure the viability of robotic technology.

In addition, robotic surgery can be combined with new concepts such as virtual reality or augmented reality, which provide valuable preoperative or intraoperative information for the surgeon.

Pediatric surgeons must be actively involved in the evolution of robotics to ensure a suitable and reasoned use of this new technology for their young patients.

Footnotes

Acknowledgments

The authors would like to thank Mr. Guy Temporal and Mr. Christopher Burel for reviewing the manuscript.

Disclosure Statement

No competing financial interests exist.

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Robot-Assisted Surgery: Current Status Evaluation in Abdominal and Urological Pediatric Surgery

Abstract

Abstract

Purpose:

Materials and Methods:

Results:

Conclusions:

Introduction

Materials and Methods

Results

Abdominal surgery 23–47

Gastric fundoplication

Hepatobiliary surgery: cholecystecomy

Hepatobiliary surgery: choledochal cyst and biliary atresia

Miscellaneous

Genitourinary tract 48–98

Pyeloplasty

Ureteral reimplantation

Other procedures: orchidopexy

Other procedures: nephrectomy

Other procedures: complex reconstructive surgery: appendicovesicostomy and augmentation cystoplasty

Miscellaneous

Conclusions

Footnotes

Acknowledgments

Disclosure Statement

References

Abdominal surgery^23–47

Genitourinary tract^48–98