Robotic-Assisted Urologic Surgery in Infants: Positioning, Trocar Placement, and Physiological Considerations

Abstract

Pediatric robotic-assisted laparoscopic procedures are becoming increasingly common. They have been shown to be safe in younger patients, including infants. Successful adoption of robotic-assisted surgery in infants requires an understanding of the technical factors unique to this patient population. This review will delineate the specific considerations to safely perform robotic-assisted laparoscopic procedures in infants, including physiological changes associated with pneumoperitoneum in infants, positioning, trocar placement, and docking.

Current Status of Pediatric Robot-Assisted Surgery in Italy: Epidemiologic National Survey and Future Directions

“…Additionally, the child has peculiar characteristics such as smaller working space and more delicate tissue han-dling that add further challenges to surgery. 10 Furthermore, intracorporeal suturing and knotting using the available laparoscopic instruments requires advanced technical skills with use of very small suture sizes and is time consuming. The robot, instead, may help to overcome all these challenges.…”

“…Since the DaVinci robot was originally designed for exclusive use in adults, its application in young children is possible only if adaptations and modifications of patient's and ports' position and robot docking are performed. 10,22 In fact, the robotic ports are generally positioned in the same line to perform several adult procedures, whereas in children we often need to triangulate the robotic ports' position, to achieve a better ergonomics and avoid external conflicts between the robotic arms. We usually adopt an 8 cm distance between the robotic ports and a 5-7 cm distance between the robotic ports and the laparoscopic assistant port.…”

“…23,24 In infants, this surgery should be safely accomplished limiting the insufflation time and keeping the insufflation pressure as low as possible. 10 Additionally, a correct setup of the operating room, including positioning of the robot, robotic console, scrub table, and anesthesia machines, is crucial to guarantee an optimal collaboration and communication among all components of the robotic team (main surgeon, assistant surgeon, anesthesiologists, and nurses) during surgery and preserve the patient's safety. 25 With Si robot system, it is recommended to limit the robot's manipulation by maintaining the robot at one fixed position in the operating room and then moving/rotating the operative table into the final position.…”

“…25 With Si robot system, it is recommended to limit the robot's manipulation by maintaining the robot at one fixed position in the operating room and then moving/rotating the operative table into the final position. 10 With Xi robot system, the robotic arms can be rotated to the selected position without changing the position of the operative table. 10 Our study outlined the importance of adequate training before starting the robotic activity.…”

“…Modifications and arrangements of the equipment and positioning of the patient and trocars are required. 10 Robot-assisted laparoscopic pyeloplasty (RALP) is, to date, the most frequent procedure performed in the pediatric population, and the only one where outcomes have been proved to be at least comparable to the open or laparoscopic techniques. 11,12 The most important limitation is still represented by the costs, which remain higher than the open approach.…”