Robotic surgery in children: adopt now, await, or dismiss?

Abstract

The role of robot-assisted surgery in children remains controversial. This article aims to distil this debate into an evidence informed decision-making taxonomy; to adopt this technology (1) now, (2) later, or (3) not at all. Robot-assistance is safe, feasible and effective in selected cases as an adjunctive tool to enhance capabilities of minimally invasive surgery, as it is known today. At present, expectations of rigid multi-arm robotic systems to deliver higher quality care are over-estimated and poorly substantiated by evidence. Such systems are associated with high costs. Further comparative effectiveness evidence is needed to define the case-mix for which robot-assistance might be indicated. It seems unlikely that we should expect compelling patient benefits when it is only the mode of minimally invasive surgery that differs. Only large higher-volume institutions that share the robot amongst multiple specialty groups are likely to be able to sustain higher associated costs with today's technology. Nevertheless, there is great potential for next-generation surgical robotics to enable better ways to treat childhood surgical diseases through less invasive techniques that are not possible today. This will demand customized technology for selected patient populations or procedures. Several prototype robots exclusively designed for pediatric use are already under development. Financial affordability must be a high priority to ensure clinical accessibility.

Virtual Fixture Assistance for Suturing in Robot-Aided Pediatric Endoscopic Surgery

“…in which W JL ≤ w JL is related to joint limit avoidance [22], W rcm ≤ w rcm is related to the entry-sphere constraint as in (4), and finally W LVF ≤ w LVF as defined in (5).…”

“…The proposed system has tools whose diameters are 3.5 mm, and the preliminary results indicate that our system can operate inside narrow workspaces, such as those in pediatric patients [4]. With the SmartArm system, we expect to bridge the gaps that prevent the wide adoption of robots in pediatric and neonate surgery [5].…”

Global trends in paediatric robot-assisted urological surgery: a bibliometric and Progressive Scholarly Acceptance analysis

“…Based on bibliographic data, global adoption trends since the introduction of robotic surgery in pediatric urology are progressive, but unimpressive compared to other specialty fields such as adult urology. The pattern of case volume reported over time corresponds with the early phases of the S-shaped diffusion of innovation curve described by Rogers (5,16). The highly varied case-mix in the literature is almost entirely comprised of reconstructive procedures.…”

“…Expiry of patents and growing presence of legitimate market competitors are increasingly threatening to radically diversify robotic technology in minimally invasive surgery. Future robotic technologies are forecast to not only be more affordable, but also smaller and better suited for use in children (5).…”

“…Robot-assistance has not yet enabled novel procedures, but instead has offered an alternative mode to undertake existing minimally invasive surgical approaches. Technological enhancements provided by robot-assistance are promoted as offering improved operative performance capabilities and enabling minimally invasive approaches when they might otherwise not be considered (1,(3)(4)(5).…”