LETTER TO THE EDITOR Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 276-277  

Considerations for robotic-assisted laparoscopic surgery in children

Peter Anto Johnson1, John Christy Johnson2
1 Department of Medical Sciences, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
2 Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada

Date of Submission27-Dec-2020Date of Decision06-Jan-2021Date of Web Publication02-Mar-2021

Correspondence Address:
Dr. Peter Anto Johnson
116 St and 85 Ave NW, Edmonton, AB
Canada

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmas.JMAS_327_20

How to cite this article:
Johnson PA, Johnson JC. Considerations for robotic-assisted laparoscopic surgery in children. J Min Access Surg 2021;17:276-7

Sir,

In the most recent issue of this journal, Sinha et al. suggest promise in the use of the da Vinci surgical system in its application for robotic-assisted laparoscopic surgery in paediatric patients.[1] Although the literature on the accuracy and precision of this technology is encouraging, its use in paediatric patients is still in its early stages and has yet to be explored in great detail. In addition to the technical intricacies, training and learning curve, port placement complications, cost and other limitations identified by the authors, we suggest additional considerations before its large-scale implementation in children.

Of these, the most concerning shortcomings of systems, such as the da Vinci, for surgical procedures are perhaps its bulkiness and lack of force feedback.[2] When combined, these two aspects deal the greatest damage to developing tissues, causing procedural injuries – notably, tearing of muscles, blood vessels and nerves. These injuries are significant, leading to permanent and occasionally serious complications including death, particularly in paediatric patients post-surgery. Novel advancements therefore should consider the compaction and streamlined design of new systems and the incorporation of sensory haptic feedback systems to reduce these injury-related complications.

As with any minimally invasive surgery performed in children, there remains the risk of severe complications resulting from surgical errors. Although soft-tissue models, image-guided and virtual reality simulations and other practical educational training have been associated with reduced error, it never replaces the necessity for 'supervised trial and error' manoeuvring and operating the robotic system on patients in surgical settings.[2] Innovations in educational training for robotic surgery include telepresence surgeries and robotic tele-mentoring, whereby expert surgeons share the same surgical field of view and controls as the training surgeon. In spite of this, there are inevitable risks associated with training when training surgeons must practice through trial and error on real patients and an emphasis must be placed on apposite pre-procedural surgical training.

Furthermore, the universal issue of accessibility and resource availability remains with this technology, perhaps all the more implicated when considering paediatric populations. For instance, while tele-transmission of surgeries is another rapidly expanding field of innovation that may offer us opportunities to enhance accessibility to paediatric populations in low-resource and rural settings, several limitations nevertheless remain.[3] Most significantly, we have observed that high-speed terrestrial networks that use asynchronous transfer mode (ATM), instead of satellite networks, for rapid data transmission are required in such remote locations. While promising, the implementation of ATM networks at hospitals are currently not only limited by resource availability and high cost, but also by legal and ethical concerns surrounding conflict of jurisdiction. As such, progression of robotic surgery for paediatric procedures in low-resource and remote settings also depends on reforms to ethical and legal practice alongside establishing access.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Sinha A, Pathak M, Vig A, Saxena R. Robotic surgery in paediatric patients: Our initial experience and roadmap for successful implementation of robotic surgery programme. J Minim Access Surg 2019;17:32-6.  
    2.Morris B. Robotic surgery. Applications, limitations, and impact on surgical education. MedGenMed 2005;7:72.  
    3.Wilson EB, Bagshahi H, Woodruff VD. Overview of general advantages, limitations, and strategies. In: Robotics in General Surgery. New York: Springer; 2014. p. 17-22.