The use of minimally invasive surgery (MIS) techniques in pediatric surgery is on the rise, with laparoscopic and thoracoscopic approaches currently the standard of care for many commonly performed operations. Cited advantages to the use of MIS include decreased post-operative pain, decreased overall length of hospital stay and improved cosmesis with smaller incisions.1,2 The popularity and benefits of MIS have lead to the expansion of these techniques to a large variety of surgical procedures. In addition, it has led the way for new technological advances such as robotic assisted laparoscopic surgery.

The utilization of robotic surgery has grown rapidly in the adult population, with broad applications for use including pelvic and genitourinary surgery, colorectal surgery and foregut surgery. Advantages to using the robotic system over traditional laparoscopy include improved surgeon ergonomics, easier visualization of traditionally difficult to access anatomic structures, and improvements in dexterity and fine motor movement.3, 4, 5 Downsides to the implementation of robotic surgery in adult literature include cost, operating room (OR) staff and surgeon training as well as increased time for equipment set up.6, 7, 8 The integration of robotic surgery to pediatrics has been slower, with additional concerns including lack of instrument variation and appropriate size for smaller patients. Patient safety concerns including increased operative duration and restricted anesthesia patient access due to the size of the robotic system have also been expressed.6, 7, 8, 9 Despite these limitations, the last ten years have demonstrated a large increase in the application of robotic surgery to the pediatric population.6,9,10 Cundy et al. found that there was over a 100% increase in case volume for robotic pediatric surgical procedures from April 2011-March 2021 with urologic and foregut procedures noting the largest increase.6,10

One particularly common application for robotic surgery in the adult population is for use in the repair of hernias. These types of repairs have gained recent popularity with a wide range of techniques for both ventral and inguinal hernia repairs.11,12 Cases of robotic diaphragmatic hernia repair have been published in the adult population as well.13 Despite the rapid trend towards the use of the robotic platform for adult hernias, little data or standardization exists for pediatric repairs. The aim of this review is to present current surgical techniques and experiences with the robotic repair of pediatric hernias.

Congenital diaphragmatic hernias (CDH) have a broad range of presentation from neonatal respiratory distress to asymptomatic with incidental discovery later in life.14 Congenital anomalies of the diaphragm include Bochdalek type (CBDH) with a posterolateral defect, Morgagni type (CMDH) with an anterior defect and diaphragmatic eventrations.15,16 While CDH are rare, the risk for incarceration and strangulation necessitates repair.16,17 Current commonly used surgical approaches include a thoracic or abdominal approach through open or MIS techniques. The majority of these repairs are done primarily, but larger defects can require a mesh patch placement.14 The first MIS approach was demonstrated in the adult population in 1994 with pediatric surgery quickly following with laparoscopic cases described as early as 1997 and 2000.18, 19, 20 The technique for MIS repair in pediatric surgery has been demonstrated to be successful with minimal incisions and without significantly prolonged operative time.17,21 Laparoscopic or thoracoscopic approach may decrease length of stay and overall morbidity in comparison to open repair, but some studies have noted an increased recurrence rate in the neonatal population.22, 23, 24

The first case of robotic repair of a CDH in pediatric surgery was in 2003 by Luebbe et al when they described a patch repair of a Morgagni CDH in a 10 year-old girl.25,26 Since then, a number of case reports and case series have described their experiences with robotic repair of CDH. Ages in robotic repair have ranged from 4 days to 15 years old with the smallest reported child being 2.2 kg.16,18 Out of twenty cases discussed by various authors, there were 4 reported cases of conversion to a thoracoscopic approach and 1 recurrence noted at follow up with the longest length of follow up being 2 years.15,16,27,28 The length of time for robot set up reported was between 7 min to 35 min and procedure length varied from 80 to 231 minutes.16,27,29,30

The majority of authors cited a 3 or 4 trocar approach with or without an assist port. The port size differed among reported cases. Anderberg et al described an approach using standard adult robotic ports including a 12 mm port for camera insertion with additional 8 mm ports for instruments and a 10 mm assist port. They noted success despite infant size of less than 10 kg.29 However, the majority of cases reported use of 5 mm robotic ports for instruments while the assist port varied from 3 to 10 mm based on patient size. The majority of authors noted that a 5 mm camera was the preferred approach for children < 10 kg.16 Most authors declined to resect the hernia sac and the majority of cases were repaired primarily with a variation of absorbable and non-absorbable suture. There were two mesh repairs reported, both in children > 50 kg with large defects.18,25 Additional technical considerations included choosing between an abdominal or thoracic approach. Smaller patients were noted to have improved visualization and instrument articulation through an abdominal approach regardless of hernia type. Minimal room for insufflation and adequate instrument use was noted when thoracic approach was attempted in neonates < 2.5 kg.15,27

Surgeons in all cases reported they felt the robotic approach was beneficial. Major advantages noted included improved dexterity and ease of suturing when compared to a laparoscopy or thoracoscopy.28 The location of the CDH can make access and tension free primary closure difficult. Authors noted that the increased articulation and range of motion of robotic instruments allowed for more precise stitch placement in order to achieve primary closure.15,30

Pediatric paraesophageal (PEH) and hiatal hernias (HH) often present with respiratory or gastrointestinal symptoms with gastro-esophageal reflux seen in 50-58% of PEH.31 While rare, they can be primary congenital defects or iatrogenic after excessive dissection during prior foregut surgery.32 Surgical approach to repair typically includes reduction of hernia contents, hernia sac excision, re-approximation of the crura and an anti-reflux procedure.32,33 MIS approach to foregut surgery is well described in both the adult and pediatric literature with laparoscopic anti-reflux surgery currently being the standard of care. Laparoscopic approaches to pediatric HH and PEH have been shown to be just as effective as open repair but without consensus data relating to differences in length of stay and post operative complications.31,34

There has been a rapid growth in the use of robotics in adult foregut surgery due to anatomic considerations that make visualization and dissection more difficult during open and laparoscopic approaches.35 In addition to these reported technical advantages, clinical outcomes have been shown to be equivalent between laparoscopic and robotic approaches.35, 36, 37 Likewise, the recent increase in robotic pediatric surgery procedures is largely due to increasing numbers in foregut specific cases.10 There have been multiple case reports detailing a robotic approach to pediatric anti-reflux surgery.38,39 Outcomes between laparoscopic and robotic approaches have also been demonstrated to be equivalent in pediatric patients.40

There is currently only one reported case of a robotic PEH repair in a pediatric patient.33 DeUgarte et al describes this repair in a three year-old 15 kg female using three 5 mm abdominal ports and one 5mm assist port. They performed a primary repair of the hernia with a floppy Nissen fundoplication. They reported increased ease of hernia sac dissection and crural approximation but did note prolonged case time due to robotic set up and the need for an additional qualified surgeon as a bedside assist.33

Pediatric indirect inguinal hernias are a common surgical complaint with an incidence of .5-8% in full term infants41,42 The choice of open or laparoscopic repair is largely based on surgeon preference with the traditional approach to repair involving a high ligation of the hernia sac through an open inguinal incision. Laparoscopic approaches are gaining popularity with a five-fold increase in case volume seen from 2009 to 2018.42 While outcomes and complication profiles have remained similar, proponents of a laparoscopic repair note laparoscopy to provide better anatomic visualization, shorter operative times and most importantly- the ability to identify and repair a contralateral hernia at the time of the operation.43 In contrast to the majority of pediatric repairs, adult inguinal hernia repairs almost always involve a mesh implant for long term durability in both an open and MIS technique. However, some pediatric surgeons may favor a mesh repair in adolescents especially in patients with higher BMI or with evidence of a direct inguinal hernia.44,45

Popular MIS approaches in the adult population include the laparoscopic total extra-peritoneal approach (TEP) and the transabdominal preperitoneal approach (TAPP). The majority of TAPP procedures are now performed robotically (rTAPP). Advantages to the rTAPP repair include improved visualization and potentially decreased risk of nerve trauma with more precise instrumentation.46 However, there have been recent randomized control trials that have failed to show clinical benefit to the rTAPP vs traditional laparoscopic TAPP.47

There are currently no published case reports regarding a robotic approach to a traditional laparoscopic pediatric hernia repair. However, a small case series explored the possible advantages of applying the rTAPP approach to adolescent males requiring a mesh repair. This technique included placement of three 8 mm trocars across the abdomen with the camera port at the umbilicus. The peritoneum was incised above the hernia defect, flaps were raised, cord structures were identified and the hernia was reduced. They described the use of an absorbable progrip mesh placed underneath the peritoneal flap. The peritoneum was then closed laterally to medially. They reported no intra-operative complications and no recurrences through up to 4 years of follow up.48

Umbilical and epigastric hernias are a common indication for surgery in the pediatric population. The current standard of care is open repair for these defects as incisions for these procedures are small and often well tolerated. In contrast, in the adult population ventral hernias are often larger and more complex requiring mesh placement and sometimes even component release for definitive repair. The benefits of robotics in ventral hernia for adults appear to be most pronounced in the more complex repairs of incisional or recurrent hernias.49,50 Children who present with recurrent or incisional hernias may also benefit from the use of the robotic platform, however these cases are rare resulting in a paucity of data in the literature. Extrapolating from adult data, robotic repairs of ventral hernias have comparable outcomes to laparoscopy with similar length of stay and post-operative morbidity51 Some disadvantages to robotic repair include an increase in operative time and cost.49 Although adult ventral hernias are commonly being repaired robotically, the data to support this approach in children is currently lacking.