Surgical practice has markedly changed over the last several decades with the advent and development of technological advances such as minimally invasive surgery (MIS). Since its introduction within pediatric surgery, robotic surgery has been utilized for an increasing variety of operations and indications. Pediatric surgeons manage a wide array of congenital, infectious, malignant, and acquired conditions in children. Robotic-assisted surgery provides a minimally invasive technique with enhanced precision and numerous advantages over open or straight-stick endosurgery (SSE) for managing this wide array of conditions. However, its widespread adoption within pediatric surgery has been slow to progress. This paper will provide an overview of pediatric robotic surgery and discuss the benefits, limitations, and strategies for successful implementation of robotics within pediatric surgical practice.

An open approach was the mainstay of surgical management until the 1980s, when laparoscopic techniques grew in popularity.1 First described in the late 1800s and early 1900s, laparoscopy gained renewed interest in 1938 when Veress described the concept of creating pneumoperitoneum using a needle puncture prior to introduction of the laparoscope.1,2 The first large series describing the use of laparoscopy in gynecological surgery was published in 1965.1,3 But laparoscopy arguably gained its most robust adoption within surgery after techniques for laparoscopic appendectomy and cholecystectomy were described in 1982 and 1985, respectively.1,4, 5, 6 Since that time, SSE has expanded rapidly for thoracic and abdominal surgery. With improvements in instrumentation and miniaturization, as well as optimization of ergonomics, minimally invasive techniques have been successfully applied to even the smallest of pediatric patients. In 2001, over 10 years after the first reports of robotic-assisted surgery in adults, the first report of robotic-assisted surgery in children was published with the successful completion of a robotic Nissen fundoplication in a 10-year-old girl.7,8 Since then, an increasing number of reports have been published discussing the rapidly expanding indications and successful utilization of robotic surgery in pediatric patients.9, 10, 11, 12

The benefits of robotic surgery include and surpass many of the advantages of SSE. Similar to SSE, robotic surgery minimizes operative trauma with smaller incisions and improved cosmesis, is associated with decreased postoperative pain with subsequently decreased need for opiate use, and the minimally invasive approach decreases recovery time and hospital length of stay.13, 14, 15, 16

The unique design of the robotic platform, however, affords it numerous advantages over SSE. The robotic endoscope provides three-dimensional visualization capable of magnifying images ten to fifteen times, far surpassing the depth perception and magnification afforded by loupes or traditional endoscopes.17 Furthermore, the robotic endoscope can be manipulated by the operating surgeon at the ergonomically-designed console, allowing for optimization of visualization without requiring surgical assists.18

The robotic platform also allows for the surgeon operating at the console to utilize and manipulate multiple robotic arms. Furthermore, these arms can be locked into place to allow for reliable and indefinite retraction without requiring assistants or risking human muscle fatigue or loss of control, as with open surgery and SSE. Meanwhile, the remaining robotic working arms can proceed with dissection with the added benefit of the robotic platform's ability for tremor filtration. In addition, robotic arms were created to mimic the movements of the human wrist, allowing for seven degrees of freedom in comparison to traditional instruments’ four degrees.18 This enhanced articulation mitigates many of the challenges of intracorporeal suturing and knot-tying.18 In combination with the option for motion scaling, which translates the larger motions of surgeons at the console into smaller movements of the robotic arms at a scale of up to 7:1, surgeons are capable of more accurate, controlled movements.19 Together, these features allow for enhanced, precise dissection of areas previously challenging to access with the ability for reconstruction of even the most diminutive anatomy in neonates and smaller children.18,20