Current Trends in Pediatric Robotic Surgery

INTRODUCTION Who would have ever imagined a few decades ago, when the first laparoscopic surgeries were considered dangerous and risky, that today’s surgeons routinely perform laparoscopy and other minimally invasive surgical (MIS) procedures on a daily basis to ease the pain and suffering of their patients with increasingly superior surgical and cosmetic outcomes? Laparoscopy dates back nearly a century ago when the first procedures were performed in dogs and subsequently in human patients. With the development of anesthesia and aseptic techniques, surgery reached a new paradigm. Laparoscopic surgery was officially introduced by Kelling in 1910 when he was able to explore an insufflated abdomen with a cystoscope. The first use of laparoscopy by a general surgeon was in 1985 when Muhe described a laparascopic cholecystectomy which in short time became the standard of care for cholelithiasis and cholecystitis. However, the procedures always tended to be limited not only by the operating surgeons’ skill set but also by technological developments. It was not until the early 1980s that Dr. Kurt Semm brought laparoscopy to the forefront when he performed and published the first laparoscopic appendectomy. At that time, only three decades ago, Dr. Semm stirred up great controversy with his procedure and he was even called unethical in trying to attempt such unnecessary and dangerous trials. His opponents criticized his attempt at innovation. However, the time was right for change and laparoscopy took off like a rocket soon after with more and more companies investing into the development of laparoscopic instrumentation and medical institutions training surgical residents in laparoscopic procedures. The great advantages were clear. Laparoscopy, due to decreased incisions and manipulation, had the potential to revolutionize surgery, translating to decreased postoperative pain and hospital stay for the patient. In the 1990s the introduction of MIS led to revolutionary changes in the field of operative medicine. However, as laparoscopy became used by an increasingly growing number of surgeons for a vast variety of procedures, the laparoscopic and thoracoscopic techniques were shown to have technical limitations and certain disadvantages, especially when sophisticated procedures were carried out. Most of the technically advanced operations were and still are difficult to perform in a minimally invasive setting and involve a steep learning curve for the entire surgical team. Other pitfalls of traditional laparoscopy include unstable video camera platform, limited motion of straight laparoscopic instruments, 2d imaging and poor ergonomics. Despite these disadvantages, the positive aspects greatly outweigh the negative ones and nowadays, laparoscopy is the standard of care for appendectomies, cholecystectomies, and a wide variety of other general surgery and surgical subspecialty procedures (eg fundoplications, cholecystectomy, gastric banding, colectomy, esophagectomy, sub/total gastrectomy, gastrojejunostomy, thymectomy, thoracic sympathectomy, lobectomy, mediastinal parathyroidectomy, left pancreatic resection and many more ). Despite great promises, pediatric surgeons were initially hesitant to accept laparoscopic surgery for common use in small children due to uncertainty about instruments and machinery because they were originally developed for use in adult patients. Current Trends in Pediatric Robotic Surgery