Pediatric Robotic Laparoscopic Surgery
Travis W. Groth, MD, Assistant Professor, Pediatric Urology
Laparoscopic surgery has been used in pediatric surgery since the 1970’s1. However, these procedures were solely used for diagnostic purposes. The first laparoscopic cholecystectomy was performed in 1985, and the first laparoscopic nephrectomy was performed in 19902,3. These procedures demonstrated the feasibility of laparoscopic surgery, along with the great promise it held to decrease patients’ morbidity of certain operations. In a short period of time, laparoscopic surgery, also referred to as minimally invasive surgery, has become the standard of care for the treatment for various surgical conditions in pediatric and adult patients. This has been made possible because of advancements in technology of endoscopic optics and miniaturization of instruments.
Currently, our department offers various minimally invasive surgery (MIS) procedures for children, including robotic assisted laparoscopic surgery for various conditions. Numerous studies have demonstrated that MIS is as effective and as safe as open surgery in children. Laparoscopic surgery involves making only a couple of incisions that are under 1cm in size to allow for the endoscope (camera) and a couple of ports for instruments to perform the entire procedure. Since the surgery can be performed through small incisions, MIS offers several benefits to patients, including decreased post-operative pain, improved cosmetics, shorter hospital stay and quicker return to full activity when compared to open surgery. Because of these advantages, MIS has become more prevalent in the treatment of pediatric urologic surgical conditions.
In 1998, Intuitive Surgical, Inc. developed and released the first da Vinci Surgical System® (e.g., robotic assisted laparoscopic surgery). Although the da Vinci Surgical System is referred to as a “robotic system” or “robotic assisted laparoscopic surgery,” it is not truly a robot, because it cannot function independently and is controlled solely by the surgeon. Robotic surgery or tele-operator surgery was first conceived by the United States Department of Defense for possible remote surgery for injured soldiers4. Computer enhanced surgery (robotic surgical systems) was developed to overcome limitations of conventional laparoscopy which include two-dimensional visualization and instrumentation with very limited articulation, making intracorporal suturing and knot tying difficult.
The da Vinci Surgical System has quickly gained prominence nationally because of the benefits the system provides for adult and pediatric surgical laparoscopic cases. The robotic system provides three-dimensional visualization, visual magnification, filtration and removal of any physiologic tremor. Also, the surgeon has improved dexterity from the EndoWrist laparoscopic instruments that allow for 90-degree articulation, much like a human wrist. These benefits allow for easier intracorporal suturing and knot tying, making the technology ideal for pediatric reconstructive urologic surgery. Surgery that used to be performed solely as an open surgical repair can now be performed as robotic assisted laparoscopic surgery with similar results, along with providing the global benefits of MIS to these patients.
The most common robotic assisted laparoscopic surgeries in pediatric urology include: pyeloplasty for ureteropelvic junction obstruction, ureteral re-implantation for vesicoureteral reflux, nephrectomy, nephroureterectomy, bladder surgery and genitourinary reconstructive surgery. Robotic assisted laparoscopic surgery has now become close to the gold standard in adult urology for prostatectomies and other laparoscopic surgeries. Nationally, close to 80 percent of all prostatectomies are performed robotically. However, robotic laparoscopic surgery has been less available for children.
Recently, the first robotic assisted laparoscopic procedure was performed at Children’s Hospital of Wisconsin for the treatment of an ureteropelvic junction obstruction. Children’s Hospital has the only dedicated pediatric robotic surgery program in Wisconsin and is one of only a handful of pediatric free-standing hospitals in the nation with its own robotic system. We also have a robotic training simulator helping to train future physicians in this new technology.
We are very excited about the future and the opportunity to provide our patients with the access and benefits of this technology at a pediatric hospital dedicated to treating children’s unique needs.
1. Gans, S.L. and G. Berci, Advances in endoscopy of infants and children. J Pediatr Surg, 1971. 6(2): p. 199-233.
2. Reynolds, W., Jr., The first laparoscopic cholecystectomy. JSLS, 2001. 5(1): p. 89-94.
3. Clayman, R.V., et al., Laparoscopic nephrectomy: initial case report. J Urol, 1991. 146(2): p. 278-82.
4. Satava, R.M., Robotic surgery: from past to future--a personal journey. Surg Clin North Am, 2003. 83(6): p. 1491-500, xii.