KEY POINTS
■ Pediatric surgeons have begun to incorporate the advancements of robotic surgery by adapting the equipment to accommodate the pediatric surgical patient. The da Vinci SI Surgical System, introduced in April 2009, boasts advanced three-dimensional (3D), high-definition (HD) visualization, EndoWrist Instrumentation, and Intuitive Motion technology.
■ Current limitations to using robotic surgery include its high cost and the current size of the instruments and minimum port distance, which limit the size and weight of patients who are candidates for robotic surgery, particularly small children.
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Advancements such as improved optics and precision, decreased motion tremor, and 3D visualization have enabled pediatric surgeons to perfect techniques used in pediatric patients during abdominal, cardiovascular, and thoracic procedures as well as in otolaryngology- and urology-related surgeries.
■ Although residents' speed using conventional laparoscopy was superior to their speed when they used robots, accuracy scores were higher when they used robots.
■ As more programs incorporate robotics into their curricula and residents perform more robotic procedures, these procedures will become more efficient, the costs will decrease, and more difficult and technically demanding cases will be tackled.
"Anyone who could operate on bunny rabbits could operate on a newborn," a prominent Boston surgeon once said to Dr. William Ladd in the early 1900s.1 Fortunately for any parent who has had a child with a disease requiring surgical treatment, Ladd did not practice on rabbits but instead focused his energy on helping to develop the field of pediatric surgery. Since then, this field has continued to progress by incorporating the technological advances of the 21st century into new procedures. Some of the latest surgical innovations include natural orifice transluminal endoscopic surgery (NOTES) and single-port laparoscopic surgery. Also included in this renaissance is robotic-assisted surgery. As the usefulness of adult robotic procedures has expanded to urology, gynecology, and otolaryngology, they have also found a role in pediatric surgery. Pediatric surgeons have begun to utilize these procedures and have adapted the equipment to accommodate the pediatric surgical patient.
CURRENT ROBOTIC ABILITIES AND SYSTEMS
In 1917 and 1921, the Čapek brothers wrote science fiction works describing automated beings and coined the term robot.2-4 Although robots have since been developed for use in a variety of fields, the use of robotics in surgery remains in its early stages. Robotics were first used during surgery in 1985, when a robotic arm was used to assist during brain biopsy.3 Worldwide, large, randomized, controlled, multicenter studies in robotic-assisted pediatric surgery still have not been performed, and most publications offer only case reviews.
In 1994, the first FDA-approved surgical robotic system was put on the market.5 Called the Automated Endoscopic System for Optimal Positioning (AESOP), it was manufactured by Computer Motion, Inc. (later acquired by Intuitive Surgical, Inc. in 2003). Computer Motion, Inc. also developed several other robotic surgical systems including the HERMES Control Center, a voice command and recognition system; the SOCRATES Robotic Telecollaboration System, which allows integrated telecommunication with the robotic devices to facilitate remote surgeries; and the ZEUS Robotic Surgical System, which is no longer marketed. In 2001, the ZEUS Robotic Surgical System was utilized to perform the first transatlantic surgical procedure, during which a patient in Strasbourg, France underwent a robot-assisted laparoscopic cholecystectomy performed by a surgeon sitting at a console 3,800 miles away in New York.3
In 1995, Intuitive Surgical, Inc. developed the da Vinci Surgical System. Originally, the system touted a three-armed patient side cart and surgeon console. Eventually a fourth arm was added to the system, and in April 2009, the da Vinci SI Surgical System was unveiled, which boasts advanced three-dimensional (3D) high-definition (HD) visualization, EndoWrist Instrumentation, and Intuitive Motion technology, which replicates the experience of open surgery. This system has an optional dual-console capability that can support training and collaboration during procedures (Figure 1). The console allows the surgeon to sit throughout the procedure and has fingertip controls that translate in real time to the robotic arms. The EndoWrist instruments utilized with the da Vinci system are modeled after the human wrist, thus allowing for 90-degree articulation (Figure 2). The instruments are now available in 5-mm and 8-mm diameters. The Vision System for the da Vinci system works by utilizing the 12-mm endoscope to transfer a 3D HD vision of the operative field to the surgeon console (Figure 3). Its panoramic 16:9 aspect ratio, 10× magnification, and 3D vision help to achieve laparoscopic depth perception (Figure 4). An 8-mm, two-dimensional version of the system is also available.6
ROBOTIC SURGERY IN OTOLARYNGOLOGY
In otolaryngology, the da Vinci Surgical System has enabled transoral robotic surgery to be safely conducted in the pediatric airway. In 2007, one institutional review board-approved study published in the Archives of Otolaryngology—Head and Neck Surgery evaluated the efficacy of the da Vinci surgical robot. For the study, four cadaveric pediatric larynxes were used as control subjects. Upon completion of the cadaveric phase, robot-assisted procedures were used to correct laryngeal clefts in five pediatric patients. The authors were successful in only two of the five robotic attempts, attributing the three failed attempts to limited transoral access. However, the surgeons were impressed with the system's "great dexterity and precision, delicate tissue handling, good three-dimensional depth perception, and relatively easy endolaryngeal suturing."7
