Tiny Patients, Big Strides: The Rise of Robotic Surgery in Pediatric Care

US: United States; FDA: food and drug administration; CE: Conformité Europeenne; TGA: Therapeutic Goods Administration; MHLW PMDA: Ministry of Health, Labour and Welfare Pharmaceuticals and Medical Devices Agency; NR: not reported; MFDS: Ministry of Food and Drug Safety; NMPA: National Medical Products Administration; IDE: Investigational Device Exemption.

A Diverse Landscape: Robotic Platform Designs

The seven authorized robotic platforms for pediatric surgery showcase a variety of designs and functionalities:

• Modular Design with Independent Arms (5 Systems): Platforms like Medtronic Hugo RAS and Asensus Senhance ALF-X feature a modular design with independent arms, typically ranging from three to four, including the dedicated optical arm for visualization. This allows for greater flexibility and maneuverability within the operating field.
• Multi-arm Architecture (5 Platforms): Several platforms, including Meerecompany Revo-i and Medicaroid Hinotori, employ a multi-arm architecture. Similar to the modular design, these systems have three to four arms, including the optical arm.
• Single-Port Platforms with Flexible Arms (2 Systems): Intuitive Surgical's Da Vinci SP represents a unique approach with its single-port design. This platform utilizes three to four flexible arms, including the optical arm, for operating through a single incision.
• Miniaturized Design for Single-Access Surgery (1 Platform): The Virtual Incision MIRA platform stands out with its miniaturized design. This innovative system allows for the insertion of two sterile arms and the optical components directly through a single incision, minimizing invasiveness.
• Flexible Endoscope with Operating Arms (1 Platform): The Medrobotics Flex Robotic System offers a distinct approach. It functions as a flexible endoscope equipped with two integrated operating arms.
• Laparoscopic Instrument Assistance System (1 System): Moon Surgical's Maestro platform deviates from the typical robotic surgical concept. It's designed to assist surgeons during laparoscopic procedures by providing support and positioning for laparoscopes and other laparoscopic instruments.

This diversity in robotic platform designs highlights the ongoing advancements in minimally invasive surgery for pediatric patients. Each platform offers distinct advantages depending on the specific procedure and the surgeon's needs.

Summary of the overall characteristics of the robotic platforms.

Robotic Platform

Patient Cart Architecture

Console Architecture

Operative Arms No.

Trocars

Instruments

Instruments’ Reusability

Advanced Energy

Medtronic

Hugo™ RAS

Modular

Open

3

Commercial

Wristed

Reusables (some disposables)

NA

Cambridge Medical Robotics

Versius®

Modular

Open

3

Commercial

Wristed

Reusables

NA

Intuitive Surgical

Da Vinci SP®

Single port

Closed

3

Dedicated + commercial

Wristed

Reusables

NA

Medrobotics Corp.

Flex® Robotic System

Flexible system

/

2

/

Wristed

Disposables

NA

Asensus

Senhance® ALF-X

Modular

Open

3

Commercial

Rigid with a kit of wristed

Reusables

Ultrasonic (rigid)

Meerecompany Inc.

Revo-i™

Multiarm

Closed

3

Commercial

Wristed

Reusables

Ultrasonic (rigid)

Wego

Micro Hand S

Multiarm

Open

2

Dedicated

Wristed

Reusables

Ultrasonic (rigid)

Medicaroid

Hinotori™

Multiarm

Semi-open

3

Dedicated

Wristed

Reusables

NA

Avatera Medical

Avatera

Multiarm

Semi-open

3

NR

Wristed

Disposables

NA

Distalmotion

Dexter

Modular

Open (with laparoscopic screen)

2

Commercial

Wristed

Disposables

NA

Moon Surgical

Maestro

Multiport instrument holder

/

1

Commercial

/

/

NA

Virtual Incision

MIRA

Single port

Open

2

NR

Wristed

Reusables

NA

Titan Medical Inc.

ENOS™ (formerly SPORT)

Single port

Open

2

NR

Wristed

Reusables

NA

SS Innovation

Mantra

Modular

Open

3

Dedicated

Wristed

Reusables

NA

Rob Surgical Systems S

Bitrack System

Multiarm

Open

3

Commercial

Wristed

Disposables

NA

NR: not reported; NA: not available.

Surgeon Console:

Surgeon Interface: Viewing the Operating Field

The way surgeons interact with these robotic platforms varies across the different designs:

• Open Console (Majority - 64.3%): Most platforms, including Medtronic Hugo RAS and Asensus Senhance ALF-X, utilize an open console design. This setup allows surgeons a clear view of the operating field through a high-definition monitor positioned at a comfortable distance. One exception within this category is the Distalmotion Dexter system. While it has an open console, it doesn't have a dedicated viewing system. Instead, surgeons rely on a standard laparoscopic screen positioned within the sterile field.
• Closed Console (Da Vinci-like Architecture - 2 Systems): Platforms like Intuitive Surgical's Da Vinci SP employ a closed console design similar to traditional Da Vinci systems. Surgeons view the operating field through a magnified, high-resolution display within the enclosed console.
• Semi-open Console (2 Systems): The Avatera Medical Avatera and Medicaroid Hinotori platforms offer a compromise between open and closed consoles. This semi-open design provides surgeons with an immersive view through a dedicated viewer but avoids the bulkiness of a fully enclosed console, potentially reducing the feeling of isolation during surgery.
• Direct Control Interface (1 System): The Medrobotics Flex Robotic System takes a unique approach. It forgoes a traditional console altogether. Instead, surgeons directly control the endoscope and two mechanical arms using an open, two-dimensional screen. This eliminates the complexity of electromechanical mediation.
• Instrument Holder System (1 System): Moon Surgical's Maestro platform deviates from the concept of a surgeon console entirely. It functions primarily as a holder for laparoscopes and other laparoscopic instruments, offering surgeons improved control and positioning during laparoscopic procedures.

This variety in console designs caters to surgeon preferences and the specific requirements of minimally invasive pediatric surgery.

Accessing the Operating Field: Trocars and Instruments

The methods for accessing the surgical field differ across these robotic platforms:

• Standard Laparoscopic Trocars (Majority: 7): Most platforms, including Medtronic Hugo RAS, Asensus Senhance ALF-X, and Cambridge Medical Robotics Versius, utilize familiar laparoscopic trocars to create access points for instruments.
• Dedicated Trocar Systems (Several Platforms: 4): Several platforms, like Wego Micro Hand S and Medicaroid Hinotori, employ dedicated trocars designed specifically for their system, potentially offering improved ergonomics or functionality.
• Single-Site Access with Da Vinci SP: The Intuitive Surgical Da Vinci SP utilizes a dedicated metallic trocar compatible with a disposable commercial single-site access system, minimizing the number of incisions needed.
• Trocar-Free Access with Medrobotics Flex: The Medrobotics Flex Robotic System operates similarly to a colonoscope, eliminating the need for trocars altogether, offering a potentially less invasive approach.

Instrument Choices for Delicate Procedures

The type of instruments used also varies across platforms, catering to the needs of minimally invasive pediatric surgery:

• Wristed or Flexible Instruments (Most Systems): Most platforms, like Intuitive Surgical Da Vinci SP and Meerecompany Revo-i, offer wristed or flexible instruments for enhanced dexterity and maneuverability within the confined operating space.
• Limited Wrist Articulation with Asensus Senhance (Optional): The Asensus Senhance ALF-X platform may be compatible with wristed instruments from specific brands like Radia, although this might not be universally available for all surgeons.
• Specialty Instruments for Wego Micro Hand S: Some configurations of the Wego Micro Hand S system include a rigid, advanced ultrasonic dissector, potentially offering additional functionalities for specific procedures.

Reusability: Balancing Cost and Efficiency

The reusability of instruments differs depending on the platform, impacting cost and efficiency considerations:

• Reusable Instruments (Dominant Approach): A significant number of platforms, including Intuitive Surgical Da Vinci SP and Meerecompany Revo-i, utilize reusable instruments after proper sterilization, offering a potentially cost-effective approach in the long run. One system, Virtual Incision MIRA, stands out for being entirely sterilizable and portable.
• Partially Reusable with Medrobotics Flex: The Medrobotics Flex Robotic System employs a combination of reusable and disposable instruments, potentially offering a balance between cost and convenience.
• Disposable Instruments (Some Systems): Platforms like Avatera Medical Avatera and Distalmotion Dexter rely solely on disposable instruments, simplifying instrument handling but potentially increasing overall surgical costs.
• Mixed System with Medtronic Hugo RAS: Medtronic Hugo RAS uses a combination of sterilizable instruments and disposable tools for specific functions like needle driving and cutting, offering flexibility based on the surgical needs.
• Laparoscopic Instrument Compatibility with Moon Surgical Maestro: Moon Surgical's Maestro platform doesn't have dedicated robotic instruments; instead, it allows surgeons to use standard laparoscopic instruments, leveraging their existing inventory.

Advanced Energy Options: Beyond Basic Functions

While all platforms support basic monopolar and bipolar energy for tissue manipulation, advanced features like ultrasonic energy are limited:

• Advanced Ultrasonic Energy (Limited Availability): Only a select few platforms, including Asensus Senhance ALF-X and Meerecompany Revo-i, currently offer advanced ultrasonic energy capabilities, potentially offering benefits like improved tissue dissection and reduced blood loss.

Staplers and Advanced Energy Availability: A Work in Progress

It's important to note that a complete range of staplers or advanced energy options isn't yet available for all the platforms reviewed. As technology continues to evolve, we can expect these functionalities to become more widely adopted across the spectrum of robotic surgery platforms for pediatric applications.

The Rise of Robotic Surgery Across Surgical Specialties: 

The use of robotic technology is rapidly expanding in the field of paediatrics beyond its initial applications in urology and general paediatric surgery. Recent publications describe successful applications of novel robotic devices in a wide range of procedures, including hepatobiliary surgery, colorectal surgery, abdominal wall reconstruction, upper gastrointestinal surgery, endocrine surgery, and even breast surgery.

Early promise, unanswered questions: 

While these initial reports are encouraging, the overall evidence base remains modest. Most studies suggest the feasibility of performing these procedures robotically, with minimal technical limitations reported. Additionally, with several new platforms receiving regulatory approval, the Asian market is likely to fuel further development in this field.

Standardization and training hurdles: 

However, there are significant challenges to address before widespread adoption. Currently, there's no standardized international training curriculum or credentialing program for robotic paediatric surgery. This lack of standardization makes it difficult to assess surgical proficiency and hinders the transferability of skills between different robotic systems.

Looking ahead: 

Despite these challenges, the future of robotic paediatric surgery appears bright. Technological innovation is poised to continue at a rapid pace, offering exciting possibilities across a spectrum of surgical specialties. However, robust clinical studies are needed to fully evaluate the long-term benefits and cost-effectiveness of these new applications.

Credits:

Marchegiani F, Siragusa L, Zadoroznyj A, Laterza V, Mangana O, Schena CA, Ammendola M, Memeo R, Bianchi PP, Spinoglio G, Gavriilidis P, de'Angelis N. New Robotic Platforms in General Surgery: What's the Current Clinical Scenario? Medicina (Kaunas). 2023 Jul 7;59(7):1264. doi: 10.3390/medicina59071264. PMID: 37512075; PMCID: PMC10386395.