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Cortes-Cerisuelo et al. Mini-invasive Surg 2019;3:1 I http://dx.doi.org/10.20517/2574-1225.2018.60 Page 7 of 10

SILS allows operating through one access site, eliminating the multiple sites traditionally used, even in small
[28]
children . When performing complex hepatobiliary cases laparoscopically in a child, including MILR,
we advocate using a hybrid approach in which the SILS-port is used in addition to traditional trocar sites.
This allows introducing more instruments from various angles without making additional incisions and
hence gives more flexibility for the intracorporal work. In such an approach, the incision for the SILS-port
can safely be extended up to 5 cm or more depending on the type of port used, an ideal length for either
extraction of bowel for an extracorporal anastomosis or for the extraction of a resected tumor. Importantly,
different from traditional laparoscopically-assisted procedures, the SILS-port, after having been taken
out the tumor specimen, will remain a seal and can be reinserted unlimited amount of times despite the
extension of the original incision. This allows for greater flexibility when performing combined intra- and
extracorporeal reconstructive work or when removing more than one tumor specimen at a time. Although
[49]
complete hepatectomy has been successfully carried out in adults uniquely through SILS , the authors have
no experience nor know of any experience with performing MILR in children exclusively through a SILS port
other than for simple atypical resections of peripheral lesions. However, the enclosed space of the pediatric
abdominal cavity in children put aside, theoretically there is no reason that such a procedure is technically not
feasible. One wonders though, given the small size of additional trocar sites in children, if it is necessary.

Robotic surgery has been recently introduced in the clinical practice and it has been accepted as an effective
[50]
option to perform high-demanding procedures including hepatobiliary surgery in adults . A recent review
on the application of robotic surgery to liver surgery in adults when compared to open or laparoscopic shows
[51]
no inferiority, however, randomized control trials are necessary to reach broader conclusions . The role
of robotic surgery in pediatric surgery remains controversial partly because of the lack of pediatric-sized
robotic instruments and equipment, the elevated cost and the need for robotic-trained pediatric surgeons.
In children, similar to adult surgery, robotic surgery has become popular in pediatric urology, being the
[52]
pyeloplasty and partial nephrectomies the more accepted procedures . Nothing is known about the role
and the advantages of robotic procedures in liver surgery in children.

Independent of the technical challenges in MILR in children, the most important task of our field will be to
assure that the current recommendations for surgical resection of the corresponding pediatric oncological
study groups, especially CHIC, are not compromised by the innovation of MILR. This is especially true
for malignant tumors such as hepatoblastoma and HCC, for which there is overwhelming evidence that
[23]
incomplete resection significantly worsens prognosis, even if followed by liver transplant . As MILR
continues to grow within pediatric oncology, more research is needed to evaluate the full impact of MILR
in children. The current evidence is summarized in Table 1, representing one article with level III evidence
(comprehensive retrospective review) and several articles with level IV evidence (case reports and case
series). A large prospective study would be the highest possible level of evidence addressing the question of
whether there are significant differences in outcome and morbidity between open and laparoscopic liver
resection for pediatric tumors and would certainly be much desired. However, similar to the obstacles found
when creating the current PHITT study, due to the rarity of hepatic tumors in children, such a trial would
have to be designed as a global effort in order to obtain adequate numbers for reliable statistical analysis.
Until then, it would be nevertheless of immense value if more literature were to become available on the
subject, whether small prospective studies or comprehensive retrospective reviews.

CONCLUSION
MILR for liver tumors is the last bastion in the evolution of pediatric hepatobiliary surgery. Slowly,
accumulating evidence around the world indicates that with experience and careful patient selection,
laparoscopic liver resections can be carried out safely and without compromising outcomes. The children
operated with this approach appear to benefit from the typical advantages of minimally-invasive surgery.