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Page 2 of 12 Navarrete-Arellano. Mini-invasive Surg 2020;4:9 I http://dx.doi.org/10.20517/2574-1225.2019.70

Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the
treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been
treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.

Keywords: Robotic surgery, thoracic surgery, thoracic robotic surgery, thoracoscopy, congenital malformations,
children

INTRODUCTION
Minimally invasive techniques are applicable in more than 60% of abdominal and thoracic operations
[1]
in children, according to evidence-based data and ethical principles can be used properly . The first
publication on thoracoscopy in children dates from 1971 in Russia and, fundamentally its application at
[2]
that time was diagnosed in thoracic diseases and neoplasms . From that date to the present, thoracoscopic
surgery in children has been applied in a wide range of thoracic pathologies, with diagnostic and
therapeutic procedures.

The global experience in thoracoscopic surgery in children is more than 30 years compared to robot-
assisted thoracic surgery (RATS), and, although the learning curve for thoracoscopy is longer compared to
RATS, there are centers in the world where this curve has been overcome. The minimally invasive surgical
[3]
(MIS) approach offers obvious advantages over the open technique to solve various thoracic pathologies .
In 1981, Rodgers reported 80 thoracoscopic procedures in children, which were performed without
mortality and with minimal morbidity, and the main technique was lung biopsy .
[4]
An important aspect in pediatric age is to prevent or avoid sequelae of surgery. Makita et al. conducted a
[5]
comparative study to identify risk factors for thoracic and spinal deformities (scoliosis, pectus excavatum,
chest asymmetry, and pectus carinatum) after lung resection during childhood, in patients undergoing
thoracoscopic surgery versus thoracotomy. Their results are as follows: nine deformities (n = 49) were
observed during follow-up in patients with thoracoscopy (18.3%), while patients with thoracotomy
reported 19 deformities (n = 25) (76%), with a P value of 0.0000022. The authors concluded that minimally
invasive thoracic surgery (MITS) reduced the risk of thoracic and spinal deformities after lung resection in
children.

The most commonly performed technique in children with thoracoscopic surgery is lobectomy, but the
learning curve is prolonged. An analysis of the learning curve in pediatric thoracoscopic lobectomy for
congenital pulmonary malformations required a minimum of 50 cases of experience to obtain stable results
[6]
with video-assisted thoracic surgery in pulmonary resections . This factor is one of the key obstacles for
the thoracoscopic technique to be applied more widely in the world in the pediatric population.

With the learning curve overcome, meticulous thoracoscopic lobectomy is feasible in children, and it is
effective in avoiding common postoperative (PO) complications, accelerating the recovery, and shortening
[7]
the hospitalization time .
[8]
Clermidi et al. published a study evaluating the feasibility of a fast-track protocol in thoracoscopic lung
resection for congenital pulmonary airway malformations (CPAM) in children in 2017. Through the three
periods, median PO hospital stay decreased (four, three, and two days, successively; P = 0.02). In the third
period, four patients underwent day-case surgery. The authors concluded that the fast-track protocol for
children undergoing uncomplicated thoracic surgery for CPAM seems feasible without extra morbidity,
and selected patients undergoing thoracoscopic resection may benefit from the absence of pleural tube and
can be operated on in day-case surgery.