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Navarrete-Arellano. Mini-invasive Surg 2020;4:9 I http://dx.doi.org/10.20517/2574-1225.2019.70 Page 5 of 12

fourth left rib, with pulmonary invasion. After the favorable evolution with the cancer medical treatment
and that the tumor could be resectable, a second surgery was planned for block resection, as follows: (1)
RATS performed a non-anatomical segmentectomy, using staplers, resection with a healthy pleura flap, and
tumor with 4 cm of the fourth left rib (using a Gigli saw); (2) before dedocking, an open resection of the
overlying soft tissues was performed, including the 5-cm-long scar, and then the closure of the chest wall;
and (3) using RATS, a mesh was applied to stabilize the chest wall, concluding surgery. The surgical time of
the console was 240 min and there was 60 mL of bleeding. The pleural tube was left, which was removed on
the second day of PO.

The conversion was a lobectomy in a 10-month-old boy weighing 7.8 kg, with a diagnosis of right basal
intralobar pulmonary sequestration due to technical difficulties. The PO complication was the prolonged
drainage of serous fluid, in an eight-month-old girl weighing 8 kg, who underwent a diaphragmatic
plication due to the diagnosis of diaphragmatic paralysis. The pleural drainage was removed on the
eleventh day and was discharged daily; this complication is of grade I, according to the classification of
[24]
Clavien et al. . The average follow-up was 24.7 months, ranging from 9 to 51 months.

We performed a detailed non-systematic review of previous publications in PubMed on the thoracic
pathology treated with robotic surgery in the pediatric population. We obtained 4, 8, 30, and 50 publications,
respectively, using the four search strategies, but only 15 publications were about our topic. Currently, the
number of children with non-cardiovascular thoracic pathology treated with robotic surgery has barely
reached 100 cases.

DISCUSSION
We present a series of 11 RATS. These data support that some robotic procedures are surgically feasible.
Our study and others confirm the technical advantages of thoracic robotic surgery, such as precise
dissection and suturing in very small spaces [20,22] , in addition to its general advantages, such as stereoscopic
and magnified vision, in 3D, scale movements, tremor filtration, and the surgeon’s console for operating
while sitting and with total ergonomics. In addition, the articulated instruments are superior to the rigid
[22]
thoracoscopic instruments in the thoracic cavity, which itself is quite rigid .
During the same period of this study, we performed a total of 254 robotic procedures in pediatric
patients, with eight conversions to open surgery. RATS corresponds to 4.3% of the total procedures in our
experience.

The first publications of RATS in children were about cardiovascular techniques, such as patent ductus
[20]
arteriosus (PDA) closure and vascular ring division [20,25] . In the 2000 study by Le Bret et al. , 56 children
underwent a surgical closure of a PDA, 28 patients with thoracoscopic technique and 28 with a robot-
assisted approach. They used the ZEUS robot surgical system (Computer Motion, Inc., Goleta, CA. USA),
concluding that the robotically assisted closure of a PDA is comparable with closure by means of the
thoracoscopic technique. However, robot-assisted approach required a longer operative time because of
the increment in complexity. Previously, starting in 1991, these authors had performed 630 procedures of
thoracoscopic closure of the PDA, and their first 28 surgeries with a robotic approach. Based on the above,
robotic assistance offers advantages and with few procedures the results are similar to the thoracoscopic
technique.

Currently, very few cases of RATS have been published. However, many studies have reported that robot-
assisted surgery is safe and feasible for pediatric patients.