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Page 6 of 12 Navarrete-Arellano. Mini-invasive Surg 2020;4:9 I http://dx.doi.org/10.20517/2574-1225.2019.70

Table 1. Comparative series of cases of thoracic robotic surgery in children
Sandler and Meehan [27] (2008) Ballouhey et al. [22] (2015) Current data
Cases 11 11 11
Gender (male/female) ? 4/7 6/5
Age ? 72 months (0-204) 68.4 months (6-180)
Weigth ? 24.4 kg (3-51.5) 21.34 kg (7.8-60)
Diagnostics Posterior mediastinal mass 2 Oesophageal atresia 3 CCAM 3
CCAM 2 Bronchogenic cyst 3 Diaphragmatic paralisis 3
Mediastinal germ cell tumor 1 Diaphragmatic hernia 2 Intralobar sequestration 1
Mediastinal teratoma 1 Oesophageal duplication 1 Diaphragmatic eventration 1
Mediastinal inflammatory mass 1 Gastric tube/oesophagoplasty 1 Mediastinal teratoma 1
Bronchogenic cyst 1 Acalasia 1 Ewing’s tumor 1
Intralobar sequestration 1 Pulmonary tuberculosis 1
Pulmonary segmentectomy 1
Congenital diaphragmatic hernia 1
Surgeries Resection of tumor masses 6 Correction oesophageal atresia 3 Lobectomy 4
Lobectomy 3 Bronchogenic cysts resection 3 Diaphragmatic plication 4
Segmentectomy 1 Diaphragmatic plasty 2 Tumor resection 2
Diaphragmatic plasty 1 Oesophageal duplication resection 1 Pleural and lung biopsies 1
Gastric tube/oesophagoplasty 1
Heller myotomy 1
Conversions 2 (18.2%) 3 (27.3 %) 1 (9.1%)
Surgical time ? 190 min (120-310) 166.4 min (24-314)
IO complications 0% 0% 0%
PO complications 0% 2 (18.2%) 1 (9.1%)
PO stay days ? 13.5 days (3-35) 3.6 days (1-12)
Follow-up ? 26.9 months (8-55) 24.7 months (9-51)

CCAM: congenital cystic adenomatoid malformation; IO: intraoperative; PO: postoperative

RATS has previously been described as part of a series of general pediatric surgeries or a series of various
thoracic pathologies [22,23,26,27] , a series of pediatric cases of specific procedures such as thymectomy for
[30]
myasthenia gravis [28,29] , tracheopexy for treatment of severe tracheomalacia , or as pediatric case reports
on esophageal leiomyoma and bronchogenic cyst [31-33] .

We compared the results of two published series with ours [22,27] . The three series are comparable, due to the
diversity of thoracic pathologies and procedures and the number of cases of RATS in children. In our series,
there was less conversion, less surgical time, less PO complications, and fewer days of PO stay. Conversion
was more frequent in patients with lower weight, especially in newborns [Table 1]. Most conversions in
RATS are in children weighing less than 5 kg, and the extreme limit is 2.5 kg .
[22]
Patients between 3 and 5 kg with RATS are a great challenge and require experienced and capable surgeons.
The fundamental technical limitation and disadvantage of RATS is in newborn patients and patients
weighing less than 3 kg.

The dimensions of the robotic instruments (8 mm) require a minimum critical space to be manipulated,
i.e., 5 mm. Their limitations are that they require more interior space in the cavity and have no energy.
In the future, it will be necessary to implement a greater miniaturization of technology, preserving the
functionality to treat children with lower weight.

The docking charts for robotic surgery suggested for surgical techniques in adults are not applicable for
children. Therefore, sometimes, 3 cm of separation was required between each trocar when surgery was
[23]
performed on infants, due to limited space in such small patients .