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Navarrete-Arellano. Mini-invasive Surg 2020;4:9 I http://dx.doi.org/10.20517/2574-1225.2019.70 Page 7 of 12
[34]
Cundy et al. conducted a systematic search in the literature of reported cases of robotic surgery in
children over a period of 11 years. They included 137 articles, with 2393 procedures in 1840 patients,
and thoracic procedures accounted for 3.2% (77 surgeries and 12 different techniques). The conversion
[18]
rate was 10% in RATS. The results show that the five most frequent RATS procedures are: lobectomy ,
[14]
[9]
[8]
[5]
thymectomy , benign mass excision , diaphragmatic plasties , and resection of malignant tumors . The
other areas and procedures of robotic surgery that were part of this research were urological procedures
(1434, 59.9%) and gastrointestinal procedures (882, 36.9%). Our small series of RATS cases coincides with
the aforementioned data, in terms of thoracic pathology, surgical techniques, and conversion rate [Table 1].
Lobectomy is the most reported RATS, thus it is important discuss the surgical technique in children: (1) it
is essential to have an excellent pediatric anesthesiologist, for the management of ventilation with a single
lung, either by selective intubation (school-aged children and teenagers), or using 6 mmHg of pressure
with CO for pulmonary collapse; (2) for school-aged patients and adolescents, there should by an assistant
2
surgeon who has the skills to handle and apply staplers, as it is the safest way to manage vascular structures,
bronchial tubes, and interlobar lung tissue.

In most of our RATS procedures, from the open technique we jump to robotic surgery, due to the low
frequency of presentation of these pathologies, and the thoracoscopic technique implies a longer learning
[27]
curve. This also happened to Meehan and Sandler . Robotic assistance is ideal for complex hepatobiliary
cases and thoracic surgery, particularly for solid mass resection [35,36] .

Despite performing several different types of operations in the first months, we felt comfortable with the
[37]
robot after approximately 15 cases. This experience is consistent with our colleagues in adult surgery .
Reports suggest anywhere between 25 and 50 cases are required to learn a single new laparoscopic
[38]
procedure . We believe that robotic surgery has a clear advantage over thoracoscopic surgery simply
because the fulcrum effect is no longer a problem.

Robotic thoracoscopic surgery has been successfully applied to the removal of mediastinal masses or cysts,
such as bronchogenic cyst, teratoma, esophageal duplication, esophageal leiomyoma, neurogenic tumor,
and thymic pathology .
[39]
Radical thymectomy is the comprehensive treatment of myasthenia gravis. The feasibility and effectiveness
[40]
of robotic thymectomy is evident in this cohort study .

In addition, performing the “early thymectomy” (performed within a year of diagnosis) resulted in
[41]
higher remission rates compared to “late thymectomy” , including minimizing the adverse effects of
[42]
immunosuppression in pediatric patients .
Other intra-thoracic pathologies that have been treated with RATS are tracheomalacia and resection of a
right paraspinal mass [43,44] .

Congenital diaphragm abnormalities, including eventration and Morgagni and Bochdalek diaphragmatic
hernias, have been successfully repaired through the use of conventional MIS. However, some reports
have shown a high recurrence rate for some defects, potentially due to the difficulty associated with rigid
[45]
instruments. Robotic surgery is the alternative to close diaphragmatic hernias more efficiently .
Acquired anomalies, such as diaphragmatic paralysis, can also be resolved with RATS. The experience
of other authors and ours confirms that robotic surgery is safe and effective for repairing diaphragm
[45]
abnormalities in children [23,45] . Slater and Meehan preferred the thoracic approach for repairing
Bochdalek congenital diaphragmatic hernia, but sometimes smaller babies, less than 2.5 kg, can improve