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Page 8 of 12 Navarrete-Arellano. Mini-invasive Surg 2020;4:9 I http://dx.doi.org/10.20517/2574-1225.2019.70

with the abdominal approach, since articulated instruments require considerable length to maneuver. The
authors operated by abdominal approach on a case of Morgagni congenital diaphragmatic hernia and
another case of Bochdalek congenital diaphragmatic hernia.

Regardless of the fact that thoracoscopic surgery in newborns is demanding for the surgeon and the
patient, surgeons with large experience in MIS, with advanced skills, and with learning curve overcome,
can perform complex procedures with efficacy and safety, such as thoracoscopic repair of esophageal atresia
[46]
[47]
with tracheoesophageal fistula , and even repair of long-gap esophageal atresia .
In our series of 11 RATS cases, five patients weighed between 5.93 and 10.6 kg, three had diaphragmatic
plication, and two lobectomy. The case of conversion to thoracotomy was a 7.8 kg patient with pulmonary
sequestration, being our first robotic lobectomy. The reason for the conversion was the difficulty in
maneuvering the articulated instruments. Then, in the second lobectomy, the smallest patient in our series
of cases (5.93 kg), we made a totally cephalic (longitudinal) docking and placed the trocars only penetrating
the thickness of the thoracic wall, with which we obtained a better space inside the thoracic cavity and we
could perform a comfortable and safe lobectomy [Figure 1]. The three cases of diaphragmatic plication
were performed without problems with RATS.

The application of MIS for the treatment of malignant solid tumors in children is very controversial. From
1966 to February 2011, the authors were unable to identify randomized controlled trials or controlled
clinical trials that evaluated MIS in the treatment of intra-thoracic or intra-abdominal solid neoplasms in
children; therefore, no definitive conclusions could be drawn about the results of MIS in these patients.
Based on the available evidence at that time, the authors could not give recommendations for the use of
[48]
MIS in the treatment of solid malignancies in children .

Following the publication of the above conclusions, several case series of intra-thoracic solid tumors treated
with VATS in children have been published.

The efficacy and safety of resection of mediastinal tumors in children were compared, using thoracotomy
in 10 cases and VATS in 21 cases. The approach was indicated as non-randomized, and the analysis of the
results was retrospective. The VATS group required significantly fewer blood transfusions, shorter duration
[49]
of thoracic drainage, and shorter hospital stay, thus suggesting VATS is less invasive .
Another series was of 17 children with thoracic neurogenic tumors, with an average weight of 11.9 kg (range:
9.3-27.4 kg). The series consisted of ten children with neuroblastoma, four with ganglioneuroma, and three
with ganglioneuroblastoma. Complete thoracoscopic resection was performed in all cases. There were no
deaths and no recurrence was observed during the follow-up period of 8.9-28.6 months. VATS resection
of mediastinal neurogenic tumors in children offers good results. The main advantages of this approach
are it avoids thoracotomy complications and improves surgical accuracy by having a better view of the
anatomy .
[50]

[51]
Irtan et al. published a series of 39 patients undergoing MIS due to neuroblastic tumors, using
thoracoscopy in 20 patients, retroperitoneoscopy in 1 patient, and laparoscopy in 18 patients. The
average diameter was 35 mm for thoracic tumors (range 7-85 mm). Resection was incomplete in six
thoracic tumors and one adrenal tumor. Conversion was necessary in three cases of thoracic tumors. PO
complications occurred in five patients. The overall survival rate was 98%. The authors concluded that, in
carefully selected cases, MIS allows the safe and efficient resection of neuroblastic tumors in children.

Publications on the treatment of malignant tumors in children by RATS are only from isolated
cases. Meehan and Sandler reported a case of mediastinal germ cell tumor, a ganglioneuroma, a
[36]