Editorial

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Open AccessEditorial

Editorial for the Special Issue “Current Development of Pediatric Minimally Invasive Surgery” of the Journal Children

by Robert Bergholz and Thomas Franz Krebs

Children 2023, 10(10), 1650; https://doi.org/10.3390/children10101650 - 03 Oct 2023

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Abstract

Dear colleagues, [...] Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

Research

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9 pages, 2514 KiB

Open AccessArticle

Thoracoscopic Guided Pericostal Sutures as a Solid Fixation for Primary Closure of Congenital Diaphragmatic Hernias

by Armin-Johannes Michel, Ulrike Metzger, Steven Alan Rice and Roman Metzger

Children 2022, 9(8), 1116; https://doi.org/10.3390/children9081116 - 26 Jul 2022

Cited by 1 | Viewed by 1476

Abstract

Purpose: To describe a minimally invasive technique with primary closure and strong suture connection that is feasible in cases of larger, most common type B defects of congenital diaphragmatic hernia (CDH). Background: The thoracoscopic approach (TA) is a favorable technique for the repair [...] Read more.

Purpose: To describe a minimally invasive technique with primary closure and strong suture connection that is feasible in cases of larger, most common type B defects of congenital diaphragmatic hernia (CDH). Background: The thoracoscopic approach (TA) is a favorable technique for the repair of CDH and is still evolving globally. A common issue is finding the optimal suture technique for secure closure in order to prevent recurrences. Whether a defect can be closed only by sutures or by using a patch depends on the size of CDH, the presence of a muscular rim along the inner thoracic surface and finally on the surgeon’s experience. From a geometrical point of view, the challenge is to transform the circular defect into a line, without tension, with a strong compound and preferably without additional material. To address this, we apply a setting of the sutures in a “T-shape” and a way to lead the sutures around the rib bones in order to increase stability. This method allows for the primary closure of CDHs and also applies to larger defects. Cases: We present seven newborns with posterolateral CDH on the left side. The defects were solely repaired by TA and by the suturing technique described in detail. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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8 pages, 1932 KiB

Open AccessArticle

Minimally Invasive Approaches for Traumatic Rupture of the Pancreas in Children—A Case Series

by Hannah Noemi Stundner-Ladenhauf, Leopold Bauer, Christian Heil, Josef Holzinger, Ottokar Stundner and Roman Metzger

Children 2022, 9(8), 1102; https://doi.org/10.3390/children9081102 - 22 Jul 2022

Cited by 1 | Viewed by 1404

Abstract

Pancreatic trauma in children is rare; therefore, both scientific knowledge and clinical experience regarding its management are limited. Abdominal sonography and subsequent computed tomography (CT) imaging are the diagnostic mainstay after severe abdominal trauma in many pediatric trauma centers. However, the diagnosis of [...] Read more.

Pancreatic trauma in children is rare; therefore, both scientific knowledge and clinical experience regarding its management are limited. Abdominal sonography and subsequent computed tomography (CT) imaging are the diagnostic mainstay after severe abdominal trauma in many pediatric trauma centers. However, the diagnosis of pancreatic injury is missed on the initial imaging in approximately one third of cases, with even higher numbers in young children. While conservative treatment is preferred in low-grade injuries, surgical interventions may be indicated in more severe injuries. We present a case series including four patients with high-grade pancreatic injury. Two patients were treated surgically with open laparotomy and primary suture of the head of the pancreas and pancreatico-enterostomy, one patient underwent endoscopic stenting of the pancreatic duct and one received conservative management including observation and secondary endoscopic treatment. We want to emphasize the fact that using a minimally invasive approach can be a feasible option in high-grade pancreatic injury in selected cases. Therefore, we advocate the necessity of fully staffed and equipped high-level pediatric trauma centers. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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13 pages, 1703 KiB

Open AccessEditor’s ChoiceArticle

Pilot Study and Preliminary Results of Biodegradable Intramedullary Nailing of Forearm Fractures in Children

by Christoph Roeder, Cristina Alves, Andreas Balslev-Clausen, Federico Canavese, Erol Gercek, Tamás Kassai, Thomas Klestil, Louise Klingenberg, Nicolas Lutz, Marcell Varga, Gergo Jozsa, Annelie Weinberg and Ludger Tüshaus

Children 2022, 9(5), 754; https://doi.org/10.3390/children9050754 - 20 May 2022

Cited by 6 | Viewed by 3329

Abstract

(1) Background: Diaphyseal forearm fractures are a common injury in children and adolescents. When operative treatment is needed, elastic stable intramedullary nailing (ESIN) is the most common surgical procedure. Although there is no clear evidence, hardware removal after fracture healing is performed in [...] Read more.

(1) Background: Diaphyseal forearm fractures are a common injury in children and adolescents. When operative treatment is needed, elastic stable intramedullary nailing (ESIN) is the most common surgical procedure. Although there is no clear evidence, hardware removal after fracture healing is performed in many patients. Often, the primary minimal invasive incision needs to be widened during implant removal. In order to decrease the burden of care of pediatric fractures, significant efforts were made to develop biodegradable implants, which make hardware removal unnecessary. Our study will conduct an observational trial on the clinical use of the Activa IM-Nail™ in forearm fractures in children between 3 and 13 years of age. The objective of this trial is to evaluate the risks and benefits of the Activa IM-Nail™. Among other objectives, the rate of refracture will be determined. (2) Methods: An international Europe-based, multicenter, prospective, single-arm, open-label study will be performed to ascertain the rate of refracture and to determine the subjective benefits of Activa IM-Nail™ for patients, parents and other caregivers. The study will include clinical follow-up including early post-operative complication, radiographs until bony healing and an additional follow-up after 1 year. At this stage, preliminary results and early complications on 76 patients are analyzed in this study and presented. (3) Results: As of April 2022, 76 patients were enrolled as per study protocol. There were 31 girls (40.8%) and 45 boys (59.2%). The mean age at the time of inclusion was 8.9 years (±2.4 years). The mean operation time was 58.9 ± 22.9 min (range, 15–119 min). The mean follow-up time was 8.9 ± 5.1 months (range, 0.2–18.6). Up to now, one refracture has occurred in one child falling from a height of about one meter 7 months after index surgery (1/76; 1.3%). (4) Conclusion: The research project assesses the safety and effectiveness of Activa IM-Nails™ as part of the surgical treatment of dislocated forearm fractures in children in the context of a PMCF study. The use of Activa IM-Nails™ with regard to various objectives, including postoperative complications and refracture rate, seems to be equal to the standard titan ESIN procedure compared to the literature. Preliminary results are encouraging and are made available. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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10 pages, 1131 KiB

Open AccessArticle

Limits in Laparoscopic Partial Splenectomy in Children

by Christian Tomuschat, Michail Aftzoglou, Johanna Hagens, Michael Boettcher and Konrad Reinshagen

Children 2022, 9(5), 605; https://doi.org/10.3390/children9050605 - 24 Apr 2022

Cited by 2 | Viewed by 1791

Abstract

The aim of this paper is to assess the effectiveness and perioperative complications of splenic surgeries in children. In 41 splenectomies, an anterior abdominal laparoscopic approach was used, with 35 including a partial laparoscopic splenectomy. Of these, three needed a conversion to open. [...] Read more.

The aim of this paper is to assess the effectiveness and perioperative complications of splenic surgeries in children. In 41 splenectomies, an anterior abdominal laparoscopic approach was used, with 35 including a partial laparoscopic splenectomy. Of these, three needed a conversion to open. Six patients had a total splenectomy, three of which were open. Patients ranged in age from 5 to 18 years. Splenectomy was performed for a variety of causes, including hereditary spherocytosis (n = 20), splenic cysts (n = 13), sickle cell disease (n = 3), primary malignancy (n = 1), sepsis (n = 1), embolism (n = 1), anemia (n = 1), and hypersplenism (n = 1). The average length of stay was 7.6 days, and the average operation time was 169.3 min. Pleural effusion in the left hemithorax was found in 31.6% of the patients, with 5.3% requiring a thorax drain. The majority of patients had the highest platelet count two weeks after surgery. There was no evidence of wound infection, pancreatic leak, colon perforation, or postoperative sepsis. The most encountered perioperative complication was bleeding with the need of transfusion (n = 6), and one patient needed a diaphragm repair. A partial splenectomy (PS) can be a difficult procedure with a steep learning curve. For most children who require a splenic operation, this should be the primary procedure of choice. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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11 pages, 2003 KiB

Open AccessArticle

Percutaneous Anorectoplasty (PARP)—An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair

by Julia Küppers, Viviane van Eckert, Nadine R. Muensterer, Anne-Sophie Holler, Stephan Rohleder, Takafumi Kawano, Jan Gödeke and Oliver J. Muensterer

Children 2022, 9(5), 587; https://doi.org/10.3390/children9050587 - 21 Apr 2022

Cited by 4 | Viewed by 5171

Abstract

Background: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. Methods: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic [...] Read more.

Background: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. Methods: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic information, details of the operative procedure, and perioperative complications and outcomes were collected. Results: A total of 10 patients underwent the PARP procedure during the study interval. Patients either had low perineal malformations or no appreciable fistula. Most procedures were guided by ultrasound, fluoroscopy, or endoscopy. Median age at PARP was 3 days (range 1 to 311) days; eight patients were male. Only one intraoperative complication occurred, prompting conversion to posterior sagittal anorectoplasty. Functional outcomes in most children were highly satisfactory in terms of continence and functionality. Conclusions: The PARP technique is an excellent minimal-invasive alternative for boys born with perineal fistulae, as well as patients of both sexes without fistulae. The optimal type of guidance (ultrasound, fluoroscopy, or endoscopy) depends on the anatomy of the lesion and the presence of a colostomy at the time of repair. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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11 pages, 271 KiB

Open AccessArticle

Parents’ Time Perspective as a Predictor of Child’s Postsurgical Pain, Emergence Delirium, and Parents’ Posttraumatic Stress Disorder Symptoms after Child’s Surgery

by Małgorzata Sobol and Marek Krzysztof Sobol

Children 2022, 9(4), 539; https://doi.org/10.3390/children9040539 - 11 Apr 2022

Cited by 1 | Viewed by 1293

Abstract

Background: The aim of this study was to predict children’s postsurgical pain, emergence delirium and parents’ posttraumatic stress disorder symptoms after a child’s surgery based on the parents’ time perspective. Method: A total of 98 children, aged 2 to 15, and their accompanying [...] Read more.

Background: The aim of this study was to predict children’s postsurgical pain, emergence delirium and parents’ posttraumatic stress disorder symptoms after a child’s surgery based on the parents’ time perspective. Method: A total of 98 children, aged 2 to 15, and their accompanying parents participated in this study. Measures of parents’ time perspective and posttraumatic stress disorder symptoms were obtained based on questionnaires. The level of children’s postsurgical pain and delirium were rated by nurses and anaesthesiologist. Results: Parents’ future-negative perspective was a predictor of emergence delirium in the group of children aged 8–15 years. Low parents’ past-positive perspective turned out to be a predictor of parents’ posttraumatic stress disorder symptoms after child’s surgery. Conclusions: The results provide evidence for associations between parents’ time perspective with child’s emergence delirium and parents’ posttraumatic stress disorder symptoms after child’s surgery. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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Open AccessArticle

Robotic Anxiety—Parents’ Perception of Robot-Assisted Pediatric Surgery

by Elisabeth Ammer, Laura Sophie Mandt, Isabelle Christine Silbersdorff, Fritz Kahl and York Hagmayer

Children 2022, 9(3), 399; https://doi.org/10.3390/children9030399 - 11 Mar 2022

Cited by 1 | Viewed by 1905

Abstract

In contrast to many other countries, robot-assisted (RA) pediatric surgery is not yet very common in Germany. Although the first pediatric RA intervention was published in 2001, RA pediatric surgery is still perceived as a “new technology”. As a consequence, little is known [...] Read more.

In contrast to many other countries, robot-assisted (RA) pediatric surgery is not yet very common in Germany. Although the first pediatric RA intervention was published in 2001, RA pediatric surgery is still perceived as a “new technology”. As a consequence, little is known about parents’ perception of this operation method. In this study, we analyzed parents‘ intention to let their child undergo RA and laparoscopic (LA) surgery. Two subsamples (online and at the University Medical Center Goettingen) received a questionnaire addressing attitude towards RA and LA pediatric surgery with the help of a case example. Results showed that parents had a higher intention to consent to LA surgery. Perceiving more benefits, assuming a positive attitude of the social environment, and feeling less anxiety increased intention. A mediation analysis indicated that the type of surgery affected intentions through assumed attitude of the social environment. Exploratory analyses showed that the perception of risks and anxiety reduced intention for only RA surgery. These findings should be considered in preoperational discussions with parents. Anxiety and perceived risks should especially be addressed in order to encounter hesitancy. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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9 pages, 651 KiB

Open AccessArticle

Telementoring in Minimally Invasive Esophageal Atresia Repair: Results of a Case-Control Study and Lessons Learned from the TIC-PEA Study (Telemedical Interdisciplinary Care for Patients with Esophageal Atresia)

by Tatjana Tamara König, Maria-Christina Stefanescu, Emilio Gianicolo, Anne-Sophie Holler and Oliver J. Muensterer

Children 2022, 9(3), 387; https://doi.org/10.3390/children9030387 - 10 Mar 2022

Viewed by 1874

Abstract

Minimally invasive esophageal atresia (EA) repair is deemed one of the most demanding procedures in pediatric surgery. Open repair is considered the gold standard and learning opportunities for minimally invasive repairs remain scarce. “Telemedical Interdisciplinary Care for Patients with Esophageal Atresia (TIC-PEA)” offers [...] Read more.

Minimally invasive esophageal atresia (EA) repair is deemed one of the most demanding procedures in pediatric surgery. Open repair is considered the gold standard and learning opportunities for minimally invasive repairs remain scarce. “Telemedical Interdisciplinary Care for Patients with Esophageal Atresia (TIC-PEA)” offers free access to an interdisciplinary network of experts for telemedical consultation (telementoring). The aim of this study was to determine the frequency of minimally invasive surgery (MIS) in TIC-PEA patients compared to the general population. TIC-PEA patients were matched and compared to controls regarding the use of MIS, patient characteristics, and complications. Patients (n = 31) were included at a mean age of 62.8 days (95%-CI: 41.4–84.3, 77% after the primary esophageal repair). The odds-ratio to have MIS was 4.03 (95%-confidence interval: 0.79–20.55) for esophageal anastomosis and 4.60 (95%-confidence interval: 0.87–24.22) for tracheoesophageal fistula-repair in the TIC-PEA group. Telementoring offered the chance to select the ideal candidate for MIS, plan the procedure, and review intraoperative images and videos with the expert. Telementoring as offered is ideal to promote MIS for EA and helps to address the individual learning curve. In order to maximize benefits, patients need to be included prior to the first esophageal procedure. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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10 pages, 557 KiB

Open AccessArticle

The Status of Laparoscopic Inguinal Hernia Surgery in Children: A Nationwide Assessment

by Andrea Schmedding, Ahmad Alsweed, Oliver Muensterer and Johannes Leonhardt

Children 2022, 9(3), 348; https://doi.org/10.3390/children9030348 - 03 Mar 2022

Cited by 4 | Viewed by 2415

Abstract

Inguinal hernia repair (IHR) is a common procedure in childhood. Laparoscopic IHR has been evolving for the last three decades. Although clear advantages have been shown, adaptation in Germany has been slow. We aim to study the current status of pediatric laparoscopic IHR. [...] Read more.

Inguinal hernia repair (IHR) is a common procedure in childhood. Laparoscopic IHR has been evolving for the last three decades. Although clear advantages have been shown, adaptation in Germany has been slow. We aim to study the current status of pediatric laparoscopic IHR. A survey was sent to all 89 pediatric surgical departments in Germany on current practices and preferences of open versus laparoscopic IHR. Two nationwide databases of administrative claims data from 2019 were analyzed and correlated with responses from the survey. A total of 56% of the pediatric surgical departments supplied data through the quality reports. The recall of our survey was 58% of all pediatric surgery departments. According to the pooled data, laparoscopic IHR was performed in 8.2% of all inpatients treated. Laparoscopic IHR was considered a training procedure in 48% of the departments. Five different laparoscopic techniques were described (most commonly percutaneous closure of the hernia under laparoscopic vision). The choice between open and laparoscopic IHR was mainly determined by the child’s age. Currently, only a minority of German children undergo inguinal hernia repair by laparoscopy. More training opportunities in the form of hands-on and video workshops may lead to more widespread employment of the laparoscopic technique. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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9 pages, 1741 KiB

Open AccessArticle

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results

by Christian Kruppa, Guido Fitze and Katrin Schuchardt

Children 2022, 9(2), 298; https://doi.org/10.3390/children9020298 - 21 Feb 2022

Cited by 2 | Viewed by 2825

Abstract

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and [...] Read more.

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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9 pages, 1253 KiB

Open AccessArticle

Continuous Wear of Night and Day Orthosis Is a Key Factor for Improvement of Fixed Equinus Deformity after the Transverse Vulpius Procedure

by Mathis Wegner, Katharina I. Koyro, Louisa Kosegarten, Anna Kathrin Hell, Heiko M. Lorenz, Volker Diedrichs and Sebastian Lippross

Children 2022, 9(2), 209; https://doi.org/10.3390/children9020209 - 06 Feb 2022

Cited by 1 | Viewed by 2774

Abstract

Background: Equinus foot deformity is secondary to either spasticity or contracture of the gastrocnemius–soleus complex. The plantar flexion is basically treated conservatively; several different surgical methods have been discussed. This paper focuses on the improvement of passive ankle dorsiflexion after a transverse Vulpius [...] Read more.

Background: Equinus foot deformity is secondary to either spasticity or contracture of the gastrocnemius–soleus complex. The plantar flexion is basically treated conservatively; several different surgical methods have been discussed. This paper focuses on the improvement of passive ankle dorsiflexion after a transverse Vulpius procedure in equinus foot deformity. Additionally, the influence of consequent postoperative wear of orthosis on the improvement of ankle range of motion was investigated. Methods: In total, 41 patients with neuromuscular impairment and 59 equinus feet deformities were surgically treated by using a transverse Vulpius procedure. A total of 19 female patients and 22 male patients with a mean age at surgery of 10.18 years (2 to 31) were included. Mean follow-up took place 12.26 ± 7.95 months after surgery. Passive ankle dorsiflexion was measured and subjective patients’ satisfaction was assessed. Results: Range of motion, measured as the maximum of passive ankle joint dorsiflexion, improved significantly from −8° ± 5.9° to 11.1° ± 6.7° directly after surgery to 16.2° ± 10.7° at follow-up. The improvement of passive ankle dorsiflexion was significantly associated with the continuous wearing of night and day orthosis (p = 0.0045). Patient subjective satisfaction was very high. Conclusion: A transverse Vulpius procedure for aponeurotic gastrocnemius and soleus muscle lengthening of equinus foot deformity resulted in a significant improvement of passive ankle dorsiflexion. Positive surgical results correlated to a continuous use of orthotic devices. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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10 pages, 1378 KiB

Open AccessArticle

Evaluation of the Versius Robotic Surgical System for Procedures in Small Cavities

by Marit Kayser, Thomas Franz Krebs, Ibrahim Alkatout, Timo Kayser, Katja Reischig, Jonas Baastrup, Andreas Meinzer, Katja Ulrich, Daniar Osmonov and Robert Bergholz

Children 2022, 9(2), 199; https://doi.org/10.3390/children9020199 - 03 Feb 2022

Cited by 9 | Viewed by 2672

Abstract

Background: The Versius^® is a recently approved robotic surgical system for general surgery procedures in adults. Before any application in children, data of its feasibility and safety in small cavities has to be compiled, beginning with inanimate models. Therefore, the aim of [...] Read more.

Background: The Versius^® is a recently approved robotic surgical system for general surgery procedures in adults. Before any application in children, data of its feasibility and safety in small cavities has to be compiled, beginning with inanimate models. Therefore, the aim of this preclinical study was to assess the Versius^® system for its performance in small boxes simulating small body cavities. Methods: In total, 8 cardboard boxes of decreasing volumes (15.75 L to 106 mL) were used. The procedures, two single stitches with two square knots each, were performed in every box, starting in the largest and consecutively exchanging the box to the next smaller one. The evaluation included procedure time, port placement and pivot point setup, arrangement of the robotic arms and instrumentation, amount of internal and external instrument–instrument collisions and instrument–box collisions. Results: All procedures could be successfully performed in all boxes. The procedure time decreased due to the learning curve in the first four boxes (15.75 to 1.87 L) and consecutively increased from boxes of 1.22 L up to the smallest box with the dimensions of 4.4 × 4.9 × 4.9 cm³. This may be based on the progress of complexity of the procedures in small cavities, which is also depicted by the synchronous increase of the internal instrument–instrument and instrument–box collisions. Conclusion: With the use of the Versius^® robotic surgical system, we were able to perform robotic reconstructive procedures, such as intracorporal suturing and knot tying, in cavities as small as 106 mL. Whether this system is comparable or even superior to conventional laparoscopic surgery in small cavities, such as in children, has to be evaluated. Furthermore, before any application in newborns or infants, ongoing evaluation of this system should be performed in a live animal model. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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Review

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34 pages, 4949 KiB

Open AccessReview

Lifesaving Treatments for the Tiniest Patients—A Narrative Description of Old and New Minimally Invasive Approaches in the Arena of Fetal Surgery

by Thomas Kohl

Children 2023, 10(1), 67; https://doi.org/10.3390/children10010067 - 28 Dec 2022

Cited by 3 | Viewed by 3345

Abstract

Fetal surgery has become a lifesaving reality for hundreds of fetuses each year. The development of a formidable spectrum of safe and effective minimally invasive techniques for fetal interventions since the early 1990s until today has led to an increasing acceptance of novel [...] Read more.

Fetal surgery has become a lifesaving reality for hundreds of fetuses each year. The development of a formidable spectrum of safe and effective minimally invasive techniques for fetal interventions since the early 1990s until today has led to an increasing acceptance of novel procedures by both patients and health care providers. From his vast personal experience of more than 20 years as one of the pioneers at the forefront of clinical minimally invasive fetal surgery, the author describes and comments on old and new minimally invasive approaches, highlighting their lifesaving or quality-of-life-improving potential. He provides easy-to-use practical information on how to perform partial amniotic carbon dioxide insufflation (PACI), how to assess lung function in fetuses with pulmonary hypoplasia, how to deal with giant CPAMS, how to insert shunts into fetuses with LUTO and hydrothorax when conventional devices are not available, and how to resuscitate a fetus during fetal cardiac intervention. Furthermore, the author proposes a curriculum for future fetal surgeons, solicits for the centralization of patients, for adequate maternal counseling, for adequate pain management and adequate hygienic conditions during interventions, and last but not least for starting the process of academic recognition of the matured field as an independent specialty. These steps will allow more affected expectant women and their unborn children to gain access to modern minimally invasive fetal surgery and therapy. The opportunity to treat more patients at dedicated centers will also result in more opportunities for the research of rare diseases and conditions, promising even better pre- and postnatal care in the future. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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12 pages, 1289 KiB

Open AccessReview

Minimally Invasive Bimanual Fetal Surgery—A Review

by Susanne Eva Brunner, Lidya-Olgu Durmaz, Andreas Meinzer, Milena Arp, Thomas Franz Krebs and Robert Bergholz

Children 2022, 9(9), 1377; https://doi.org/10.3390/children9091377 - 13 Sep 2022

Viewed by 1538

Abstract

Background: The aim of this review is to discuss experimental and clinical techniques and interventions of fetal surgery which have been performed minimally invasively by the means of a three-port approach for the fetoscope and instruments for the left and right hand of [...] Read more.

Background: The aim of this review is to discuss experimental and clinical techniques and interventions of fetal surgery which have been performed minimally invasively by the means of a three-port approach for the fetoscope and instruments for the left and right hand of the surgeon (bimanual minimally invasive fetal surgery). Methods: a print and electronic literature search was performed; the titles and abstracts were screened and included reports were reviewed in a two-step approach. First, reports other than minimally invasive fetal surgery were excluded, then a full text review and analysis of the reported data was performed. Results: 17 reports were included. The heterogeneity of the included reports was high. Although reports on human fetoscopic surgical procedures can be found, most of them do not pick out bimanual fetal surgery as a central theme but rather address interventions applying a fetoscope with a working channel for a laser fiber, needle or flexible instrument. Most reports were on experimentation in animal models, the human application of minimally invasive fetoscopic bimanual surgery is rare and has at best been explored for the prenatal treatment of spina bifida. Some reported bimanual fetoscopic procedures were performed on the exteriorized uterus via a maternal laparotomy and can therefore not be classified as being truly minimally invasive. Discussion: our results demonstrate that minimally invasive fetoscopic bimanual surgery is rare, even in animal models, excluding many other techniques and procedures that are loosely termed ‘minimally invasive fetal surgery’ which we suggest to better label as ‘interventions’. Thus, more research on percutaneous minimally invasive bimanual fetoscopic surgery is warranted, with the aim to reduce the maternal, uterine and fetal trauma for correction of congenital malformations. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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15 pages, 940 KiB

Open AccessReview

Robotically Assisted Surgery in Children—A Perspective

by Thomas Franz Krebs, Isabel Schnorr, Pascal Heye and Franz-Martin Häcker

Children 2022, 9(6), 839; https://doi.org/10.3390/children9060839 - 06 Jun 2022

Cited by 5 | Viewed by 1860

Abstract

The introduction of robotically assisted surgery was a milestone for minimally invasive surgery in the 21st century. Currently, there are two CE-approved robotically assisted surgery systems for use and development in pediatrics. Specifically, tremor filtration and optimal visualization are approaches which can have [...] Read more.

The introduction of robotically assisted surgery was a milestone for minimally invasive surgery in the 21st century. Currently, there are two CE-approved robotically assisted surgery systems for use and development in pediatrics. Specifically, tremor filtration and optimal visualization are approaches which can have enormous benefits for procedures in small bodies. Robotically assisted surgery in children might have advantages compared to laparoscopic or open approaches. This review focuses on the research literature regarding robotically assisted surgery that has been published within the past decade. A literature search was conducted to identify studies comparing robotically assisted surgery with laparoscopic and open approaches. While reported applications in urology were the most cited, three other fields (gynecology, general surgery, and “others”) were also identified. In total, 36 of the publications reviewed suggested that robotically assisted surgery was a good alternative for pediatric procedures. After several years of experience of this surgery, a strong learning curve was evident in the literature. However, some authors have highlighted limitations, such as high cost and a limited spectrum of small-sized instruments. The recent introduction of reusable 3 mm instruments to the market might help to overcome these limitations. In the future, it can be anticipated that there will be a broader range of applications for robotically assisted surgery in selected pediatric surgeries, especially as surgical skills continue to improve and further system innovations emerge. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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9 pages, 551 KiB

Open AccessReview

The Role of the Versius Surgical Robotic System in the Paediatric Population

by Ewan M. Brownlee and Mark Slack

Children 2022, 9(6), 805; https://doi.org/10.3390/children9060805 - 30 May 2022

Cited by 4 | Viewed by 2121

Abstract

The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, [...] Read more.

The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, dexterity, and ergonomics, could make it a superior choice over the traditional laparoscopic approach. However, its implementation in the paediatric surgery arena has been limited primarily due to the unavailability of appropriately sized instruments as per paediatric body habitus, therefore, requiring more technologically advanced systems. The Versius surgical robotic system is a new modular platform that offers several benefits such as articulated instruments which pass through conventional 5 mm ports, compact arms for easier manoeuvrability and patient access, the ability to mimic conventional port placements, and adaptive machine learning concepts. Prior to its introduction to paediatric surgery, it needs to go through a careful pre-clinical and clinical research program. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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13 pages, 2864 KiB

Open AccessEditor’s ChoiceReview

Making Hardware Removal Unnecessary by Using Resorbable Implants for Osteosynthesis in Children

by Pascal Heye, Christoph Matissek, Clemens Seidl, Marcell Varga, Tamas Kassai, Gergö Jozsa and Thomas Krebs

Children 2022, 9(4), 471; https://doi.org/10.3390/children9040471 - 29 Mar 2022

Cited by 10 | Viewed by 2791

Abstract

Introduction: Following osteosynthesis, children generally require a second surgery to remove the hardware. This becomes unnecessary, by using resorbable implants. Limiting the number of required surgeries and their associated risks, this technique provides critical aspects of minimally invasive surgery. This review focuses on [...] Read more.

Introduction: Following osteosynthesis, children generally require a second surgery to remove the hardware. This becomes unnecessary, by using resorbable implants. Limiting the number of required surgeries and their associated risks, this technique provides critical aspects of minimally invasive surgery. This review focuses on resorbable implants for osteosynthesis for the treatment of fractures in children and discusses their clinical features. Method: We provide an overview of the two most common technologies used in resorbable osteosynthesis materials: polymer- and magnesium-based alloys. Clinical examples of osteosynthesis are presented using polymer-based ActivaTM products and magnesium-based Magnezix^® products. Results: Polymer-based implants demonstrate surgical safety and efficacy. Due to their elasticity, initial placement of polymer-based products may demonstrate technical challenges. However, stability is maintained over the course of healing. While maintaining good biocompatibility, the rate of polymer-resorption may be controlled by varying the composition of polyesters and copolymers. Similarly, magnesium-based implants demonstrate good mechanical stability and resorption rates, while these characteristics may be controlled by varying alloy components. One of the significant shortcomings of magnesium is that metabolism results in the production of hydrogen gas. Both technologies provide equally good results clinically and radiographically, when compared to non-resorbable implants. Conclusion: Resorbable osteosynthesis materials demonstrate similar therapeutic results as conventional materials for osteosynthesis. Resorbable implants may have the potential to improve patient outcomes, by sparing children a second surgery for hardware removal. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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22 pages, 650 KiB

Open AccessReview

Fetal Surgery for Gastroschisis—A Review with Emphasis on Minimally Invasive Procedures

by Lidya-Olgu Durmaz, Susanne Eva Brunner, Andreas Meinzer, Thomas Franz Krebs and Robert Bergholz

Children 2022, 9(3), 416; https://doi.org/10.3390/children9030416 - 15 Mar 2022

Cited by 5 | Viewed by 3109

Abstract

(1) Background: The morbidity of gastroschisis is defined by exposure of unprotected intestines to the amniotic fluid leading to inflammatory damage and consecutive intestinal dysmotility, the viscero-abdominal disproportion which results in an abdomen too small to incorporate the herniated and often swollen intestine, [...] Read more.

(1) Background: The morbidity of gastroschisis is defined by exposure of unprotected intestines to the amniotic fluid leading to inflammatory damage and consecutive intestinal dysmotility, the viscero-abdominal disproportion which results in an abdomen too small to incorporate the herniated and often swollen intestine, and by associated pathologies, such as in complex gastroschisis. To prevent intestinal damage and to provide for growth of the abdominal cavity, fetal interventions such as amnio exchange, gastroschisis repair or covering have been evaluated in several animal models and human trials. This review aims to evaluate the reported techniques for the fetal treatment of gastroschisis by focusing on minimally invasive procedures. (2) Methods: We conducted a systematic database search, quality assessment and analyzed relevant articles which evaluate or describe surgical techniques for the prenatal surgical management of gastroschisis in animal models or human application. (3) Results: Of 96 identified reports, 42 eligible studies were included. Fetal interventions for gastroschisis in humans are only reported for EXIT procedures and amnio exchange. In animal models, particularly in the fetal sheep model, several techniques of open or minimally invasive repair of gastroschisis or covering the intestine have been described, with fetoscopic covering being the most encouraging. (4) Discussion: Although some promising minimally invasive techniques have been demonstrated in human application and animal models, most of them are still associated with relevant fetal morbidity and mortality and barely appear to be currently applicable in humans. Further research on specific procedures, instruments and materials is needed before any human application. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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2 pages, 170 KiB

Open AccessReply

Reply to Peña, A. Comment on “Küppers et al. Percutaneous Anorectoplasty (PARP)—An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair. Children 2022, 9, 587”

by Julia Küppers, Viviane van Eckert, Nadine R. Muensterer, Anne-Sophie Holler, Stephan Rohleder, Takafumi Kawano, Jan Gödeke and Oliver J. Muensterer

Children 2022, 9(9), 1382; https://doi.org/10.3390/children9091382 - 14 Sep 2022

Viewed by 777

Abstract

Thank you so much for your thoughtful comments [...] Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

2 pages, 169 KiB

Open AccessComment

Comment on Küppers et al. Percutaneous Anorectoplasty (PARP)—An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair. Children 2022, 9, 587

by Alberto Peña

Children 2022, 9(9), 1381; https://doi.org/10.3390/children9091381 - 14 Sep 2022

Cited by 1 | Viewed by 816

Abstract

I read the above-mentioned article with a great deal of interest [...] Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

11 pages, 4188 KiB

Open AccessTechnical Note

Tips and Tricks—3 Use Cases of Interdisciplinary Knowledge Transfer in Minimally Invasive Pediatric Surgery

by Mareike Grosshauser, Tim Ohletz, Valérie Oesch and Cécile Olivia Muller

Children 2022, 9(9), 1270; https://doi.org/10.3390/children9091270 - 23 Aug 2022

Cited by 1 | Viewed by 1325

Abstract

In the pediatric surgical environment, we can enrich our knowledge and improve our skills through interdisciplinary knowledge transfer in exchange with other surgical or even non-surgical disciplines. To demonstrate this, we present in this article three patient cases of method transfer enabling new [...] Read more.

In the pediatric surgical environment, we can enrich our knowledge and improve our skills through interdisciplinary knowledge transfer in exchange with other surgical or even non-surgical disciplines. To demonstrate this, we present in this article three patient cases of method transfer enabling new techniques in minimally invasive pediatric surgery. 1. The somewhat modified application of the AeroStat rigid tip laparoscopic cholangiography catheter during the single-step laparoscopic cholecystectomy facilitates the safe intraoperative cholangiography with common bile duct flushing. 2. A magnetic rod is used during laparoscopic enterotomy to locate and retrieve ingested magnets. 3. Using a patient-specific MRI 3D model representing a syndromic high anorectal malformation improves surgical planning and parental education. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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10 pages, 1497 KiB

Open AccessEditor’s ChoiceSystematic Review

Esophageal Magnetic Compression Anastomosis in Esophageal Atresia Repair: A PRISMA-Compliant Systematic Review and Comparison with a Novel Approach

by Anne-Sophie Holler, Tatjana Tamara König, Caressa Chen, Michael R. Harrison and Oliver J. Muensterer

Children 2022, 9(8), 1113; https://doi.org/10.3390/children9081113 - 25 Jul 2022

Cited by 11 | Viewed by 1953

Abstract

The use of magnet compression to endoscopically create an esophageal anastomosis is an intriguing approach to esophageal atresia repair, but published cases with an existing available device have demonstrated mixed success. One major shortcoming has been the formation of subsequent severe, recalcitrant strictures [...] Read more.

The use of magnet compression to endoscopically create an esophageal anastomosis is an intriguing approach to esophageal atresia repair, but published cases with an existing available device have demonstrated mixed success. One major shortcoming has been the formation of subsequent severe, recalcitrant strictures after primary repair. To address the limitations of the existing device, we recently introduced and reported success with specially designed bi-radial magnets that exhibit a novel geometry and unique tissue compression profile. The aim of this study is to compare the outcomes using our novel device (novel group, NG) with those of previous reports which utilized the historical device (historic group, HG) in a PRISMA-compliant systematic review. Seven studies were eligible for further analysis. Additionally, one of our previously unreported cases was included in the analysis. Esophageal pouch approximation prior to primary repair was performed more frequently in the NG than in the HG (100% NG vs. 21% HG; p = 0.003). There was no difference in the overall postoperative appearance of postoperative stricture (95% HG vs. 100% NG; p = 0.64). The number of postoperative dilatations trended lower in the NG (mean 4.25 NG vs. 9.5 HG; p = 0.051). In summary, magnetic compression anastomosis adds a new promising treatment option for patients with complex esophageal atresia. Prior approximation of pouches and a novel magnet design have the potential to lower the rate of stricture formation. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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9 pages, 2508 KiB

Open AccessCase Report

Transanal Endoscopic-Assisted Pull-Through Colectomy for Children with High Intestinal Aganglionosis

by Ulrike Metzger, Armin-Johannes Michel, Mircia-Aurel Ardelean and Roman Patrick Metzger

Children 2022, 9(5), 588; https://doi.org/10.3390/children9050588 - 21 Apr 2022

Cited by 1 | Viewed by 3600

Abstract

Intestinal aganglionosis in children is a common cause of neonatal and infantile obstruction or ileus. Diagnosis is based on a histologically proven absence of enteric ganglion cells in deep biopsies of the gut wall. Therapeutic goal is a one-stage repair with a resection [...] Read more.

Intestinal aganglionosis in children is a common cause of neonatal and infantile obstruction or ileus. Diagnosis is based on a histologically proven absence of enteric ganglion cells in deep biopsies of the gut wall. Therapeutic goal is a one-stage repair with a resection of the affected segment. The endorectal pull-through (ERP) can be performed entirely transanally in a lot of the cases. In patients with difficult preparation or a high aganglionosis ERP often needs to be assisted by laparoscopy or laparotomy. We present two cases with a technical modification performing a totally transanal pull-through colectomy without any trocars other than an umbilical camera trocar. The procedure starts with a classical endorectal technique. Usually, the transanal preparation is limited by reaching the colon descendens. A camera trocar is inserted and under laparoscopic vision the preparation is completed placing the instruments directly via the opened anus. After reaching the healthy colon segment, the pull-through is completed transanally. One of the main advantages of ERP is the sparing dissection. Our modification combines advantages of laparoscopy and ERP. The umbilical camera allows an excellent view while the instruments for dissection are used like with ERP without any further trocar or traction of the anal sphincter. The dispensation of any transanal trocar allows a higher grade of freedom in preparation and possibly a smaller trauma on the distal anal channel. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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9 pages, 2644 KiB

Open AccessTechnical Note

Double Pre-Bending of an Intramedullary Nail Is the Minimal Invasive Osteosynthesis Solution for Dia-Metaphyseal Fractures of the Radius in Children: Technical Note and Case Series

by Carsten Krohn

Children 2022, 9(4), 579; https://doi.org/10.3390/children9040579 - 18 Apr 2022

Cited by 5 | Viewed by 4941

Abstract

Whereas in paediatric traumatology for diaphyseal fractures of the radius (intramedullary nail), as well as metaphyseal fractures (K-wire), minimal invasive methods for osteosynthesis were established as gold standard, the ideal osteosynthesis of fractures of the dia-metaphyseal area remains controversial. In this article, the [...] Read more.

Whereas in paediatric traumatology for diaphyseal fractures of the radius (intramedullary nail), as well as metaphyseal fractures (K-wire), minimal invasive methods for osteosynthesis were established as gold standard, the ideal osteosynthesis of fractures of the dia-metaphyseal area remains controversial. In this article, the author describes his own minimal invasive technique, using an intramedullary nail that must be pre-bent twice to achieve a stable reduction, with three-point support. The material used for this new surgical technique is an ordinary intramedullary nail. If not available, the operation can also be performed with a sufficiently lengthy K-wire. The intramedullary nail needs to be pre-bent twice, which follows a standardised procedure. A small case series is included to visualise the scope of this minimal-invasive method. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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12 pages, 12543 KiB

Open AccessPerspective

Current Development of Minimally Invasive Repair of Pectus Excavatum (MIRPE)

by Frank-Martin Haecker, Thomas Franz Krebs and Kai-Uwe Kleitsch

Children 2022, 9(4), 478; https://doi.org/10.3390/children9040478 - 31 Mar 2022

Cited by 11 | Viewed by 5335

Abstract

For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing [...] Read more.

For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing frequency worldwide and considered as the “gold standard”. After its introduction, the method experienced numerous modifications such as routine thoracoscopy and/or sternal elevation, increasing safety of the procedure. Placement of multiple bars and/or the so called cross-bar technique were introduced to correct complex CWDs. Standardized pain management, the introduction of cryo-analgesia and a standardized postoperative physiotherapy program including deep breathing exercises facilitate the establishment of an enhanced recovery after surgery (ERAS) process. However, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. Furthermore, several studies report near-fatal complications, not only during bar placement, but also during bar removal. This review focuses upon the most relevant modifications, including recent published surgical techniques of MIRPE, in order to describe current developments in the field. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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7 pages, 9765 KiB

Open AccessTechnical Note

Current Concepts in Endoscopic Bladder Neck Injection: Combined Antegrade and Retrograde Endoscopic Injection of the Bladder Neck in Children with Neurogenic Bladder

by Frank-Martin Haecker, Anja Mettler and Alexander Mack

Children 2022, 9(4), 449; https://doi.org/10.3390/children9040449 - 23 Mar 2022

Cited by 2 | Viewed by 2120

Abstract

Introduction: Urinary incontinence is common in patients with neurogenic bladder, and efficient management is an ongoing challenge. Besides open surgical procedures like bladder neck reconstruction, artificial sphincter implantation, or sling procedures, endoscopic bladder neck injections of bulking agents enable minimally invasive access with [...] Read more.

Introduction: Urinary incontinence is common in patients with neurogenic bladder, and efficient management is an ongoing challenge. Besides open surgical procedures like bladder neck reconstruction, artificial sphincter implantation, or sling procedures, endoscopic bladder neck injections of bulking agents enable minimally invasive access with promising results. Several studies report on the effect of antegrade vs. retrograde endoscopic injection techniques. We report our preliminary experience of combined antegrade and retrograde endoscopic injection of the bladder neck in children with neurogenic bladder, in selected cases combined with intravesical Botox^® injection. Methods: With the patient in lithotomy position, antegrade urethrocystoscopy was performed using a 9.5 Fr cystoscope. In parallel, percutaneous suprapubic bladder access introducing a second 9.5 Fr. cystoscope was accomplished. Four quadrant Dx/H injections were performed, with the two surgeons guiding each other by parallel endoscopy to the optimal localization for injection. In selected patients, the procedure was completed with transurethral intravesical Botox^® injection. Results: A total of 6 children underwent the combined procedure (2/6 patients including intravesical Botox^® injection). The mean follow-up was 15 months (range 3 to 48). 5 Patients experienced a significant improvement of urinary incontinence, however one patient demonstrated complete failure. Conclusions: Even if we present only preliminary results with a limited number of patients, we present a minimally invasive technique with encouraging results. In carefully selected patients, combined antegrade and retrograde endoscopic injection of the bladder neck is a useful tool to treat urinary incontinence. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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10 pages, 3370 KiB

Open AccessCase Report

First Pediatric Pyeloplasty Using the Senhance^® Robotic System—A Case Report

by Juergen Holzer, Peter Beyer, Florian Schilcher, Clemens Poth, Dietmar Stephan, Christian von Schnakenburg, Wim van Gemert and Ludger Staib

Children 2022, 9(3), 302; https://doi.org/10.3390/children9030302 - 22 Feb 2022

Cited by 5 | Viewed by 2062

Abstract

A pediatric robotic pyeloplasty has been performed with the Senhance^® robotic system for the first time in January 2021 on a 1.5-year-old girl with symptomatic ureteropelvic junction stenosis. A Senhance^® robotic system (Asensus Surgical^® Inc., Durham, NC, USA) with three [...] Read more.

A pediatric robotic pyeloplasty has been performed with the Senhance^® robotic system for the first time in January 2021 on a 1.5-year-old girl with symptomatic ureteropelvic junction stenosis. A Senhance^® robotic system (Asensus Surgical^® Inc., Durham, NC, USA) with three arms and 5 mm instruments was used, providing infrared eye tracking of the 5 mm camera and haptic feedback for the surgeon, facilitating suturing of the anastomosis and double-J stent insertion. The robotic surgery lasted 4.5 h, was uneventful and successful, without recurrence of the ureteropelvic junction obstruction after six months, and with normal development of the patient’s growth and organ function. The use of the robotic system was shown to be safe and feasible; long term follow-up will be conducted subsequently in pediatric surgery. Full article

(This article belongs to the Special Issue Current Development of Pediatric Minimally Invasive Surgery)

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