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21 Robotic-Assisted Intestinal Duplication Resection
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145
21.8 Comparisons
withConventional
Laparoscopic Surgery
Compared with traditional laparoscopic surgery,
the Da Vinci system has much higher resolution
and clarity, which can maintain lens clarity without being affected by smoke, so it can ensure the
smoothness of the entire operation process without
interruption [9]. In addition, intestinal duplication
cysts usually share the same wall as the normal
intestinal canal, making it difcult to distinguish
their boundaries with the naked eye under ordinary
laparoscopy. Therefore, performing traditional
laparoscopic surgery under complete laparoscopy
is difcult. In most cases, it is necessary to expand
the umbilical incision, pull out the affected intestine, remove the local intestine, and perform intestinal anastomosis [10]. Although compared to
traditional open surgery, there has been a signicant improvement in surgical trauma and exposure
time of the intestines to the air, some intestinal
tubes still need to be exposed to the air, and intestinal anastomosis is unavoidable, so there is still a
risk of intestinal adhesions and stulas after surgery. Compared with ordinary laparoscopic equipment, the imaging system of the Da Vinci system
enables better magnication and a clearer local
eld of view [11], which can help surgeons distinguish between the cyst wall and the normal intestinal to peel off the cyst under complete laparoscopy.
This avoids both dragging the intestine out of the
body and contaminating the abdominal cavity as
well as intestinal anastomosis, further reducing the
incidence of intestinal obstruction, adhesion and
stula. In addition, the highly exible robotic arm
of the Da Vinci system can help complete the operation in a very narrow space, and its ne multiangle rotating robotic arm is incomparable to that
of traditional laparoscopy. Moreover, the robotic
system can lter out manual jitter, decrease the
surgeon’s fatigue, and reduce incorrect operations.
Finally, the learning curve of the Da Vinci system
is signicantly lower than that of conventional
laparoscopy, and surgeons with some experience
in laparoscopic surgery can quickly adapt to the
operation.
The Da Vinci system also has drawbacks
mainly reected in 1) long procedure time and 2)
high total hospitalization costs. The current high
surgical cost is the biggest problem for the Da
Vinci system to be carried out routinely, and this
additional cost is at the patients’ own expense
[12]. Therefore, with the premise that this kind of
surgery can be completed well by traditional laparoscopic surgery, the Da Vinci system still needs to
experience a long period to be widely available. It
is believed that with the advancement of technology, this problem will eventually be solved when
the localization of instruments can be realized. For
the problem of time- consuming installation, the
application of the current generation of machines
has signicantly shortened the installation time,
and it is believed that with the development of
technology, the disadvantage of time-consuming
installation will also be well resolved.
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21.9 Case Presentations
andVideo
Figure 21.2.
Z. Gao and Y. Jin
Fig. 21.2 (a) Suspending the local intestine to the
abdominal wall; (b) Cyst puncture and aspiration; (c)
Peeling off the cyst; (d) After lesion resection, the local
intestinal tract remains intact; (e) The cyst is removed by
retrieval bag; (f) Closing the plasma muscular layer of the
local normal intestine
21 Robotic-Assisted Intestinal Duplication Resection
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References
1. Jeziorczak PM, Warner BW. Enteric Duplication. Clin
Colon Rectal Surg. 2018;3:127–31.
2. Kiratli PO, Aksoy T, Bozkurt MF, et al. Detection
of ectopic gastric mucosa using 99mTc pertechnetate: review of the literature. Ann Nucl Med.
2009;23:97–105.
3. Erginel B, Soysal FG, Ozbey H, et al. Enteric duplication cysts in children: a single-institution series
with forty patients in twenty-six years. World J Surg.
2017;41:620–4.
4. Yan J, Lei W, Yan J, et al. Ileocecal duplication in children: a single-center experience of 115 cases. Eur J
Pediatr. 2022;181:3937–44.
5. Górecki W, Bogusz B, Zając A, et al. Laparoscopic
and laparoscopy-assisted resection of enteric duplication cysts in children. J Laparoendosc Adv Surg Tech
A. 2015;25:838–40.
6. Schleef J, Schalamon J. The role of laparoscopy in
the diagnosis and treatment of intestinal duplication
in childhood. A report of two cases. Surg Endosc.
2000;14:865.
7. Autorino R, Zargar H, Kaouk JH. Robotic-assisted
laparoscopic surgery: recent advances in urology.
Fertil Steril. 2014;102:939–49.
8. Herron DM, Marohn M; SAGES-MIRA Robotic
Surgery Consensus Group. A consensus document on
robotic surgery. Surg Endosc. 2008;22:313–25
9. Watanabe G, Ishikawa N. [da Vinci surgical system].
Kyobu Geka. 2014;67:686–9. Japanese.
10. Kim SH, Cho YH, Kim HY. Alimentary tract duplication in pediatric patients: its distinct clinical features
and managements. Pediatr Gastroenterol Hepatol
Nutr. 2020;23:423–9.
11. Pötscher A, Bittermann C, Längle F. Robot-assisted
esophageal surgery using the da Vinci® Xi system:
operative technique and initial experiences. J Robot
Surg. 2019;13:469–74.
12. Cundy TP, Marcus HJ, Hughes-Hallett A, et al.
Robotic surgery in children: adopt now, await, or
dismiss? Pediatr Surg Int. 2015;31:1119–25.
Robotic-Assisted Partial
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Nephrectomy for Duplicated
System
ChangTao andLongSun
22
22.1 Introduction
In adult urology, partial nephrectomy is often
used for nephron-sparing renal cancer. In pediatric urology, partial nephrectomy is often used
in children with duplicated kidneys and ureters.
Duplicated kidneys and ureteral malformations
in children are common, with an incidence of
approximately 0.8%. There are even rarer triple
ureters. It is often associated with ureterocele,
ectopic ureteral opening, vesicoureteral reux,
and recurrent urinary tract infections that require
surgical intervention [1, 2]. The clinical manifestations of repetitive kidney are varied, the
complications and renal function of the affected
side are not the same in each patient, and the
surgical scheme is also different [3–5]. Partial
nephrectomy is one of the most common
options, but it is also a very challenging surgery.
Laparoscopic nephrectomy requires a long
learning curve and should not be performed by
beginners [6, 7].
22.2 Indications
andContraindications
Indications:
1. Recurrent UTI: the patient has limited growth
and development.
2. Hypoplasia of duplicated kidney, with or
without ureteropathy. (Ectopic ureteral opening and ureteral cyst).
3. Poor or no functional portion of the dupliacted
collection system, with or without ureteropathy.
(Ectopic ureteral opening and ureteral cyst).
4. Giant hydronephrosis of duplicated kidney,
with or without ureteropathy. (Ectopic ureteral opening and ureteral cyst).
5. High-grade VUR (grade 3-5) of duplicated
kidney
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_22.
C. Tao (*) · L. Sun
Department of Pediatric Urology, Children’s
Hospital, Zhejiang University School of Medicine,
Hangzhou, China
e-mail: dr.taoc777@zju.edu.cn;
sunlong2018@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_22
Contraindications:
There are generally no obvious contraindications
to surgery unless vital signs are unstable or there is
abnormal function of the heart, liver, lung and other
organs. Patients with poor nutritional status and
intolerance to anesthesia and pneumoperitoneum
surgery. Surgery during acute infection increases the
difculty of operation and bleeding and is generally
considered a relative indication [8, 9].
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22.3 Preoperative Preparation
If there was a urinary tract infection, the infection
was controlled for 2 weeks before surgery.
Laboratory tests included routine hematuria,
coagulation function, liver and kidney function,
etc. Imaging tests include abdominal and urinary
B-ultrasound, VCUG, MRU, ECT, etc. No operation contraindications were found after anesthesia consultation.
Bowel preparation included cleansing enema
24 hours before surgery, fasting for 8 hours and
being water-free for 2 hours before surgery.
Preoperative antibiotics should be administered intravenously 30 minutes before surgery.
Depending on the half-life of the selected antibiotics and the length of surgery, the drugs can be
administered intraoperatively to ensure that the
effective concentration of drugs covers the entire
procedure. Urinary catheters and gastric tubes
were used before the operation.
Although intraoperative blood transfusion is
rarely needed, due to the risk of renal pedicle vascular damage, preoperative preparation of red
blood cells and plasma is still routinely needed.
22.4 Position andDocking
Eighty degree was taken from the healthy side
lying position, as far as possible close to the edge
of the bed, and the waist pad was used properly.
The arm is bent at the elbow and placed in a bedside brace, with the healthy leg bent and the
affected leg extended back. The compression
parts were protected with gel pads. After the
position was determined, the wide tape xed the
position. Lens hole located at the umbilical region
(Fig. 22.1, point C). With the lens facing down,
arm No. 1 was placed below the xiphoid process,
and arm No. 2 was placed at the mid-clavicle
hypogastrium region. The distance between the
arms was generally greater than 5 cm. A 5 mm
auxiliary hole is placed between the No. 2 arm
and the lens hole. The pneumoperitoneum pressure should be maintained at 8-12 mmHg according to the age of the child. Three instruments are
commonly used: single-pole bending shear, biopolar forceps with holes and needle drivers.
C. Tao and L. Sun
Fig. 22.1 Layout of the robotic-assisted Trocar laparoscopic partial nephrectomy
22.5 Surgical Steps
After the ports were established, the lens was
entered and the apparatus was installed. Identify
intraperitoneal anatomical markers and release
intraperitoneal adhesions within the visual eld;
open the lateral peritoneum outside the paracolonic sulcus; release the intestinal tube, so that
the intestinal tube turns inward and downward
and pay attention to protect the reproductive vessels when dissociating. Gerota’s fascia was
opened in front of the middle level of the kidney
(Fig. 22.2a), fully dissociating the upper and dorsal sides of the duplicated kidney, and the proximal Gerota’s fascia could be pulled through the
abdominal wall to increase the exposure space
(Fig. 22.2b). The patient on the right side could
increase the exposure space by raising the liver
by increasing the traction needle distance.
To better expose the blood vessels of the duplicated kidney, 3-0 round needles were used to pull
the upper kidney of the duplicated kidney through
the abdominal wall (Fig. 22.2c). Some children
have ectopic vessels in the superior kidney, which
can be clipped by hemo-Lok. The renal hilum of
the duplicated kidney was dissociated, the renal
pedicle vessels and branch vessels were exposed,
and the renal pedicle veins and arteries were
clipped and ligated with high selectivity (Fig.
22.2d). The supplying vessels of the lower kidney
should not be damaged. Generally, the dilated
renal pelvis of the duplicated kidney can be
exposed after vascular disconnection, and the
ab
cd
ef
22 Robotic-Assisted Partial Nephrectomy for Duplicated System
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151
renal pelvis and the afliated ureter can be dissociated. The ureter of the duplicated kidney can be
dissociated by 3-5cm and then dissociated (Fig.
22.2e). The proximal ureter can be dissociated to
the renal sinus, and some missing branch vessels
should be closed at the same time (Fig. 22.2f).
Fig. 22.2 (a) Open Gerota’s fascia; (b) Gerota’s fascia was
pulled by traction; (c) Duplicated kidney was pulled by traction; (d) Renal pedicle veins and arteries were clipped and
ligated with high selectivity, respectively; (e) Transection of
duplicated ureter; (f) Ligation of some missing branch ves-
sels; (g) Expose the dividing line between the upper and
lower kidneys (white line); (h) Vutting and coagulation of
the upilicated kidney y electric scissors or ultrasonic knife;
(i) Dissociation of duplicated ureter; (j) Ligation of the
duplicated ureter; (k) Close the posterior peritoneum
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LMN
C. Tao and L. Sun
Fig. 22.2 (continued)
After complete disconnection of blood vessels in
the duplicated kidney, the dividing line between
the upper and lower kidneys of the duplicated kidney can be judged according to the color difference line of ischemia in the duplicated kidney and
surrounding brous tissue (Fig. 22.2g). In some
patients with unclear dividing lines, the renal pelvis of the duplicated kidney can be opened to
judge the dividing line between the upper and
lower kidneys of the duplicated kidney. The renal
parenchyma can be completely cut by cutting and
coagulation along the boundary between the
upper and lower kidneys using electric scissors or
an ultrasonic knife (Fig. 22.2h). If the wound was
bleeding, it could be stopped by an ultrasonic
knife or 4-0 barbed wire suture of the kidney from
the section.
After the peritoneum is dissected anteriorly in
the lower kidney, a dilated duplicated ureter is
found (Fig. 22.2i), usually with the ureter of the
lower kidney. The repeated ureter was dissociated
to the proximal end, and the broken end was
retracted to the distal end. Attention was given to
protecting the blood supply of the lower ureter.
The double ureters were co-sheathing below the
level of the iliac vessels. At this level, the ureter
could be ligated (Fig. 22.2j). If allowed, the ureter
could be dissociated to the entrance of the bladder
to avoid stump syndrome. For children with difculty in common sheath dissociation, the advantages of robotic surgery can be used to disconnect
the duplicated ureter to the ureterovesical junction, split the repeated ureter, and retain the common sheath part of the repeated ureter. After
disconnection, the distal ureter wound can be
sutured and closed.
The wound was thoroughly rinsed with warm
saline to check whether there was any bleeding.
After complete hemostasis, the peritoneal laceration on the side was closed with a 4-0 barbed
wire and the colon was anatomically reset.
Specimens were removed from the umbilical
incision and sent for pathological examination.
Pelvic drainage tubes were placed from the
umbilical incision and the incisions were closed
(Fig. 22.2k).
22 Robotic-Assisted Partial Nephrectomy for Duplicated System
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153
Antibiotics are routinely used to prevent infection. Keep the drainage tube open. Eat after defecation and get out of bed as soon as possible.
Abdominal drainage for 2-3 days or 24 hours
with less than 10 ml of drainage uid. If there
were no special symptoms, the patient could be
discharged 5 days after the operation.
22.6 Technical Points andSkills
The placement of the trocar is not xed and can
be adjusted according to the age of the child to
provide more space for manipulation. At the
same time, the auxiliary arm can conveniently
operate and ligate blood vessels. To mobilize the
ureter to the lowest position, the position of the
mechanical arm in the lower abdomen should be
closer to the midline or even to the healthy side.
Proper traction improves the efciency of
exposure and dissection. In particular, traction of
the upper pole of the duplicated kidney can more
clearly expose the blood vessels and renal
pelvis.
The treatment of blood vessels is the key and
should not be omitted; otherwise, bleeding of the
wound may affect the eld of vision or even
transfer to open surgery. The dividing line
between the upper and lower kidneys was judged,
and the duplicated ureter was resected completely. If the vascular management is good, the
boundary between the upper kidney and the
lower pole kidney can be easily shown, facilitating complete nephrectomy of the duplicate
kidney.
The repeated ureter should be cut as low as
possible, close to the bladder entrance. If difcult, the ureter may be dissected, and the end
sutured. To reduce the incidence of stump
syndrome.
22.7 Postoperative Complications
1. Hemorrhage is mainly caused by missing
branch vessels or inaccurate ligation of ves-
sels. Intraoperative bleeding can be caused by
barbed wire suture on the wound surface or
gelatin sponge packing and perrenal fascia
suture for compression hemostasis. If bleeding was heavy, open hemostasis was performed if necessary.
2. Lower pole kidney injury mainly damages the
supply vessels of the lower pole kidney. If the
main blood vessels are damaged, there is a
risk of lower pole kidney atrophy.
3. Urethral extravasation resection of the kidney is
caused by incomplete nephrectomy, residual
partial collection system, or ureteral anastomosis clockwise distance is too wide, and water
sealing is not enough. In general, the drainage is
unobstructed, conservative treatment can generally be cured, and surgical repair is needed if
necessary.
4. Ureteral stump infection. Residual ureter dilation or excessive, easy ureteral stump infection, children with recurrent urinary tract
infection, or perineal secretions. Antiinfection effective, recurrent attacks need surgical removal of the stump.
5. Intestinal complications. The intestinal canal
was damaged by careless operation or the
mesentery was not closed to form an internal
hernia. During the operation, careful operation was required to avoid clamping the intestinal canal and close the mesentery hiatus.
22.8 Comparisons with
conventional laparoscopic
surgery
The key point of repeated hemirenectomy is full
exposure of the renal pedicle vessels. Due to the
anatomic variation of repeated renal vessels, the
hilum requires a clear eld of vision and careful
identication of branching vessels. The mechanical arm can pull the kidney upward to fully
expose the hilum vessels, which is conducive to
the dissection and dissociation of blood vessels
and can more accurately ligate repeated renal
vessels [10, 11]. Special robotic surgical instruments have multiple degrees of motion, which
can perform more precise dissociation and suture
operations for parts that are difcult to handle by
conventional laparoscopic instruments, and the
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C. Tao and L. Sun
probability of renal vascular injury in the lower
position is signicantly reduced. If the lower
renal collecting system is damaged, the wound
surface is continuously sutured with barbed wire,
and the robot-assisted laparoscopic suture is
clearer and more convenient than the conventional laparoscopic suture [12]. In addition,
robotic laparoscopic surgery has a clearer eld of
vision, exible and accurate mechanical wrist
and is more thorough in ligation or suturing of
the ureter end than conventional laparoscopic
surgery [13].
References
1. Avlan D, Gundogdu G, Delibas A, et al.
Pyelpureterostomy in the management of the lower
pole pelvi-ureteric junction obstruction in incomplete
duplicated systems. Urology. 2010;76:1468–71.
2. Doery AJ, Ang E, Ditcheld MR. Duplex kidney: not
just a drooping lily. J Med Imaging Radiat Oncol.
2015;59:149–53.
3. Jain S, Chen F. Developmentalpathologyof congenitalkidneyand urinary tract anomalies. Clin Kidney J.
2018,12:382–99.
4. Biles MJ, Finkelstein JB, Silva MV, et al. Innovation
in robotics and pediatric urology:robotic ureteroureterostomy for duplex systems with ureteral ectopia. J
Endourol. 2016;30:1041–8.
5. Wei C, He DW, Liu X, et al. Laparoscopic reconstructive surgery for hydronephrosis with incomplete
duplex kidney. Chin J Uro. 2017;38:281–5.
6. Michaud JE, Akhavan A. Upper pole heminephrectomy versus lower pole ureteroureterostomy for ectopic upper pole ureters. Curr Urol Rep. 2017;18:21.
7. Didier RA, Chow JS, Kwatra NS, et al. The duplicated collecting system of the urinary tract: embryology, imaging appearances and clinical considerations.
Pediatr Radiol. 2017;47:1526–38.
8. Zhou XG, Ma LF, Tao T, et al. Clinical research
of robot-assisted laparoscopic hemictomy for
children’s complete duplex kidney. Chin J Urol.
2020;41:531–5.
9. Zhao D, Chen G, Tao C. Robot-assisted ureteral reconstruction for ureteral triplication with
large ureteral cyst treatment. Asian J Surg. 2023;
21:S1015-9584(23)00205-1.
10. Herz D, Smith J, McLeod D, et al. Robot-assisted
laparoscopic management of duplex renal anomaly: comparison of surgical outcomes to traditional
pure laparoscopic and open surgery. J Pediatr Urol.
2016;12:44.e1–7.
11. Ballouhey Q, Binet A, Clermidi P, et al. Partial
nephrectomy for small children: robot-assisted versus
open surgery. Int J Urol. 2017;24:855–60.
12. Grimsby GM, Merchant Z, Jacobs MA, Gargollo
PC. Laparoscopic-assisted ureteroureterostomy
for duplication anomalies in children. J Endourol.
2014;28:1173–7.
13. Agarwal D, Kandpal DK, Chowdhary SK.
Laparoscopic ipsilateral ureteroureterostomy for the
management of children with duplication anomalies.
J Indian Assoc Pediatr Surg. 2016;21:92–3.
Robotic-Assisted Nephrectomy
https://t.me/medicina_free
for Dysplasia Kidney
ChangTao andLongSun
23
23.1 Introduction
In 1991, Clayman etal. reported the rst laparoscopic nephrectomy, which represents entering
the era of minimally invasive surgery [1]. In 1992,
Gagner and others successfully separated the retroperitoneum by using a balloon dilator, making
the retroperitoneal pathway possible [2]. In the
same year, Gaur and others took the lead in performing nephrectomy through the retroperitoneal
route [3]. Additionally in the same year, Kavoussi
and Koyle rst applied laparoscopic technology
to nephrectomy in children [4]. In 2001,
Guilonneau et al. performed nephrectomy with
Da Vinci robot-assisted laparoscopy for the rst
time [5]. Gettman etal. rst reported the performance of pyeloplasty in children using Da Vinci
robotic technology in 2002 [6]. Since then, robotic
surgery has been increasingly applied to renal surgery in children, including nephrectomy.
Minimally invasive surgery is the develop-
ment trend of surgery. However, higher technical
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_23.
C. Tao (*) · L. Sun
Department of Pediatric Urology, Children’s
Hospital, Zhejiang University School of Medicine,
Hangzhou, China
e-mail: dr.taoc777@zju.edu.cn;
sunlong2018@zju.edu.cn
requirements for the operator are needed in laparoscopic surgery due to the long learning curve
and difculty in suturing and knot, especially in
infants and children with limited abdominal
space. With the continuous upgrading of the
robotic surgical system, the advantages of 3D
vision and ergonomics, coupled with the stability of the manipulator and its great advantages in
ne operation, robotic-assisted nephrectomy has
gradually become a new choice, which has been
recognized by doctors at home and abroad [7].
At present, robotic surgery for children in China
is still in the initial stage. Personalized surgical
plans need to be selected for different conditions. Robotic- assisted technology is not only an
extension of laparoscopic surgery but also the
development direction of laparoscopy in the
future [8]. It will become a routine surgical
choice. This chapter will provide an overview of
robotic-assisted laparoscopic nephrectomy in
children.
23.2 Indications
andContraindications
With the continuous improvement of minimally
invasive technology and the application of
advanced equipment and instruments, the indications of traditional open nephrectomy or laparoscopic surgery can basically be applied to robotic
surgery. The key point of the operation is the ne
anatomical operation to avoid or reduce conver-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_23
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