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Da Vinci robot system is the most successful and widely used surgical system. To date, this da Vinci robot system has undergone four genera­tions. The rst generation (da Vinci Standard Surgical System) was commercialized in 1999, the second (da Vinci S Surgical System) and the third generations (da Vinci Si Surgical System) were commercialized in 2006 and 2009, respec­tively. The fourth generation is the da Vinci Xi Surgical System, which came into the market in

2014. Up to 2019, there are 5582 da Vinci surgi­cal system worldwide and 81 of those are in China. In terms of the number of da Vinci robotic surgeries, gynecological surgery ranks followed by urological surgery and general surgery. In China, urological surgery accounts for about 43% of the total number of da Vinci robotic sur­geries and general surgery accounts for about

tomy, ureteral reimplantation, and cystoplasty. Among them, robotic-assisted pyeloplasty is the most commonly. Its feasibility, safety and effec­tiveness have been demonstrated to be compa­rable to open or laparoscopic robotic surgery for children [4–6]. The number of robot-assisted ureteral reimplantation has been increased from less than 1% in 2000–2012 to 6% in 2016 [7]. In addition, the surgical success rate was increased and even reached 100% in hospitals in China. The robot-assisted nephroureterectomy, ranks third in urological surgery volume, although the operation time is increased signicantly due to the robotic installation time. However, with the assistance of the amplication of the da Vinci 3D surgical eld and exible robotic arms, it is still advantageous in reducing postoperative complications and increasing surgical success rate.

In pediatric general surgery, the application of robotic surgery is not popular yet when compared to pediatric urology. Among applications, robot­assisted fundoplication is the most common gen­eral surgery in children, especially for children with a history of gastrostomy, adhesions caused by previous abdominal surgery, initial fundopli­cation failure and combined neurological impair­ment [8]. Due to the high cost of robotic surgery, the rationality of its application in simple fundo­plication remains to be questioned. However, for choledochal cyst radical surgery, which requires ne anatomy and a large number of sutures in a narrow anatomical space, robotic surgery has its own advantages in cyst dissection and choledo­chojejunostomy. A large number of cases under robotic treatment of choledochal cysts have been reported, and the incidence of surgical complica­tions and postoperative recovery time are signi­cantly decreased compared to traditional laparoscopic surgery. In addition, robot-assisted treatment of Hirschsprung’s disease and anal atresia has also been carried out. Owe to robotic 3D surgical eld with exible robotic arms, sur­geon’s satisfaction has been signicantly improved. Nevertheless, the long-term follow-up study on intestinal function for patients with both megacolon and anal atresia is still lacking. Therefore, the effectiveness, safety, and repeat­ability of robotic-assisted surgery for compli-

more applications. However, the special patho­physiological status of children compared with adults also limits the extensive development of robotic surgery. First, the narrow lacunar operat­ing space of children is its greatest limitation. Robot surgical instruments are large, and the 8-mm-diameter trocar is too large for children’s intercostal space and thorax, especially for infants younger than 1year old. The size of the trocar, in turn, directly affects the size of the sur­gical instrument, resulting in a very limited choice of 5 mm instruments. In addition to dimensional differences, there are many differ­ences in design of 5mm and 8mm instruments. Devices in size of 5 mm are smaller with their joint motion mechanism different from that of 8mm devices; and a larger curve radius is needed to make a motion similar to that of an 8 mm instrument. In addition, the 5mm device options are limited and the mechanical motion is less precise. Second, the da Vinci robot instructions for two trocar distances are at least 5cm to avoid robotic arm collisions. But due to the small body surface area of the child, da Vinci surgery of tro­car location in children is more special. We should ensure that no collision occurs when the smaller thoracic or abdominal cavity simultane­ously accommodates the lens, robotic arms, and trocar. Meanwhile, the use of the fourth arm is limited. Third, infant airways are more vulnera­ble to pneumoperitoneum than adults, with reduced airway compliance and increased air­way pressure. Especially for infants weighing less than 10 kg, pressures exceeding 9 mmHg have signicant effects on respiratory mechanics and hemodynamics [12]. While insufcient clin­ical experience can signicantly prolong robotic surgery time, which further aggravates the nega­tive physiological effects of CO2. In addition, ination can increase vagal tone, leading to bra­dycardia and reducing ventricular preload, thus endangering infants whose cardiac system is not yet mature [13]. Fourth, children have limited abdominal ination and pressure, and children weighing 10kg have abdominal ination of less than 1 L, which reduces the operable space of robotic devices to some extent, and the propor-

and too relatively larg surgical instruments for children. Therefore, further developments in the robot surgical system are required, and indications for its use in pediatric surgery are still under investigation. Robotic-assisted sur­gery is undoubtedly a promising technology and will be used more widely in future.