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J. Wang and J. Cai
28.3 Preoperative Preparation
The preoperative preparation for da Vinciassisted adrenal tumor resection includes imaging assessment, blood pressure control, bowel
preparation, psychological preparation, and
blood preparation. Imaging evaluation includes
CT scan, MR scan, and ultrasound. The main
purpose of imaging assessment is to accurately
evaluate the location and size of the tumor and
the presence of IDRF such as vascular encapsulation. 3D digital reconstruction or 3D printing
technology can be used to assist the evaluation
when necessary. Some adrenal tumors, especially pheochromocytomas, may have severe
hypertension, and some patients may also have
hypertensive heart disease. For these patients,
preoperative blood pressure control is very
important, and it is generally required that the
blood pressure be stable in the target range for
more than two weeks before surgery. Bowel
preparation includes eating easily digestible
food, cleansing the enema 24hours before surgery, fasting for 8 hours, and being water- free
for 2hours before surgery. On the day of surgery,
based on the situation of defecation and abdominal distension, glycerin enema can be given to
make intraoperative intestinal conditions suitable for surgery as much as possible.
Psychological preparation includes preoperative
doctor patient communication and nursing education, so that the guardians do understand the
procedure of the surgery, possible complications, and precautions during the perioperative
period, so as to alleviate the anxiety of the family
and children. Regarding blood preparation, preoperative preparation of red blood cells and
plasma is routinely required before huge adrenal
tumor resection.
28.4 Position andDocking
Surgical position should be determined according to the location of the tumor.
(a) Right side adrenal tumor:
Body position: The patient takes the left
side lying position, the right side is padded
50–70°, the abdominal wall is close to the
edge of the bed, upper limbs are abducted
and supported by hand support plate. The left
lower limb is extended downward, and the
right lower limb of the affected side is exed
slightly backward and downward. All
stressed parts are padded with sponge pads
and xed with adhesive tape.
Hole position: (1) Make a midline incision (8mm) at the umbilical area (point c) to
establish a pneumoperitoneum, insert da
Vinci trocar into the abdomen. (2) Make
another dermatoglyphic incision on the
medial side of the anterior superior iliac
spine (point 1). (3) Make a dermatoglyphic
incision (8mm) slightly above the midpoint
of the line between the xiphoid process and
umbilicus (point 2). (4) A 5 mm auxiliary
operating hole is disposed under the xiphoid
process (point a).
Docking: (1) Establish the pneumoperitoneum via the umbilical da Vinci trocar. (2)
Set the host "renal" mode, leave the “arm 4”
empty, connect the “arm 3” to the umbilical
trocar (point c), use the main camera to
determine the surgical eld, press and hold
the "targeting" button to adjust the other
robotic arms. (3) “Arm 1” and “arm 3” are
connected to the other two da Vinci trocars at
point 1 and point 2, respectively. (4) The
operating instruments are installed guided by
the main camera.
(b) Left side adrenal tumor:
The surgical position of the left side adrenal tumor is the mirror inversion of the rightside tumor position. But there are some
differences in the location of the holes: Point
c is still in umbilical area, point 1 is in the
mirror site of right-side tumor, Point 2 is
placed under the xiphoid process, the auxiliary holes are arranged 3–5 cm behind the
midpoint of the connection between point C
and point 2. “Arm 1” is left empty during
docking.
28.5 Surgical Steps
(a) Right side adrenal tumor
• Step 1. Position and docking (see position
and docking section for details).
ab
cd
ef
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Fig. 28.1
of the liver was exposed and released. (b) Opening the
posterior peritoneum; (c, d) The adhesion between the
tumor and the abdominal wall was progressively separated; (e) Normal adrenal tissue near the inferior vena
Surgical steps. (a) The right deltoid ligament
• Step 2. Auxiliary instruments are used to
hold the liver, expose the right deltoid
ligament of liver, gradually release it to
increase the freedom of the right liver, and
cava and there is a clear boundary between the adrenal
tissue and the tumor; (f) The adrenal tissue was incised
with a linear cutting stapler; (g) Central adrenal vein of
right adrenal gland; (h) Placing the specimen into a
retrieval bag
help expose the right adrenal gland area
(Fig.28.1a).
• Step 3. The posterior peritoneum is
opened between the tumor and the upper
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Fig. 28.1 (continued)
J. Wang and J. Cai
pole of the kidney, gradually releasing the
tissue between the kidney and the tumor.
Attention should be paid to the protection
of renal arteries, especially the upper pole
accessory renal arteries that may exist in
some patients (Fig.28.1b).
• Step 4. Continue to release the adhesions
between the tumor and the lateral abdominal Wall. There are no large vessels in this
area and separation is relatively safe
(Fig.28.1c).
• Step 5. After the tumor has a certain
degree of freedom, push the tumor to the
lateral side, increase the space between
the tumor and the inferior vena cava, and
gradually separate the adhesion between
the tumor and the inferior vena cava
(Fig.28.1d).
• Step 6 If there is normal adrenal tissue
near the inferior vena cava and there is a
clear boundary between the adrenal tissue
and the tumor, part of the adrenal tissue
might be preserved (Fig. 28.1e).
Disconnection of the adrenal gland with a
linear cutting stapler is recommended
after sufcient dissociation (Fig.28.1f). If
no normal adrenal tissue could be preserved, the central adrenal vein must be
found, clipped with Hemolock and cut
with scissors (Fig.28.1g).
• Step 7 Specimen should be placed in a
retrieval bag and then removed
(Fig.28.1h).
(b) Left side adrenal tumor
The operation principle of the left adrenal
tumor resection is the same as that of the
right, but the following points need to be
noted. First, the splenophrenic ligament
needs to be released to increase the freedom
of the spleen in order to achieve a better
exposure of the left adrenal area. Second, the
left central adrenal vein ows back into the
left renal vein instead of the inferior vena
cava, so the order of tumor separation is
slightly different.
28.6 Technical Points andSkills
1. Body position: Patients should take the
healthy side lying position, the tumor side is
padded 50–70°, and the abdominal wall is
close to the edge of the bed. The body should
tilt enough to allow the bowel to move and
accumulate on the healthy side, which greatly
helps to expose the surgical area. However,
when the body is tilted, it interferes with the
working angle of the robot arm, so the abdominal wall must be placed close to the side of
the bed, so that the robot arm can have enough
range of motion.
2. Touch the tumor gently: The adrenal tumor
resection procedure must strictly adhere to the
principles of oncology and avoid rupture of
the tumor as much as possible to reduce the
chance of implantation metastasis. Although
28 Robotic-Assisted Adrenal Tumor Resection
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surgical robots have many advantages, they
are known to lack force feedback. Therefore,
during the operation, attention must be paid to
avoid violent operation leading to tumor rupture, and the operation of clamping the tumor
should be avoided. In addition, excessive
compression of adrenal tumors, especially
pheochromocytomas, can cause a transient
release of adrenaline and lead to severe hypertension, which is very dangerous.
3. Try to fully expose the surgical area: Release
of the deltoid ligament increases liver freedom, and release of the splenophrenic ligament liberates the spleen sufciently, which
are essential for adrenal tumor resection.
Minimally invasive surgery often fails because
the surgical area is poorly exposed.
4. Precise bleeding control: The hemostatic
effect of bipolar coagulation is excellent. In
this area, as long as there is no injury to the
inferior vena cava and central adrenal vein, it
can easily be addressed. The key point is to
accurately locate the bleeding point, keep the
operative eld clear, and avoid injury to large
vessels.
28.7 Postoperative Complications
1. Postoperative bleeding: The da Vinci robot’s
three-dimensional magnication imaging system allows us to obtain a highly clear operative eld, bipolar electrocoagulation can
achieve efcient hemostasis, and severe massive bleeding after surgery is very rare.
2. Abdominal pain: Most of the reasons are
due to the abdominal wall tension or inappropriate trocar insertion depth during the
docking process. Performing the docking
process step by step, fully releasing abdominal wall tension, can avoid the occurrence
of such complications.
3. Adrenocortical insufciency: Adrenal insufciency may occur after resection of one
adrenal gland, especially after the resection
of an adrenocortical tumor. Adrenocortical
tumors secrete large amounts of adrenocorticosteroids, which may result in the suppres-
sion of contralateral adrenal function, and
adrenocortical insufciency is more likely to
occur after tumor resection [2, 11].
Appropriate postoperative glucocorticoid
supplementation according to the situation is
sometimes necessary.
4. Tumor implantation and recurrence: Tumor
rupture during surgery may lead to tumor
implantation and recurrence [10, 11].
Especially in malignant tumors such as adrenocortical carcinoma, tumor rupture can have
serious consequences. Adrenocortical carcinoma is not sensitive to chemoradiotherapy.
There is no effective treatment for adrenocortical carcinoma once it is implanted and
relapses.
28.8 Comparisons
withConventional
Laparoscopic Surgery
Comparing with conventional laparoscopic surgery, the da Vinci robot surgical system has a
three- dimensional magnication imaging system, jitter-ltering function, and multidegree-offreedom rotatable manipulator and makes adrenal
tumor resection safer and easier. The main advantages are as follows:
1. The manipulator arm of the da Vinci robot
surgical system is more exible and manipulative, allowing the surgeon to isolate the
tumor from more angles and challenge tumors
with larger diameters.
2. The manipulator arm is more stable, more
accurate, can achieve more ne separation,
and can more easily complete the ne anatomy of the adrenal gland and partial resection
of the adrenal gland and other operations.
3. The 3D high-denition visual eld, threedimensional sense, accurate, and efcient
hemostasis by bipolar electrocoagulation,
reduce intraoperative injury and postoperative
complications.
4. The control table operation can protect the
health of doctors and signicantly reduce
labor intensity and harm to the body.
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J. Wang and J. Cai
References
1. Mihai R. Rare adrenal tumors in children. Semin
Pediatr Surg. 2014;23:71–5.
2. Lopes RI, Suartz CV, Neto RP, et al.Management of
functioning pediatric adrenal tumors. J Pediatr Surg.
2021;56:768–71.
3. Oesterreich R, Varela MF, Moldes J, et al.
Laparoscopic approach of pediatric adrenal tumors.
Pediatr Surg Int. 2022;38:1435–44.
4. Lopes RI, Dénes FT, Bissoli J, et al.Laparoscopic
adrenalectomy in children. J Pediatr Urol.
2012;8:379–85.
5. Sturgeon C, Kebebew E.Laparoscopic adrenalectomy
for malignancy. Surg Clin North Am. 2004;84:755–74.
6. Cobb WS, Kercher KW, Sing RF, et al.Laparoscopic
adrenalectomy for malignancy. Am J Surg.
2005;189:405–11.
7. Monclair T, Brodeur GM, Ambros PF, et al. The
International Neuroblastoma Risk Group (INRG)
staging system: an INRG Task Force report. J Clin
Oncol. 2009;27:298–303.
8. Nomine-Criqui C, Germain A, Ayav A, et al.Robotassisted adrenalectomy: indications and drawbacks.
Updates Surg. 2017;69:127–33.
9. Lowrey T, Cochran D, Frimberger D, Sundaram BM,
Mercer S, Rensing A.Pediatric robotic adrenalectomy
for virilizing adrenal tumor in a 4-year-old female.
Urology. 2021;156:260–2.
10. Raman SR, Shakov E, Carnevale N, et al. Robotic
adrenalectomy by an open surgeon: are outcomes different? J Robot Surg. 2012;6:207–12.
11. Parikh PP, Rubio GA, Farra JC, et al. Nationwide
analysis of adrenocortical carcinoma reveals higher
perioperative morbidity in functional tumors. Am J
Surg. 2018;216:293–8.
Robotic-Assisted Ovarian Tumor
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Resection
JinhuWang andJiabingCai
29
29.1 Introduction
Ovarian tumors refer to a variety of lesions in the
ovary, which can be roughly divided into physiologic and pathological categories. Physiologic
lesions refer to follicular cysts and luteal cysts,
and pathological lesions include a variety of
benign and malignant tumors such as teratomas,
endodermal sinus tumors [1–3]. Ovarian tumors
are the most common children’s reproductive system tumors. However, the incidence is signicantly lower than that of adult women, and mainly
benign tumors or borderline tumors. Statistics
show that malignant tumors account for about
2–10%. This chapter discusses ovary- sparing
tumor resection for benign ovarian tumors.
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_29.
J. Wang (*) · J. Cai
Department of Oncology Surgery, Children’s
Hospital, Zhejiang University School of Medicine,
Hangzhou, China
e-mail: wjh@zju.edu.cn
29.2 Indications
andContraindications
29.2.1 Indications
The da Vinci technique can be applied to all
benign ovarian tumors. However, attention must
be paid to the following points: First, simple
ovarian cysts usually undergo clinical observation rst. Only cysts with progressive enlargement and over 4cm in diameter during observation
require surgical treatment. Second, no evidence
of malignancy is revealed in the preoperative
assessment [4, 5].
As a contraindication, malignancy is not a
candidate for ovarium-sparing surgery.
29.3 Preoperative Preparation
The preoperative preparation for da Vinciassisted ovary-sparing tumor resection includes
imaging assessment, laboratory tests, bowel
preparation, and psychological preparation.
Imaging evaluation includes ultrasound and MR
scans. The main purpose of imaging assessment
is to assess the location of the tumor and whether
the tumor boundary is clear. In laboratory tests,
the level of tumor markers is a key indicator to
exclude malignancy. Bowel preparation includes
eating easily digestible food, cleansing the enema
24hours before surgery, fasting for 8hours, and
being water-free for 2hours before surgery. On
© 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_29
191
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J. Wang and J. Cai
the day of surgery, based on the situation of defecation and abdominal distension, glycerine
enema can be given to make intraoperative intestinal conditions suitable for surgery as much as
possible. Psychological preparation includes preoperative doctor-patient communication and
nursing education, so that the guardians understand the surgical procedure, possible complications, and precautions during the perioperative
period, to alleviate the anxiety of the family and
children.
29.4 Position andDocking
Body position: The patient is in the supine position with head low and feet high (10–20°).
Hole position: (1) Make a midline incision
(8mm) at the umbilicus (point c) to establish a
pneumoperitoneum, and insert da Vinci trocar
into the abdomen. (2) Make another two dermatoglyphic incisions on the left and right sides of
the umbilicus (point 1 and point 2, respectively).
Usually, three points are on a straight line, and
the distance between each point is at least 6cm.
In older children, lower point 1 and 2 to the
medial side of the bilateral anterior superior iliac
spine were lower for better cosmetic results.
Auxiliary port is not needed.
Docking: (1) Establish the pneumoperitoneum via the umbilical da Vinci trocar; (2) Set
the host “pelvic” mode, leave the “arm 4” empty,
connect the “arm 3” to the umbilical trocar (point
c), use the main camera to determine the surgical
eld, and press and hold the “targeting” button to
adjust the other robotic arms; (3) “Arm 1” and
“arm 3” are connected to the other two da Vinci
trocars at point 1 and point 2, respectively, and
(4) The operating instruments are installed guided
by the main camera.
29.5 Surgical Steps
Step 1: Position and docking (see Position and
Docking section for details).
Step 2: Bilateral ovarian inspection. The
appearance, size, and morphology of bilateral
ovaries were observed (Figs.29.1a & b).
Step 3: On the opposite side of the infundibular part of the ovary, a preincision line was
made by using the electrocoagulation hook
(Fig.29.1c).
Step 4: The ovarian parenchyma is opened
along the preincision line with forceps and a
needle holder. Note that even if there is some
bleeding during separation, electrocoagulation
should not be used (Fig.29.1d).
Step 5: Find the tumor and isolate it gradually.
Blunt separation is used (Fig.29.1e).
Step 6: Suture and reconstruct the ovary
(Figs.29.1f & g).
ab
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193
c
d
ef g
Fig. 29.1 Surgical steps. (a & b) Bilateral ovarian inspection; (c) A precision line was made; (d) The parenchyma of
the ovarian was opened with forceps and a needle holder; (e) The tumor (terotoma) was located and progressively separated; (f & g) Suturing and reconstructing the ovary
194
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J. Wang and J. Cai
29.6 Technical Points andSkills
1. Body position: The position of the head low
and feet high is very important. This position
helps the bowel to move upward and ensures
a better operating vision of the pelvic
cavity.
2. Auxiliary port: Auxiliary ports are usually not
needed.
3. Electrocoagulation: Do not use electrocoagulation during open surgery even if there
is some bleeding during separation.
However, when the bleeding spot is clearly
visible, precise bipolar coagulation can be
used.
4. Try to keep the tumor intact.
29.7 Postoperative Complications
1. Postoperative bleeding: Ovarian suturing and
reconstruction can effectively avoid postoperative bleeding. Severe massive bleeding
after surgery is very rare [4, 5].
2. Abdominal pain: Most of the reasons are due to
abdominal wall tension or inappropriate trocar
insertion depth during the docking process.
Performing the docking process step-by-step,
and fully releasing abdominal wall tension; the
occurrence of such complications can be
avoided.
3. Tumor recurrence: The rate of recurrence is
about 1–2%.
29.8 Comparisons with
Conventional Laparoscopic
Surgery
Compared with conventional laparoscopic surgery:
1. The manipulator arm of the da Vinci robot sur-
gical system is more exible and manipulative,
allowing the surgeon to isolate the tumor from
more angles and protect the ovary.
2. Bipolar electrocoagulation provides a more
precise means of hemostasis.
3. The control table operation can protect the
health of doctors and signicantly reduce
labor intensity and harm to the body.
References
1. Banlı-Cesur I, Tanrıdan-Okcu N, Özçelik Z. Ovarian
masses in children and adolescents: analysis on 146
patients. J Gynecol Obstet Hum Reprod. 2021;50:101901.
2. Takayasu H, Masumoto K, Tanaka N, Aiyoshi T,
Sasaki T, Ono K, et al. A clinical review of ovarian
tumors in children and adolescents. Pediatr Surg Int.
2020;36:701–9.
3. Shaikh F, Murray MJ, Amatruda JF, Coleman N,
Nicholson JC, Hale JP, Pashankar F, Stoneham SJ,
Poynter JN, Olson TA, Billmire DF, Stark D, RodriguezGalindo C, Frazier AL.Paediatric extracranial germcell tumours. Lancet Oncol. 2016;17:e149–62.
4. Oue T, Uehara S, Sasaki T, Nose S, Saka R,
Yamanaka H, et al.Treatment and ovarian preservation in children with ovarian tumors. J Pediatr Surg.
2015;50:2116–8.
5. Dural O, Yasa C, Bastu E, Ugurlucan FG, Yilmaz G,
Yuksel B, et al. Laparoscopic outcomes of adnexal
surgery in older children and adolescents. J Pediatr
Adolesc Gynecol. 2017;30:128–31.
Robotic-Assisted Resection for
https://t.me/medicina_free
Mediastinal Tumors
ZhengTan andJianZhang
30
30.1 Introduction
The mediastinum is an umbrella term for organs
between the two pleural cavities and is also the
most common site of occurrence of thoracic
tumors in children [1, 2]. To facilitate identication of the site where the mass of the mediastinum is located, the mediastinum is usually
divided into four segments, that is, superior, middle, anterior, and posterior. The superior mediastinum lies just above the plane between the fourth
thoracic vertebra and the lower border of the
manubrium sternum and is prone to thymoma,
lymphoma, and bronchial cysts, among others;
the anterior mediastinum is located in front of the
heart and lungs and is usually characterized by
lymphomas, thymomas, teratomas, and seminomas. The middle mediastinum is located between
the anterior border of the pericardium and the
thoracic spine, and common masses include
bronchial cysts, pericardial cysts, lymph node
tumors, and germ cell tumors. The posterior
mediastinum is located behind the heart and lung.
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_30.
Z. Tan (*) · J. Zhang
Department of Thoracic Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: tanzheng@zju.edu.cn; 6517018@zju.edu.cn
The most common tumors are neurogenic tumors,
followed by intestinal tumors such as esophageal
duplication. Neurogenic tumors, lymphomas,
primary cysts, and germ cell tumors are the most
common in children.
Mediastinal tumors in children are congenital
and neoplastic diseases with a variety of clinical
manifestations, ranging from being incidentally
detected on asymptomatic X-ray examination to
symptoms associated with invasion and compression, and some systemic symptoms, with chest
pain, cough, and fever as common manifestations. The diagnosis and treatment of mediastinal
benign and malignant diseases have always been
a challenge in thoracic surgery. A reasonable differential diagnosis can often be made on the basis
of clinical history, physical examination, and
radiologic workup. The age of the child at the
time of diagnosis is very important; the most
common mediastinal tumor in newborns and
children under twoyears of age is posterior mediastinal neuroblastoma. Various lymphomas are
the most common mediastinal tumors in children
over twoyears old [3]. The location and imaging
features of mediastinal tumor are also critical for
diagnosis. The most common anterior mediastinal mass is thymic hyperplasia, and anterior
mediastinal teratomas frequently contain calcication and cystic areas. However, the posterior
mediastinal tumor contains calcication, suggesting the presence of neuroblastoma, which is
the most common posterior mediastinum tumor.
Esophagography is of value in cases of suspected
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
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