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enterogenic and bronchogenic cysts. Congenital
malformations with cystic features include bronchial cysts, lymphangiomas, and esophageal
duplication. Bronchial cysts are usually located
in the carina but may occasionally be found elsewhere. Esophageal duplication may be found
along the esophagus, and patients may suffer
from dysphagia, sore pharynx, or reux. Alphafetoprotein (AFP) and β-human chorionic gonadotropin (β-HCG) levels are helpful for predicting
benign or malignant teratomas [4]. Meanwhile,
AFP and β-HCG are helpful to monitor for the
recurrence of malignant teratomas and may
increase in germ cell tumors, leading to an enormous size. However. Histological examination of
the tissue is necessary for a precise diagnosis in
the majority of cases.
Mediastinum has a narrow space, complex
structure, diverse tissue sources, and is adjacent
to major vessels, heart, and other important
organs. At present, the treatment principle for
mediastinum tumors is still surgery-based comprehensive treatment [5, 6]. Traditional open surgery may destroy the integrity of the sternum or
chest wall, resulting in large trauma, more bleeding, poor exposure, obvious postoperative pain,
and more perioperative complications [7–9].
With the development of video-assisted thoracoscope technology, it has been widely used in surgical operations [10]. Compared with traditional
thoracotomy surgery, it is a safe and effective
procedure for mediastinal tumors and has the
advantages of minimal trauma, clear vision, and a
low complication rate. However, the mediastinum space is narrow, and the thoracoscopic
instruments are long, which may cause hand
tremor, accessory injuries. Some areas cannot be
reached, making resection difcult [11]. In the
21st century, the introduction of robotic-assisted
thoracoscopy surgery (RATS) provided an additional tool for minimally invasive surgery. In
2001, Yoshino etal. [12] rst reported that RATS
was used for mediastinal tumor resection, which
can overcome the inherent defects of thoracoscopy, provide more accurate, stable and comfortable surgical operations, and be more minimally
invasive, safe and thorough. Mediastinal tumors
have been proposed as the ideal indication of
RALS, especially in narrow spaces [13]. In recent
years, it has been gradually promoted and applied
in clinical practice [14, 15].
30.2 Indications
andContraindications
30.2.1 Indications
The indications for robot-assisted mediastinal
tumor resection are similar to those of traditional
thoracoscopic surgery (TRS), mainly as follows
[16, 17]: (1) the diagnosis of a mediastinal tumor
is clear, and no invasion of great vessels, trachea,
esophagus, pericardium or lung tissue is found
(2) no pleural thickening and adhesion were
found in preoperative examination; (3) the patient
has no serious cardiopulmonary dysfunction or
coagulation dysfunction and can tolerate singlelung ventilation. Patients with thymoma complicated and myasthenia gravis need stable symptom
control after active medical treatmen; and (4) the
distance between the two adjacent trocars should
not be less than 3–5cm to avoid mutual “ghting” affecting the operation. There are certain
limitations for patients who are too young.
30.2.2 Contraindications
The child who undergoes RATS must be in physical condition to withstand the cardiorespiratory
changes associated with this procedure. The contraindications are as follows:
1. Severe congenital heart disease not surgically
treated
2. Acute and chronic bronchopulmonary
diseases
3. Severe pleural adhesion
4. Coagulopathy
5. The size of the tumor and pleural adhesions
are no longer absolute contraindications for
surgery
6. Infectious, anatomical or systemic problems
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30.3 Preoperative Preparation
The preoperative preparation for RATS includes
preoperative examination, blood preparation, preoperative fasting time, preoperative antibiotic
administration, anesthesia preparation and preparation of surgical instruments. Tumor marker
detection, enhanced CT and MR are essential preoperative examinations. Due to the risk of massive bleeding, routine preparation of red blood
cells and plasma is needed. The time of fasting
and water prohibition before the operation was
consistent with the TRS. Different anesthesia and
intubation methods were selected according to the
tumor size and its relationship with surrounding
structures, especially for patients with large
tumors who are more prone to respiratory damage
during anesthesia. Generally, general anesthesia +
single-lung endotracheal intubation + articial
pneumothorax is used. If necessary, an occlusion
device is added for single-lung ventilation to
facilitate visual eld exposure in the surgical area
and intraoperative lung protection and reduce the
incidence of perioperative complications. Large
masses can easily displace the mediastinal structures, compressing the tracheobronchial tree,
superior vena cava, or right ventricular outow
tract, and may also reduce cardiac output.
Decreased functional residual capacity, decreased
vital capacity and increased pulmonary contractility can affect anesthesia induction. These alterations are extenuated with the addition of paralysis.
Meanwhile, when the patient changes from spontaneous to positive-pressure ventilation, the trachea will become narrow. All of these factors may
lead to the critical condition in these patients,
which is associated with general anesthesia.
30.4 Position andDocking
The trocar holes of the robot-assisted mediastinal
tumor vary depending on the tumor location. For
anterior superior mediastinal tumors, the affected
side chest pad is 30° higher, and the arm is a exion pillow. For middle and posterior mediastinal
tumors, the lateral prone position is chosen, the
latter with the help of gravity to better expose the
tumor, avoid touching the lungs, and obtain clear
vision. For tumors at the top of the pleura, lateral
lying at 90° with head high and feet low is used to
fully expose the structure at the top of the pleura
and avoid damage to the peripheral blood vessels
and nerves.
The most important technical aspect of RATS
is the positions of the four ports, named three
manipulator arm ports and one auxiliary port.
However, some units do not need the auxiliary
port [11]. The basic principles of incision design
are as follows: fullly consider of convenience,
safety, minimally invasive and thoroughness of
lesion resection. Attention should be given to the
distance between the trocar ports, which should
be more than 3–5cm. All ports except the initial
camera port are positioned under direct vision,
operate to avoid collisions with robotic instruments and cameras. In addition to the specic
location of the tumor, the port location was also
inuenced by the surgeon’s experience and personal preference [18]. Here, we attempted to provide the reader with a basic port placement
strategy.
30.4.1 Trocar Position ofAnterior
Superior Mediastinal Tumor
For anterior mediastinal tumors, the observation hole is located on the midaxillary line, and
the operation holes are distributed between the
anterior axillary line and the midaxillary line
based on the location of the tumor. The auxiliary hole is located between the observation
hole and the operation hole, and it is best to stay
away from them as far as possible to avoid
interference caused by the mechanical arm
(Fig. 30.1a).
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Z. Tan and J. Zhang
a
b
Fig. 30.1 Da Vinci Robot surgical incision position of
the anterior mediastinal tumor (a), mediastinal tumor
(b), the middle and posterior superior mediastinum (c),
and posterior lower mediastinal tumors (except the
anterior mediastinal tumor) (d). O represents the observation hole (robot arm 3); 2 represent operating hole
(robot arm 2); 4 represent operating hole (robot arm 4).
A represents the auxiliary hole. (c) the affected chest
wall tilts forward. The observation hole and the auxiliary hole are located in the mid-axillary line, and the
two operating holes are located near the anterior axillary line and the subscapular line, respectively; (d) the
affected chest wall tilts forward. The observation hole
and the operation holes are located in the mid-axillary
line, and the auxiliary hole is located at the anterior
axillary line
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30.4.2 Trocar Location of Pleural
Apex Mediastinal, Middle
Mediastinal Tumors and
Posterior Superior
Mediastinal Tumors
In addition to the tumor location, the design of
the middle and posterior mediastinal tumor port
is more focused on the surgeon’s experience and
personal preference. For middle and posterior
mediastinal tumors, some surgeons have suggested that the port position are “3-4-6-9,” that is,
the sixth intercostal of the posterior-axillary line
is the observation port, the third and ninth intercostal of the anterior-axillary line is the operation
port, and auxiliary ports are set in the fourth
intercostal of the midaxillary line if necessary
[19]. Some surgeons used the “6-4-7” port position to remove the posterior superior mediastinal
tumor, that is, the sixth intercostal position of the
posterior-axillary line is the observation port, the
seventh intercostal position of the posterioraxillary line or scapular line, the fourth intercostal position of the anterior-axillary line or the
midclavicular line is the operation port, and the
fth or sixth intercostal position of the midaxillary line is the assistant port [20]. Some surgeons
also used the “5-3-8” port position to remove the
inferior mediastinal tumor, that is, the fth intercostal of the anterior-axillary line was the mirror
port, the third intercostal of the midaxillary line,
the eighth intercostal of the posterior-axillary
line or scapular line was the operation port, and
the sixth or seventh intercostal of the midaxillary
line was the assistant port when necessary [21].
Here, we suggest that three 8 mm incisions be
made in the eighth or ninth intercostal space at
the intercostal mid-axillary line, the seventh
intercostal space at the midclavicular line and the
eighth intercostal space at the subscapular line. A
5mm incision was made in the ninth intercostal
space at the posterior-axillary line as the auxiliary hole (Fig. 30.1b). In some tumors of the
middle and posterior superior mediastinum, the
hole positions are shown in Fig. 30.1c are also
feasible. The hole positions are shown in Fig.
30.1d are suitable for posterior lower mediastinal
tumors. For elderly children with pleural apex
mediastinal tumors, the incision position can be
appropriately upward.
30.4.3 Docking
The total anesthetic time can be shortened
through familiarity with hardware and arm movements and a well-rehearsed docking routine,
which is also helpful for iatrogenic injuries and
complications. Some studies have suggested that
the surgeon’s experience is the most important
factor in reducing docking time [22, 23].
The detailed steps are as follows: (1) set the
host “chest surgery” mode; (2) leave “arm 1”
empty, connect “arm 3” to the observation trocar,
and use the main view mirror to determine the
surgical eld. Press and hold the “targeting” button to adjust the other robotic arms; (3) “Arm 2”
and “Arm 4” are connected to the trocar at point
2 and point 3, respectively; (4) release the pressure of the trocars on the chest wall.
30.5 Surgical Steps
Robotic surgery is similar to thoracoscopic surgery. Here is an example of robot-assisted posterior mediastinal tumor resection.
Step 1. A reliable and intraoperative stability cen-
tral venous line is essential.
Step 2. Endotracheal intubation + one-lung venti-
lation, articial pneumothorax if necessary
(carbon dioxide pressure is generally 6–8
mmHg). The radial arterial and central venous
pressures are monitored to evaluate the intraoperative hemodynamics.
Step 3. The surgical area was routinely sterilized,
and the disinfection area was 15 cm away
from the incisions.
Step 4. An observation port is established, and
two operation ports are placed under direct
vision, as well as the assistant port (Fig.30.2a).
Step 5. Docking with the robot system. The depth
of the trocars is between the rst line and the
second line and does not exceed the second
line (Fig.30.2b).
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Fig. 30.2 Surgical procedures of robot-assisted posterior
mediastinal tumor resection. (a) put in the cadiere forceps
(left) and the Bipolar Maryland forceps (right); (b) trocar
position of the mediastinal tumor of the Da Vinci Robot.
The depth of the trocars is between the rst line and the
second line and does not exceed the second line. O
represents the observation hole (robot arm 3); 2 represent
represents the operating hole (robot arm 2); 4 represents
the operating hole (robot arm 4); (c, d) robot-assisted posterior mediastinum tumor resection; (e, f) damage to
blood vessels, nerves, and lungs was avoided during the
operation; (g, h) Bipolar Maryland forceps are used to
divide the nutrient vessels from the paraspinal intercostal
artery (g) and umbilical vein nutrient vessel (h)
JK
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Fig. 30.2 (continued)
201
Step 6. As in open surgery [24], correct vascular
display and vascular security are the keys to
the complete removal of tumors. Tumor dissection usually starts from disease-free tissue
surrounding the tumor (Fig. 30.2c, d). The
blood vessel supply of the tumor was determined by dissecting the surrounding tissues
layer by layer to avoid damage to blood vessels, nerves, trachea, lung, etc. Figure 30.2e,
f). Once the vascular supply to the mass has
been determined, bipolar Maryland forceps
are usually used to properly divide the mass.
(Fig. 30.2g, h). Attention should be given to
the nutrient vessels of the paraspinal intercostal artery to prevent the broken end from
retracting to the vertebral foramen for bleeding. Then, the mass is gently placed in a plastic endo-bag and consequently retrieved
through one of the ports.
Step 7. End of surgery: (1) removed the robotic
arm and observe the trocar incision for bleeding; (2) check for bleeding at the chest wall
incision; (3) thoracic drainage tube is placed
or not; (4) shutting off the thorax.
30.6 Technical Points andSkills
1. The trocar location is served for the convenience of operation. Based on adhering to the
principle of comprehensive coverage and non-
interference, the port location can be appropriately changed according to the tumor
location and size.
2. Relevant literature reports suggest that the
probability of one side phrenic nerve injury
during anterior mediastinal surgery is 7%
[25]. To reduce phrenic nerve injury, rst,
make full use of energy instruments, preferably cold knife, cold shear, or blunt separation.
If electrocoagulation or electrosection is used,
leave enough distance to prevent thermal
injury. In addition, the instruments cannot
directly touch the nerve immediately after
work to prevent residual heat injury. Phrenic
nerve is easily exposed along the junction of
left internal thoracic artery and subclavian
artery and can be distinguished downward.
3. If necessary, lesion should be assessed through
thoracic biopsy to determine the feasibility of
resection, which is particularly important with
thymomas.
4. Due to the narrow operation space of posterior
mediastinal neurogenic tumor, the operation
is difcult, especially when the tumor is large
and adhesion and separation with surrounding
tissues are difcult. Special attention should
be given to the management of blood vessels.
Blood vessels can be coagulated after double
ligation with titanium clip or ligation clip,
separated by an ultrasonic knife, or separated
after robot bipolar electrocoagulation. For
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thicker blood vessels, linear cutting stapler
can also be used to nail and disconnect [26].
Improper operation may cause the broken end
of blood vessels to retract into the spinal
canal, which needs to be converted to thoracotomy, or cause bleeding or spinal cord
injury. Tumors adjacent to important nerves or
with important nerve origin have a narrow
intervertebral foramen and are difcult to
operate, which easily causes nerve side injury.
5. During the operation, the endoscope is rst
placed for observation. If there is serious
dense adhesion, it can be separated passively
around the observation port, separated from
the narrow space around the trocars, and then
the adhesion can be released step by step.
6. Management of severe visceral bleeding
depends on the experience of the surgeon, the
bleeding site, the size of the patient, and
whether the patient is hemodynamically stable. When in doubt, the surgeon should
quickly switch to thoracotomy.
30.7 Postoperative Complications
The postoperative complications of robot- assisted
mediastinal tumor surgery are similar to those of
traditional thoracoscopic surgery, but the incidence of postoperative complications varies in
different centers due to differences in surgical
methods, approaches, and other factors. The common postoperative complications are as follows:
1. Common pulmonary complications after
mediastinal tumor surgery include pneumonia, atelectasis, pleural effusion, respiratory
insufciency and respiratory failure, requiring
re-endotracheal intubation, ventilator-assisted
ventilation, etc. After the operation of robotassisted mediastinal tumor, some thoracic
drainage tubes are not placed or the position
of drainage tubes is high, and a small pleural
effusion or liqueed fat can appear in bilateral
lower thorax. If they are not drained or
absorbed in time, local external pressure atelectasis and pneumonia easily occur and
should be treated early. At the same time, get
out of bed early, expectoration actively and
atomization inhalation after the operation are
helpful for prevent the occurrence of pneumonia. If pneumonia occurs, timely sputum culture should be performed, and antibiotics
should be reasonably and effectively used
according to the drug sensitivity test.
2. The compression of lung tissue by huge mediastinal tumors easily causes atelectasis, lung
collapse, pulmonary brosis, obstruction of
lymphatic reux, venous compression, etc.
Once the compression is relieved, the rapid
expansion of lung and the increase in return
blood volume can induce acute pulmonary
edema. Although relapsing pulmonary edema
is rare, it develops rapidly and has high mortality. Therefore, in clinical work, the treatment of
pulmonary edema focuses on prevention, early
detection, and timely diagnosis and treatment.
3. Other complications may occur after the operation of mediastinal tumor. Chylothorax,
esophageal stula, esophageal stenosis, and
vagus nerve injury may occur after surgery for
esophageal tumor. Sympathetic nerve injury
may occur after the operation of pleural apex
tumor. Myasthenia gravis easily appears after
a thymoma operation. Tracheogenic tumors
may cause air leakage and pneumothorax
after operation.
4. Delayed bleeding: Aeration pressure may
cause mild to moderate bleeding to be missed
during surgery. Therefore, at the end of surgery, examination of the operating eld at a
lower inatable pressure may prove benecial
and reliable. In addition to direct accidental
intraoperative trauma, subsequent complications may result from inadequate suturing or
clamping and from poor dissection or ischemia due to thermal injury.
30.8 Comparisons
withConventional
Thoracoscopic Surgery
The narrow space of mediastinum, twodimensional visual eld and insufcient
exibility of instruments make it easy for the
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occurrence of peripheral blood vessels, nerves
damage, and hand tremor to occur. Meanwhile,
some areas cannot be reached, and the technical
requirements for surgeons are high [11].
Robot surgery integrates the advantages of
traditional thoracotomy and thoracoscopic surgery, with the advantages of less trauma, clearer
vision, more exible and stable operation and
more complete tumor resection, leading minimally invasive thoracic surgery to a new level.
Meanwhile, robot-assisted surgery can provide
more accurate, stable and comfortable operation and help to improve the complete resection
rate of the huge tumor, the cleaning thoroughness of mediastinal fat before and reduce the
intraoperative complications, improve the postoperative efcacy of cancer and related
diseases.
However, studies [27, 28] have showed that
the duration of robot-assisted mediastinal tumor
resection is longer than that of thoracoscopic surgery, which might be related to the docking time
at the beginning of operation and the lack of a
smooth operation. However, at present, an
increasing number of domestic and foreign studies report that the duration of robot-assisted surgery is gradually shortening.
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Complications of Robotic-Assisted
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Surgery in Children
QiangShu andShuhaoZhang
31
Since 2000, a growing number of surgeons
reported the feasibility and success of using
robotic-assisted surgery in many pediatric surgical subspecialities [1–3]. This technique has been
gradually used for treating complex congenital
malformations in children, and has shown advantages in complex reconstructive surgeries such as
radical choledochal cyst surgery, ureteral reimplantation and radical megacolon surgery.
The advantages of robotic surgical system are
obvious in children’s narrow surgical operating
space and reconstructive surgery which requires
a large number of ne anatomical manipulation
and sutures; however, the occurrence of complications still cannot be avoided. Due to the special
pathophysiological status of children, robotic
surgical systems are more vigilant for the occurrence of complications in pediatric patients.
More than 50% of all laparoscopic injuries
happen at the rst step: insertion of the Veress
needle to establish a pneumoperitoneum, then
Q. Shu
Department of Cardiac and Thoracic Surgery,
Children’s Hospital of Zhejiang University School of
Medicine, Hangzhou, China
e-mail: shuqiang@zju.edu.cn
S. Zhang (*)
Department of General Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: 6519040@zju.edu.cn
the primary trocar is inserted. During the past 30
years, the incidence of injuries has been signicantly decreased. Among all laparoscopic procedures, intestinal injuries account for 0.04%, and
large-vessel injuries account for 0.02%–0.04%.
However, 30%–50% of intestinal injuries and
13%–50% of vascular injuries are not detected
immediately during surgery, leading to relatively
high morbidity and mortality. The main complications include laparoscopic orice-related
complications, CO2 pneumoperitoneum- related
complications, and self-defects of da Vinci
robotic surgical complication system although
complications of robotic-assisted surgery are
relatively low, with most complications occurring in the early surgical phase and being minor.
Most high-grade complications may present late
[3–5]. Herein, we aim to categorize the complications to further understand the clinical ties and
work out possible strategies for prevention.
31.1 Laparoscopic ChannelRelated Complications
Complications may occur throughout the process
of channel establishment and closure. Vascular
injury and abdominal organ injury are common
during the setting phase (veress needle puncture
and trocar insertion) [6]. These injuries account for
about 50% of complications in laparoscopic surgery [7]. Trocar site hernias, on the other hand, are
© 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_31
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