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206
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Q. Shu and S. Zhang
more common during the closure phase [6].
Patient’s factors like previous abdominal surgery
and obesity, as well as anatomical variations and
inadequate bowel preparation may increase the risk
of complications. Surgeon’s experience and poor
device maintenance are also important factors.
31.1.1 Vascular Injury
Vascular injury can occur in different sites and
lead to various consequences. Supercial lesions
may affect the epigastric vessels and abdominal
wall, while intra-abdominal injuries may involve
vessels in the mesentery, omentum, iliac, or even
the aorta/vena cava. The resulting complications
can range from parietal hematoma to intraabdominal hemorrhage.
The potential causes of trocar hole bleeding
during closure are diverse. First, the trocar
implantation process itself can injure the abdominal wall and trigger bleeding. Second, improper
placement of the trocar can damage the inferior
epigastric vessels. Third, non-standardized trocar
placement techniques, such as oblique entry, may
lead to an increased risk of bleeding from abdominal wall vascular or muscle injury. Fourth, inadequate suturing of the trocar hole, specically
failure to suture the muscle layer, is a common
cause of bleeding. Finally, patients may present
unique factors that increasing risk of bleeding,
including variations in the distribution of abdominal wall vasculature.
31.1.2 Abdominal Organ Injury
Patients who have undergone abdominal surgery,
such as caesarean, broid uterus, umbilical hernia or umbilical lesions, are at a high risk for
developing adhesions. These adhesions can
increase the risk of injury to abdominal organs
during laparoscopic surgery, and should always
be taken into consideration.
As previously reported, a signicant proportion of intestinal injuries may be undetected
during laparoscopic surgery, with estimated rate
ranging between 30% and 50%. This can result
in increased mortality and is considered the
third leading cause of death in laparoscopic procedures [7]. Injuries to solid organs, such as the
liver, spleen, and kidney, can lead to signicant
abdominal bleeding and may require a laparotomy for treatment. Visceral injuries can involve
various organs, including the omentum, stomach, intestines, liver, or spleen, depending on
the site of entry and the lling degree of the hollow organ. Therefore, it is recommended to
place a gastric tube before performing operations that involve Palmer’s point or the Leepoint Huang.
To ensure a safe procedure, the presence of
gas or malodorous liquids can indicate the penetration of the intestines, while the liver or spleen
damage may result in the aspiration of blood.
Treatment for visceral organ injuries may involve
either laparoscopy or laparotomy, depending on
the input of the interdisciplinary team [8].
When creating an intraperitoneal access and
pneumoperitoneum, there is a notable risk of
intestinal injury. The risk is higher in laparoscopic procedures than in laparotomy. Although
rare, intestinal injuries account for most laparoscopy-related fatalities and are a signicant cause
of morbidity in all laparoscopic surgeries.
Suturing is a common method for dealing with
intestinal injuries during surgery. However, it’s
important to note that not all intestinal injuries
can be immediately detected during the operation, unlike vessel injuries which can be observed
right away. Patients may develop peritonitis after
surgery, which can present as either specic or
unspecic symptoms. It’s important to keep an
eye out for persistent pyrexia, tachycardia, or
intestinal obstruction as these could be signs of
intestinal injury. Failure to diagnose this condition in a timely manner can lead to serious complications and even death. For less severe injuries,
tension-free, single-layer, interrupted sero-submucosal 3-0 Vicryl or 4-0 polydioxanone sutures
are recommended. More extensive injuries may
require excision and anastomosis.
31 Complications of Robotic-Assisted Surgery in Children
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31.1.3 Trocar-site Hernia
Laparoscopic surgery is associated with certain
complications, such as trocar-site hernia (TSH)
or port-site hernias (PSH). Previous studies
showed that the incidence of these types of hernias in laparoscopic surgeries ranged from 0% to
0.1%, particularly when non-bladed trocars are
used [9, 10].
Trocar site hernias (TSH) can cause serious
consequences, and no optimal prevention strategies have been produced yet. One approach to
reduce the risk of TSH is that surgeons can use
ports that are larger than 10mm in diameter. We
found that TSH is more common with trocars that
are positioned along the midline, as opposed to
off-midline positions. These ndings are consistent with those reported by Tonouchi et al. [11],
who proposed that TSH is linked to the anatomical and inherent weaknesses of the common
umbilical site, especially the paraumbilical region.
The trocar site should be closed following the
use of trocars that are 10mm or larger. In fact,
some surgeons suggested that the trocar site may
need to be closed regardless of the diameter of
the trocar, with closure recommended for children when the trocar diameter is larger than 5
mm, and for adults when the diameter is greater
than 7 mm. Additionally, the type of trocar used
can also impact the incidence of trocar site hernias (TSH), as non-bladed trocars that split tissue
instead of cutting it have been associated with a
lower occurrence of hernias and ileus, even in
cases where fascial closure was not performed.
31.2 CO2 Pneumoperitoneum
The use of CO2 to insufate the peritoneal cavity
during surgery can provide improved visualization of the anatomy and allow for minimally
invasive procedures via small incisions. However,
this can also increase intra-abdominal pressure
(IAP), which leads to various pathophysiologic
changes in adjacent organ systems.
Improper needle placement during initial CO2
insufation process may cause adverse outcomes.
In some cases, CO2 can be injected into
unintended spaces, such as the intravascular, subcutaneous, or preperitoneal space, and even into
the omentum, mesentery, abdominal and pelvic
organs, or retroperitoneum [12]. If the needle is
misplaced into a vessel, it can lead to a serious
and potentially fatal CO2 venous embolism.
However, it’s worth noting that CO2 is typically
better tolerated by the body than air embolism or
nitrous oxide embolism, since it’s more soluble
in blood. In other cases, CO2 insufation can
result in a pneumothorax, which can occur when
the gas enters the thoracic cavity through a tear in
the visceral peritoneum or as a result of a preexisting bulla rupturing.
When CO2 is forced into the mediastinum and
pericardium via the inferior vena cava, or when
CO2 passes through the defect in the membranous portion of the diaphragm, pneumopericardium may occur [13].
31.3 Robotic System-Related
Complications
Though developed for several generations, the
robot surgical system is still not optimistic and
may cause operative complications. One system
limitation is the absence of tactile feedback.
Surgeons cannot directly touch the surgical site,
hindering their ability to determine tissue properties and tension during suturing. Without this
feedback, suturing errors may occur, potentially
leading to tissue ischemia, anastomosis, or
uncertain hemostasis, which increases the risk of
postoperative complications. Additionally, given
the limited operating space within the human
body, collisions between robotic devices may
occur, particularly within pediatric patients
where the operating space is smaller. Preoperative
preparation is time-consuming and requires
anesthesia, which poses increased risks, especially for children with poor cardiopulmonary
function. Maintenance and purchase costs of the
equipment are also high. Furthermore, the technical complexity of robotic system increases the
probability of mechanical failure during use
when compared to general endoscopic surgery
systems.
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Q. Shu and S. Zhang
Intraoperative electrical burns are a frequent
injury of the digestive tract, with injuries commonly occuring in the rectal, colon, and duodenal
regions. Rectal injury can be addressed in a
timely fashion through direct suturing, colostomy, or other treatment methods based on injury
size and incision depth, and general surgeons
should be consulted as necessary. Postoperative
care should focus on active anti-infection, continuous gastrointestinal decompression , and parenteral nutrition based on individual patient
needs. Colon injuries also frequently occur and
can be treated with intraoperative direct suturing
for shallow injuries, while deep or extensive injuries may require additional treatment with assistance from a general surgeon. Duodenal injuries
most frequently occur with right renal cancer surgery or Wilms tumor in pediatric patients, which
require specialist care given to prevent the severity of the consequences. As such, detailed preoperative evaluations and considerate intraoperative
operations are crucial to minimizing complication risks.
To prevent spleen tearing, surgeons should
avoid direct traction of the spleen during the
traction operation of left upper pole of kidney
and left adrenal gland surgery. Freeing the splenocolon and splenorenal ligaments is essential.
In the perirenal organ surgery, such as ipsilateral
adrenal gland surgery and pyeloplasty, kidney
injury is the most common. To achieve blunt
combination during separation and correctly
grasp the anatomical level and relevant positional relationship is important. Liver injury is
typically seen in right adrenal gland or transperitoneal nephrectomy cases. During separation, it
is important to be mindful of the anatomical
location of the liver and separate tissue with care
to reduce electrocoagulation injury. Although
relatively rare, pancreatic injury is more prevalent during left adrenal gland and left nephrectomy. If the pancreatic contusion is found during
the operation, physicians from relevant departments should be consulted promptly to avoid
pancreatic stula [14].
Operations, particularly in retroperitoneal
dissection, can cause the risk of major vessel
injury. The retroperitoneal space typically
includes the distal abdominal aorta, common
iliac arteries, external iliac arteries, and internal
iliac arteries, although lacerations in these vessels are infrequent. Identifying large vessel
injury early, limiting bleeding, and transitioning
to laparotomy when laparoscopic methods are
unsuccessful for hemostasis are crucial for
effective treatment. Medical hemostasis such as
TachoSil may be benetial. It is recommended
that a vascular surgeon should perform the operation [7].
Although there are still complications similar
to traditional laparoscopy in the application of
robotic surgery system in the eld of pediatric
surgery, and there are special complications
related to pediatrics, robotics will be more widely
used in the medical eld in the near future and
ultimately can achieve the best therapeutic outcomes for patients.
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