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Robotic Resident andFellow
https://t.me/medicina_free
Training
QiangShu andZongWeiHuang
5
With the continuous development and progress
of medical technology, minimally invasive surgery has become a major trend in the development of surgical procedures. Clinical surgery is
also gradually changing from traditional open
surgery to minimally invasive surgery. In the
eld of minimally invasive surgery, surgical
techniques have evolved again from general laparoscopic techniques to robotic surgical systems.
This shows that medical technology can be
described as rapidly changing. In Europe and the
United States, robotic surgery has been widely
popularized. In recent years, an increasing number of hospitals in China have started to apply
robotic surgery technology. In China, the
installed base of da Vinci robots and the number
of surgeries are also increasing year by year.
While robotic surgery presents opportunities for
modern medicine, it also presents challenges. In
particular, learning and training in robotic surgery is a daunting and extremely important task.
In recent years, there has been a large body of
literature reporting a high incidence of compli-
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
Z. Huang (*)
Department of General Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: huangzongwei1013@zju.edu.cn
cations associated with robotic surgery. For
example, in 2013, the U.S. Food and Drug
Administration (FDA) reported 3697 adverse
events of robotic surgery. In summary, the causes
were mainly due to inadequate training of the
robotic system [1]. Therefore, in the process of
standardized training in robotic surgery, it is particularly important to ensure the safety of
patients’ lives and improve the skill level and
expertise of surgeons. The Society of American
Gastroenterology Surgery (SAGES) and the
Minimally Invasive Robotic Association (MIRA)
state that surgeons must undergo specialized
training before using robotic surgery. Only after
rigorous training and passing an examination
can a surgeon perform robotic surgery [2].
5.1 The Current State
ofRobotics Training
Today, international training programs in robotic
surgery are primarily provided by the U.S.Food
and Drug Administration (FDA), which has
authorized the da Vinci robot manufacturer,
Intuitive Surgical, to provide training certication for surgeons using the system. The company’s professional technicians usually conduct this
training. The training aims to provide the participants with the basic skills to operate the da Vinci
robot through standardized training. In addition,
the basic skills training curriculum (BSTC) and
the fundamental skills of robotic surgery (FSRS)
© 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_5
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Q. Shu and Z. Huang
can establish standards for the curriculum of
robotic surgery training [3, 4]. To standardize the
curriculum and certication of robotic surgeons,
in 2013, 14 international surgical society organizations worked together to develop the
Fundamentals of Robotic Surgery (FRS) training
standard [5]. The criteria indicate that the safe
performance of robotic surgery is the essential
skill that surgeons need to master. However, both
the developers and raters of the current training
program are drawn from robotic surgery certication bodies. Due to the lack of a third-party
organization to determine the rating results, there
is a possibility of unclear or somewhat subjective
scoring criteria.
Intuitive Surgical’s robotics training standards divide training into preclinical and clinical
phase training. Preclinical training consists of
three courses: an e-learning course, a live simulation course, and an animal experiment course.
After that, they needed to enter the clinical
period training, go through the process of surgical observation, serve as the rst assistant of surgery, operate under the supervision of senior
doctors, and complete 15 cases of robotic surgery within 3months before they could ofcially
obtain the qualication certicate of da Vinci
surgery robotic surgery issued by Intuitive
Surgical, Inc., authorized by the National Health
Planning Commission. When the da Vinci robot
was rst introduced, most of the robotic surgery
training for domestic and foreign surgeons had
to be conducted at the Jockey Club Minimally
Invasive Surgery Training Centre at the Chinese
University of Hong Kong. Courses at this training center included operating room layout, surgical system preparation, patient position
placement, surgical operation pathways, and
robotic surgery application skills [6]. With the
establishment of the da Vinci International
Training Center at the General Hospital of the
Chinese People’s Liberation Army in Beijing
and the da Vinci International Training Center at
Shanghai Changhai Hospital, these two training
centers are gradually becoming the main training
bases for robotic surgery in China. In addition, a
robotic training simulation center based on a
Mimic simulator was established in Tianjin,
which has actively explored the systematization
and localization of robotic surgery training. At
present, the installed volume of da Vinci robots
and surgical procedures in China is increasing
rapidly. However, the training system for robotic
surgery still needs to be improved, and the standardization of robotic training is lagging behind
hardware construction.
5.2 Preclinical Training
5.2.1 Online Learning Courses
In robotic surgery training, the rst step is to
learn the theoretical knowledge and understand
the basic knowledge of the development history
of robots, machine models, operation principles,
machine structure, names, and performance of
each component, so that trainees can fully realize the advantages of robotic surgery systems.
Theoretical knowledge of robotics is the foundation of the training course, and this phase of
the course can be learned through online platforms. Currently, the main online learning platforms are Intuitive Surgical and FRS.Intuitive
Surgical’s online learning courses focus on
robot structure and operational features, while
FRS’s online learning courses focus on robot
surgery theory and anatomy. One of them, the
online learning platform of Intuitive Surgical
(https://www.davincisurgerycommunity.com),
grants the robotics theory course using a learning program that categorizes and registers different models of robots and health care workers
with different roles in the operating room. The
training and assessment of online learning
ensure that each participant has acquired basic
theoretical knowledge by the time he/she starts
performing robotic surgery [7].
5.2.2 On-Site Simulation Courses
Due to the high cost of robotic surgical systems
and the fact that training in robotic operation is
constrained by the time of clinical application, it
is unlikely that the skills of robotic surgery can be
5 Robotic Resident andFellow Training
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31
acquired directly through the learning of clinical
surgery. Thus the robotic surgery simulator has
become an important tool for surgeon training,
providing trainees with a training environment
similar to that of robotic surgery through simulation on an operating table. It also allows for the
development of simulation training programs and
provides multiple training modules. Leading surgeons and training experts design the training
content of the simulator based on what is needed
for real robotic surgery operations. The training
generally includes the operation of the surgeon’s
console system, coordination training, moving
the collar, electrocoagulation hemostasis training, clamping, cutting, vascular separation, suturing, and knotting training [8]. The current use of
the more mature DVSS simulator, which is integrated like a backpack on the back of the da Vinci
robotic surgeon console, enables the application
of simulation training procedures directly to the
da Vinci. A professional scoring system designed
to assess the operator’s mastery can be used during robotic surgery simulator training. The operator needs to successfully pass a training program
before moving on to the next program, thus continuously improving operational skills. The use
of the simulator allows the surgeon to master
robotic surgery more intuitively, improves operator coordination, and compensates for the lack of
tactile feedback during robot operation. Related
studies have shown that the operating and surgical skills of the lead surgeon improve signicantly after training in a simulation course, a
course that bridges the gap between basic training and practical clinical application [9].
5.2.3 Animal Experimentation
Course
Although the robotic simulator is important for
the mastery of basic surgical movements and for
the improvement of operational prociency, it is
not fully equivalent to the operation of a real
machine. After completing simulator training,
the next step requires physical operation on a real
da Vinci robot. The training molds generally have
simulated organ materials, tissue vessels, training
collars, and so on. Operators can gradually master the use of common robotic surgery instruments and basic operation skills from easy to
difcult. After mastering the basic skills of physical manipulation, the entire surgical steps are
nally simulated and trained on live animals.
Live animals are generally chosen from experimental live pigs because their anatomy is close to
human anatomy. This part of the training requires
special robots and corresponding animal feeding
facilities, and the corresponding training costs
are high. During training, the entire surgical
operation can be performed on live pigs, from the
installation of the robotic arm and the placement
of the trocar at the puncture hole. Live animal
training can experience operation techniques
such as freeing, resection, hemostasis, ligation,
and suturing of living tissues. Preclinical training
such as gallbladder removal, freeing, transection
and reconstruction of the ureter, dissection of the
hilar vessels and nephrectomy, intestinal resection, and intestinal anastomosis can be accomplished [10]. The animal experimentation course
at Changhai Hospital Training Center in China
includes training and assessment in lens and
instrument manipulation, tissue suturing, electrical energy use, blunt separation exercises, vascular freeing and ligation, and specialty project
exercises [11].
5.3 Clinical Period Training
After completing the basic training and assessment in the preclinical period, we will enter the
learning and training phase of the clinical period.
There are generally two options for the clinical
phase of training. In accordance with the DVSS
training requirements, the supervised training of
the clinical phase can be started within the trainee’s hospital if the surgeon already has a surgeon
in his or her medical institution who is skilled in
performing robotic surgery. However, most hospitals in China are currently using the DVSS system for the rst time, and the surgeons in training
are at institutions where robotic surgery is not yet
routinely performed, so they need to go to medical institutions that are already equipped to
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Q. Shu and Z. Huang
perform robotic surgery to observe and learn the
surgery and receive supervisory training. Surgical
observation is a very important part of the primary stage of clinical phase supervisory training.
On-site observation of surgery can make trainees
familiar with the entire surgical operation process. Through the operation and explanation of
the attending surgeon, they can understand the
details, precautions, and surgical techniques in
surgery and lay the foundation for them to carry
out robotic surgery. After observing a large number of robotic surgeries, the trained physicians
gradually began to act as surgical rst assistants.
After having some experience in robotic surgery
as rst assistants, they started to operate under
the guidance of robotic supervising experts to
complete gallbladder resection, gastrointestinal
anastomosis, biliary-intestinal anastomosis, partial hepatectomy, and so on. They are gradually
able to carry out robotic surgical procedures in
conventional specialties independently. During
this period, expert supervisors adjusted the trainees’ surgical operations in a timely manner and
monitored the trainees’ performance during critical intraoperative operations. They are able to
perform the operations effectively while ensuring
the safety of patients’ lives, avoiding surgeons
from performing operations blindly before mastering the operating skills, and improving the surgeons’ operating level. Currently, during clinical
training, trainees are required to lead 15 da Vinci
robotic surgeries within 3 months of clinical
completion after going through the process of
surgical observation, serving as the rst assistant
to the surgery, and leading the surgery under the
supervision of a senior physician before they are
ofcially certied by the National Health
Planning Commission to perform da Vinci robotic
surgery authorized by Intuitive Surgical, Inc., in
the United States [12].
5.4 Training oftheSurgical
Nurse Team
Robotic surgical systems are much more cumbersome than typical laparoscopic surgical systems
and require good coordination between nursing
staff and surgeons during surgery. Surgical nurses
can only form tacit cooperation with the surgeon if
they are systematically trained and familiar with
the surgical steps. Good nursing cooperation can
signicantly shorten the operation time and provide a guarantee for the safety and successful completion of the operation. Therefore, prior to
performing robotic surgery, the nursing team also
needs training related to robotic surgery. The training of the surgical nurses and the surgeons can be
done simultaneously, or the nursing team can be
trained separately. A surgical nurse team needs at
least two groups of nurses to be trained, and after
training out one group, new members should be
reasonably arranged to be trained so that the two
groups can easily change shifts with each other.
Changhai Hospital of the Second Military Medical
University has carried out the construction of a
nursing team for robotic- assisted radical prostate
cancer surgery and trained the nursing staff who
need this surgical team. The training includes four
steps: theoretical learning, simulation, on-site
teaching, and centralized reinforcement. A “ladder” training system was eventually formed from
the initial dedicated learning, expanding the training scale in the middle of the training period and
quality control at the end of the training period.
After such systematic training, the preoperative
preparation time for robotic surgery was signicantly reduced, and the professional level of the
nursing staff was improved [13].
5.5 Conclusion
Robotic surgery is currently the development
direction of minimally invasive surgery technology, and it has become a mainstream surgical
technique in Europe and America. At present,
robotic surgery in China is in a rapid development stage. In the future, this technology will
also become the development trend of surgery.
However, launching a robotic surgery program
comes with a huge nancial investment. Irregular
operation damages the equipment and affects the
safety of the procedure, and the physicians
involved need to undergo rigorous and
standardized training to master robotic surgery
5 Robotic Resident andFellow Training
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techniques. There will also be an increasing
demand for robotic surgery training courses in
the industry today, making it imperative to plan
and design robotic surgery training programs.
Due to the complexity of robotic surgery techniques and the long learning curve, traditional
laparoscopic surgery training methods are no
longer able to meet today’s training needs.
Therefore, exploring standardized, safe, and
effective training methods for robotic surgery can
promote the rapid and smooth development of
robotic surgery. The current step- by- step training
approach of web-based theoretical learning, simulator trainer module operation, robot physical
operation practice, and robot animal live surgery
training not only avoids the tedium of previous
surgical teaching training but also increases the
operator’s interest in robotic surgery. Through
different stages of progressive and cross-training,
a foundation can be laid for the practical clinical
application of robots for surgery, which facilitates the diffusion of robotic surgery techniques.
References
1. Alemzadeh H, Raman J, Leveson N, etal. Adverse
events in robotic surgery a retrospective study of 14
years of FDA data. PLoS One. 2016;11:e0151470.
2. Herron DM, Marohn M.SAGES-MIRA robotic surgery consensus group. A consensus document on
robotic surgery. Surg Endosc. 2008;22:313–25.
3. Foell K, Finelli A, Yasufuku K, etal. Robotic surgery
basic skills training: evaluation of a pilot multidisciplinary simulation-based curricIllum. Can Urol Assoc
J. 2013;7:430–4.
4. Stegemann AP, Ahmed K, Syed JR, etal. Fundamental
skills of robotic surgery: a multi-institutional randomized controlled trial for validation of a simulationbased curricIllum. Urology. 2013;81:767–74.
5. Smith R, Patel V, Satava R.Fundamentals of robotic
surgery: a course of basic robotic surgery skills based
upon a 14 society consensus template of outcomes
measures and curriculum development. Int J Med
Robot. 2014;10:379–84.
6. Le HM, Do TN, Phee SJ. A survey on actuators driven surgical robots. Sensor Actuat A-Phys.
2016;2016:323–54.
7. Intuitive Surgical da Vinci community. 2015. http://
www.davincisurgerycommunity.com. Accessed 15
Jun 2016.
8. Alzahrani T, Haddad R, Alkhayal A, etal. Validation
of the da Vinci surgical skill simulator across three
surgical disciplines:a pilot study. Can Urol Assec J.
2013;7:E520–9.
9. Bric JD, Lumbard DC, Frelich MJ, etal. Current state
of virtual reality simulation in robotic surgery training: a review. Surg Endosc. 2016;30:2169–78.
10. Ping H, Qiu Z, Zhang X. Exploration on standardization training of robotic-assisted surgery in China.
Chin Med Rec. 2018;19:97–9.
11. Li J, Liu Y. Construction of the Da Vinci Surgical
robot international training center. Hospital administration. J Chin People’s Liberat. 2017;24:1156–8.
12. Zheng H, Cheng J. Standardized training in robotic
surgery in urology and andrology. Natl J Androl.
2020;26:751–8.
13. Shen Q, Yang B, Wang Y, et al. Construction and
training of robot-assisted laparoscopic prostatectomy
nursing team. Nursing J Chin People’s Liberation
Army. 2014;31:58–60.
Robotic-Assisted Esophagoplasty
https://t.me/medicina_free
for Congenital Esophageal Atresia
ShaotaoTang andLiangLiang
6
6.1 Introduction
Pediatric esophagoplasty is mainly performed
for esophageal anastomosis in neonates with
congenital esophageal atresia (EA). This chapter
mainly describes the procedures of robotassisted thoracoscopic esophageal anastomosis
and tracheoesophageal stula repair.
To date, fewer than ten cases of roboticassisted thoracoscopic esophageal surgery have
been reported worldwide. In 2009, Meehan et al.
[1] reported the rst case of robotic-assisted thoracoscopic surgery (RATS) for congenital esophageal atresia with tracheoesophageal stula, but
the recurrent esophagotracheal stula was
repaired again 2 weeks after the operation. In
2015, Ballouhey et al. [2] reported three cases of
RATS for congenital esophageal atresia with tracheoesophageal atresia, but two cases were converted. Because of the size of the instruments of
the robotic system, it is unlikely to be mainstream
for esophageal anastomosis in newborns. Meehan
S. Tang
Department of Paediatric Surgery, Xiehe Hospital
Afliated to Tongji Medical College of Huazhong
University of Science & Technology, Wuhan, China
L. Liang (*)
Department of Thoracic Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: liangliangsx99@zju.edu.cn
[3] demonstrated that the weight of neonates
(usually under 3 kg), the decient intercostal
space for robotic 8.5 mm scope and small working space for articulating robotic instruments
were the main disadvantages of carrying out the
procedure. Recently, Tang et al. [4, 5] reported
the rst case of RATS for esophageal atresia
without tracheoesophageal atresia in China and
later one case of RATS for esophageal atresia
with tracheoesophageal atresia that was successfully operated in on in 2020.
6.2 Indications
andContraindications
Surgical indications include congenital esophageal atresia with esophagotracheal stula and
congenital esophageal cyst. Due to the small
number of cases, there is no unied conclusion
on the choice of the minimum age of robotic
chest surgery. It is relatively difcult to perform
robot-assisted thoracoscopic esophageal atresia
anastomosis for newborns. At present, there is no
unied standard for surgical indications and contraindications, and the operation mainly depends
on the prociency of robot surgery in clinical
units.
According to our experience, it is difcult for
children weighing less than 5 kg to receive an 8
mm robotic endoscopic system because of the
intercostal space, so caution should be taken
when choosing robotic surgery for newborns.
© 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_6
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6.3 Preoperative Preparation
6.3.1 Preoperative Examination
Routine examination of blood and body uids,
such as routine blood tests, liver and kidney function, and blood coagulation function, is
necessary.
Contrast esophagography (Fig. 6.1) is an
examination item that must be completed before
operation. Other examinations include chest
X-ray, electrocardiogram and echocardiography
to determine whether there are other systemic
malformations, such as congenital heart disease
and congenital anal atresia.
6.3.2 Patient Preparation
Children should be treated with fasting and uid
replacement before surgery.
6.3.3 Equipment Preparation
General robot systems, bipolar electrocoagulation, Maryland forceps, Cadiere forceps, etc.
Other special instruments can be adjusted according to the surgeon’s habits.
6.4 Position andDocking
6.4.1 Surgical Position
Usually, the patient is placed in a left recumbent
with 45° forward tilt, and the right upper limb is
xed on the side of the head (Fig. 6.2).
6.4.2 Layout of Operation Ports
The ports were asymmetrically placed as
described below: (1) 12mm 30° camera in the
fth intercostal space (ICS) on the right midaxillary line, CO2 gas was introduced at a pressure of
6mmHg; (2) anterior arm through the third ICS
on the right midaxillary line with a distance of
3 cm from the camera port; (3) posterior arm
through the seventh ICS on the posterior axillary
line with a distance of 5cm from the camera port,
respectively; (4) auxiliary trocar (3 mm) was
placed in the sixth ICS of the anterior axillary
line. The robot completes the docking from the
back of the child (Fig. 6.3).
Fig. 6.1 Contrast esophagography of EA before the
operation Fig. 6.2 Surgical position and layout of Trocarthe trocar
6 Robotic-Assisted Esophagoplasty for Congenital Esophageal Atresia
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a
Fig. 6.3 The layout of the Trocar for da Vinci and the position for docking. (a) Position of docking; (b) layout of Trocar
6.5 Surgical Procedures
b
periesophageal blood supply as much as possi-
ble. The tracheoesophageal stula was exposed,
After routine surgical area disinfection, lay disposable sterile sheets. The ports were placed as
described above. Bipolar electrocoagulation
severed azygos vein, explored the thoracic cavity, and evaluated the distance between the
proximal esophageal blind end and distal tracheoesophageal stula (or distal esophageal
blind end). An electric hook and Maryland forceps were used to peel off the proximal and distal ends of the esophagus and retain the
and the tracheoesophageal stula was cut off by
double suture with 5-0 prolene suture. The pos-
terior wall of the esophagus was anastomosed
intermittently with 5-0 absorbable sutures, the
nasogastric tube was placed into the gastric cav-
ity through the anastomosis, and then the ante-
rior wall of the esophagus was anastomosed
intermittently with 5-0 absorbable sutures. The
chest drainage tube was placed, and the skin
was sutured (Fig. 6.4).
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S. Tang and L. Liang
a
c
Fig. 6.4 The surgical steps of the surgery. (a) Open the proximal esophagus; (b) dissociate the distal esophagus; (c)
suture the posterior wall; (d) suture the anterior wall
6.6 Technical Points andSkills
Because of the narrow intercostal space and thoracic volume, it is difcult to insert 12mm trocar,
and the distance between the port holes is small,
so the manipulator easily collides inside and outside the thoracic cavity, which will increase the
difculty of the operation. To solve the above
problems, the sequential expansion method can
be used to place trocar [4, 5]: rst, 3 mm trocar,
then 5mm trocar, and then 8mm or 12mm trocar,
to gradually increase the intercostal space. In
addition, the asymmetrical layout trocar makes
the distance between the anterior arm port (or
posterior arm port) and camera port different
(3 cm and 5 cm respectively), which breaks
through the limit of the intercostal space and chest
space, and avoids collision of the manipulator.
b
d
6.7 Postoperative Complications
Postoperative complications are similar to tradi-
tional video-assisted thoracoscopic surgery,
including anastomotic leak, anastomotic stric-
ture, recurrence of tracheoesophageal stula, and
pleural effusion.
Anastomotic leakage is the most common
complication after esophageal atresia, and the
current incidence of anastomotic leakage is 15%
to 20% [6–8]. The main causes of anastomotic
leakage may be poor local blood supply of the
anastomotic site, infection or poor nutritional status of the children affecting local tissue healing.
Therefore, injury of large nutrient vessels should
be avoided during the operation. In the robot system, the exposure to the blood vessels in the
esophageal wall will be clearer due to the magni-
6 Robotic-Assisted Esophagoplasty for Congenital Esophageal Atresia
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cation of the eld of vision, and it is easier to
retain the small blood vessels. When anastomotic
leakage occurs after surgery, routine management measures include continued fasting, adequate thoracic drainage, use of broad-spectrum
antibiotics, use of proton pump inhibitors and
total parenteral nutrition support.
6.8 Comparisons
withConventional
Thoracoscopic Surgery
Because the da Vinci robot is a high-resolution
3D lens, the visual eld is magnied by 10–15
times, which provides the operator with a threedimensional high-denition image, which makes
the tissue structure around the esophageal atresia
and esophagotracheal stula clearer, reduces the
damage to the blood supply around the esophagus, and makes the process of esophageal anastomosis more accurate. At the same time, the robot
has a simulated wrist manipulator with a utter
ltering function, which is more stable and exible than the traditional video-assisted thoracoscope, and provides satisfactory ergonomic
experience for operators and assistants. Therefore,
it is feasible for pediatricians with rich experience in open surgery and skilled operation of
robotic surgery and anesthesiologists to complete
RATS in EA together [9].
Because the robot system needs a certain
amount of space between the manipulators, children who are too young may be unable to operate
because of the interference between the manipulators in the small chest cavity. Therefore, it
greatly limits the application of robotic surgery in
low-age, low-weight infants. Robotic surgery
cannot be performed if preoperative pulmonary
infection leads to severe chest adhesion or if the
child is unable to tolerate articial pneumothorax. In addition, some experts have raised the
problem that robot surgery takes a relatively long
operation time.
References
1. Meehan JJ.Robotic surgery in small children: is there
room for this? J Laparoendosc Adv Surg Tech A.
2009;19:707–12.
2. Ballouhey Q, Villemagne T, Cros J, etal. Assessment
of paediatric thoracic robotic surgery. Interact
Cardiovasc Thorac Surg. 2015;20:300–3.
3. Mattioli G, Petralia P. Pediatric Robotic Surgery.
Cham: Springer International Publishing. 2017.
4. Cao G, Zhang Q, Zhou Y, et al. Robotic thoracoscopic surgery for esophageal atresia: the rst
case report in China. Chin J Minim Invasive Surg.
2021;11:1026–8.
5. Wang Y, Tang ST, Cao GQ, et al. Robot-assisted thoracoscopic surgery on type III esophageal atresia: the
rst case report in China. Chinese Journal of Robotic
Surgery. 2022;3:423–7.
6. Upadhyaya VD, Gangopadhyaya AN, Gupta DK,
et al. Prognosis of congenital tracheoesophageal stula with esophageal atresia on the basis of gap length.
Pediatr Surg Int. 2007;23:767–71.
7. Kovesi T, Rubin S.Long-term complications of congenital esophageal atresia and/or tracheoesophageal
stula. Chest. 2004;126:915–25.
8. Askarpour S, Peyvasteh M, Javaherizadeh H, et al.
Evaluation of risk factors affecting anastomotic leakage after repair of esophageal atresia. Arq Bras Cir
Dig. 2015;28:161–2.
9. Pierre AF, Thomas B, Aurelien B, et al. The potential
and the limitations of esophageal robotic surgery in
children. Eur J Pediatr Surg, 2020;32:170–6.
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