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8 Robotic-Assisted Segmentectomy
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51
stapler. The intersegmental plane was determined
by the extent of the inatenation and collapse
junction between the lung segments or after arterial ischemia, and the intersegmental plane was
separated by electrocoagulation with a linear cutter or an ultrasound knife.
8.6 Technical Points and Skills
The thoracic space in pediatric patients is relatively small, which limits the placement of operating and observation ports. It may not be possible
to create a straight line arrangement of ports, so it
is important to choose the maximum distance
between ports to avoid interference between
robotic arms.
For patients with a sequestered lung, there
may be abnormal collateral blood supply. In such
cases, the operating ports on the side closer to the
spine should be placed downward as much as
possible to prevent difculties during the
procedure.
For patients with a well-vascularized sequestered lung, gentle traction should be applied to
avoid bleeding that may obstruct the view.
During dissection of the pulmonary veins,
caution should be exercised, as the vessel walls
are relatively thin, especially when separating
them from the posterior wall, to prevent damage
to the blood vessels.
For proximal segment ligation of the pulmonary artery and pulmonary vein, it is recommended to perform at least two ligations to
prevent slippage and major bleeding.
After bronchus division, it is advisable to perform continuous absorbable suture with at least
one stitch to minimize the risk of suture line
detachment and pneumothorax.
8.7 Post-operative
Complications
1. Pneumothorax: if there is continuous gas
leakage from the closed thoracic drainage
tube after surgery, it can be temporarily
observed; small alveolar gas leakage can heal
by itself; if there is a continuous large amount
of gas leakage, bronchopleural stula should
be considered, and timely surgical treatment
should be performed.
2. Atelectasis, contusion caused by pullclamp on lung tissue during operation, and
atelectasis caused by obstruction of bronchial secretions after operation are also
common. Postoperative physical therapy
can be strengthened for children and supplemented by atomization to help discharge
sputum.
3. Bleeding: if a large amount of bright red uid
continues to be extracted from the drainage
tube, the possibility of postoperative bleeding
should be considered.
4. Residual lesions: due to the large scope of
lesions in some CPAM cases, unclear boundaries and ease of pushing normal lung tissue,
residual lesions may occur after lung segment or wedge resection and other lung preservation operations [11–13]. In Stanton’s
report, 15% (9/60) of patients developed
residual lesions after pulmonary segmental
resection [13]. In Johnson’s report, 6.6% of
patients underwent lung preservation surgery
and underwent secondary surgical resection
due to residual lesions [11]. When performing segmentary resection or irregular resection, the surgeon should strictly grasp the
indications of surgery, accurately judge the
scope of the lesion, clarify the involvement
of the lesion, and make a careful decision in
combination with intraoperative lesion
exploration to avoid residual lesions. When
residual lesions are found during postoperative follow-up, according to current literature
reports, most authors choose to rescease the
lesions, and the specic surgical method
depends on the residual lesions [12, 13].
With respect to the timing of reoperation,
there are few reports about it in the literature,
and Fascetti et al believed that for residual
cases, resurgical resection should be performed approximately 5 months after surgery [12].
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Q. Shu and Z. Tan
8.8 Comparisons
withConventional
Thoracoscopic Surgery
Compared with traditional laparoscopic thoracic
surgery, the robotic surgical system has unique
advantages: (1) clear and accurate threedimensional vision. The common cavity mirror for
two-dimensional plane vision, a two-dimensional
view cannot accurately position the distance, and
the robot’s vision for three- dimensional vision
simulates human eyes, seeing more clearly, more
accurately positioning the distance; (2) intelligent
action: the operator of hand and wrist action can
be converted into real-time accurate mechanical
action, and action height simulation coincides
with surgery; (3) motion correction and shake ltering function: the surgical instruments that can
turn the wrist can bend and rotate far more than the
limit of the hand. Shiver ltering and intuitive
movement allow the physician to operate steadily
and naturally; (4) remote control: the operator
does not need to go on the operating table, save
space, avoid crowding between the main knife and
the assistant, and avoid obstruction of the surgical
eld of view; (5) suitable for pediatric surgery:
Compared with adults, the pediatric body cavity
space is small, and traditional surgical operations
are limited. The progress of endoscopic surgery
has gradually solved this problem, but there are
still shortcomings in the accurate operation of
localized lesions. Fine operation in a limited space
can reduce the side injury of the operation, improve
the curative effect, and minimize the pain of children [2]; (6) reduce surgeon fatigue: Compared
with traditional surgery and endoscopic surgery, a
good three-dimensional eld of vision and simplied coordination, ergonomic design of the doctor’s operation table can minimize the fatigue and
physical injury of the doctor.
References
1. Adzick NS, Harrison MR, Crombleholme TM, etal.
Fetal lung lesions: management and outcome. Am J
Obstet Gynecol. 1998;179:884–9.
2. Lakhoo K.Management of congenital cystic adenomatous malformations of the lung. Arch Dis Child
Fetal Neonatal Ed. 2009;94:F73–6.
3. Khosa JK, Leong SL, Borzi PA. Congenital cystic adenomatoid malformation of the lung: indications and timing of surgery. Pediatr Surg Int.
2004;20:505–8.
4. Yan-Sin Lo A, Jones S. Lack of consensus among
Canadian pediatric surgeons regarding the management of congenital cystic adenomatoid malformation
of the lung. J Pediatr Surg. 2008;43:797–9.
5. Wong A, Vieten D, Singh S, et al. Long-term outcome of asymptomatic patients with congenital
cystic adenomatoid malformation. Pediatr Surg Int.
2009;25:479–85.
6. Vu LT, Farmer DL, Nobuhara KK, etal. Thoracoscopic
versus open resection for congenital cystic adenomatoid malformations of the lung. J Pediatr Surg.
2008;43:35–9.
7. Rothenberg SS.First decades experience with thoracoscopic lobectomy in infants and children. J Pediatr
Surg. 2008;43:40–5.
8. Rothenberg SS, Kuenzler K, Middlesworth W, etal.
Thoracoscopic lobectomy in infants less than 10kg
with prenatally diagnosed cystic lung disease. J
Laproendosc Adv Surg Tech A. 2011;21:181–4.
9. Yang CF, D’Amico TA. Thoracoscopic segmentectomy for lung cancer. Ann Thorac Surg.
2012;94:668–81.
10. Okada M, Tsutani Y, Ikeda T, et al. Radical hybrid
video-assisted thoracic segmentectomy: long-term
results of minimally invasive anatomical sublobar
resection for treating lung cancer. Interact Cardiovasc
Thorac Surg. 2012;14:5–11.
11. Johnson SM, Grace N, Edwards MJ, et
al. Thoracoscopic segmentectomy for treatment
of congenital lung malformations. J Pediatr Surg.
2011;46:2265–9.
12. Fascetti-Leon F, Gobbi D, Pavia SV, etal. Sparinglung surgery for the treatment of congenital lung malformations. J Pediatr Surg. 2013;48:1476–80.
13. Stanton M, Njere I, Ade-Ajayi N, et al.Systematic
review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg.
2009;44:1027–33.
Robot-Assisted Laparoscopic
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Repair ofHital Hernia
JiangengYu andYueGao
9
9.1 Introduction
Hiatal hernia (HH) refers to the abdominal segment of esophagus, gastric fundus, and even the
whole stomach and part of abdominal organs herniated into the mediastinum through the abnormally wide esophageal hiatus, which is mainly
caused by congenital developmental abnormality
of the diaphragm and can lead to gastroesophageal reux. The prevalence rate of Chinese population is 3.3%. There are more females than
males, which are common in the elderly. HH can
be divided into sliding type, para-esophageal
type, mixed type, and giant esophageal hiatal hernia according to the location of hiatal defect and
the number of herniated tissues [1]. Most of the
esophageal hiatal hernia in children is mixed
type, most of the stomach or the whole stomach
is herniated into the mediastinum, and the herni-
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_9.
J. Yu (*)
Department of Cardiac and Thoracic Surgery,
Children’s Hospital of Zhejiang University School of
Medicine, Hangzhou, China
e-mail: 6192007@zju.edu.cn
Y. Gao
Department of Thoracic Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: 6520096@zju.edu.cn
ated stomach is at risk of torsion, incarceration,
or strangulation; other organs in the abdominal
cavity can also be herniated into the mediastinum. Gastroesophageal reux disease (GERD)
refers to the reux of gastric contents to the
esophagus and even the oropharynx, causing a
series of symptoms and complications inside and
outside the esophagus. GERD is a common concomitant symptom of HH.The prevalence of HH
with GERD in Western countries is as high as
10–20% [2]. With the increase of abdominal
pressure, the abdominal segment of esophagus,
cardia, and gastric fundus entered the mediastinum, resulting in recurrent vomiting, upper gastrointestinal bleeding, retrosternal pain,
dysphagia, and other symptoms. The gold standard of diagnosis of HH is upper gastrointestinal
radiography, and gastroscopy or CT can be used
as auxiliary examination. Children less than
1year old with sliding hiatal hernia can be treated
conservatively, including medicine, posture, diet,
and so on. Para-hiatal hernia, mixed and giant
hiatal hernia, and sliding hiatal hernia with obvious symptoms and ineffective conservative treatment all need surgical treatment. The purpose of
the operation is to restore the anatomical position
of the esophagus and stomach, repair the esophageal hiatus, and establish an anti-reux structure
[3]. The surgical methods of HH include traditional open surgery and laparoscopic surgery.
Laparoscopic surgery has the advantages of
safety, less pain and less scar, so it has gradually
become the standard operation of HH, and its
© 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_9
53
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J. Yu and Y. Gao
safety and effectiveness have been widely veried [4–6]. However, the laparoscopic system still
has some shortcomings, such as unstable imaging system, 2D imaging eld of vision, limited
movement of instruments, poor ergonomics, and
so on. In recent years, robot-assisted laparoscopic
surgery has more obvious advantages because of
its three-dimensional images, ultra-highdenition surgical eld of vision, and exible
surgical instruments, which overcome the limitation of two-dimensional vision and degree of
freedom of laparoscopic surgery [7].
9.2 Indications
andContraindications
Indications: (1) HH with complications, such as
severe esophagitis, ulcer, bleeding, stricture,
organ incarceration, and so on; (2) paraesophageal hernia and giant hiatal hernia; (3) no obvious
improvement after medical treatment; (4) acute
gastrointestinal volvulus incarceration is an indication of emergency operation [3]. In theory, all
children who can undergo laparoscopic surgery
can be operated by robot, but considering that
there is a certain distance between the robotic
arms, the children who are too young and underweight may not operated by robot because of the
narrow operating space. However, the age limit
can also be reduced appropriately according to
the surgical prociency of the surgeon.
Contraindications: premature infants or newborns with poor tolerance; complicated with
other severe congenital malformations, cardiopulmonary dysfunction; severe pulmonary infection; patients with a history of abdominal surgery
and severe abdominal adhesions [3]. However,
with the continuous maturity of surgery and anesthesia techniques, the indications of laparoscopic
surgery in children are constantly expanding, and
some previous contraindications no longer exist.
9.3 Preoperative Preparation
Children with routine fasting, dehydration and
electrolyte disorders, anemia, and malnutrition
should be corrected before operation.
Antibiotics are routinely administered half an
hour before surgery. Preoperative placement of
gastric tube and catheter can reduce the volume
of stomach and bladder. Preoperative femoral
vein catheterization will facilitate a large amount
of uid replacement during and after operation.
The mode of anesthesia is endotracheal intubation intravenous inhalation combined
anesthesia.
9.4 Position andDocking
The patient was placed in a supine position
before the surgery. The robot arm and assistant
are located on the right side of the child, the
instrument nurse stands on the left side of the
child, and the anesthesiologist is located on the
head end of the child. The 8 mm trocar was
inserted into the skin of the umbilical margin of
the child to establish the observation hole, the
lens was connected to explore the abdominal
cavity, and the pneumoperitoneum (6–8mmHg)
was established. Under the direct view of the
lens, the 8mm trocar was placed as the robot
operation hole at the incision under the rib edge
of the left and right midline of the clavicle, and
the 5 mm trocar was placed as the auxiliary
hole at the 2cm incision on the right side of the
at umbilical cord (Fig. 9.1). After the robot
system is ready, the manipulator is connected to
the trocar respectively to release the tension
between the trocar and the abdominal wall. The
left-hand robot arm was implanted with
Maryland bipolar separation forceps and the
right-hand robot arm was implanted with ultrasonic knife.
a
b
c
9 Robot-Assisted Laparoscopic Repair ofHital Hernia
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Fig. 9.1 The trocar positions of da Vinci robotic surgical
system
55
9.5 Surgical Steps
First pass the abdominal from the left subcostal
arch with 2-0 nonabsorbable thread, pick up the
liver, pass from the falciform ligament of the
liver, and thread out from the right abdominal
wall with the assistant from both ends of the tight
thread on the outer abdominal wall, suspend the
liver, and fully expose the esophageal cardia
region (Fig.9.2a), then the operator and assistant
assist in bringing the gastric and lower esophageal segments herniated into the thoracic cavity
to the abdominal cavity. At least the abdominal
segment esophagus 3 cm in length was maintained. The phrenoesophageal and hepatogastric
ligaments were dissected free with a scalpel to
expose the lower esophagus and cardia and covered free along the upper cardia with the perito-
d
Fig. 9.2 da Vinci robotic surgical system repair of paraesophageal hiatus hernia in infants and children. (a) Suspend
the liver to expose the esophageal-cardia areas; (b) fully
expose both diaphragmatic feet; (c) the tightness of the
e
closed hernia hole was detected by the suction device; (d)
the right side of the abdominal esophagus is xed to the diaphragm; (e) the top side of the abdominal esophagus is xed
to the diaphragm; (f) fundoplication (Nissen procedure)
f
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J. Yu and Y. Gao
neum or hernia sac between the lower esophagus
and cardia until the lower esophagus and fundus
were no longer pulled into the mediastinum. Care
was taken to avoid excessive depth of dissociation and to adequately protect vagal branches and
esophageal muscularis. The left and right hemidiaphragmatic feet were freed, a cuff was
bypassed from the back of the esophagus and
elicited from the left hemidiaphragm, and the
assistant fully exposed the bilateral hemidiaphragmatic feet by grasping the cuff with an
accessory hole and pulling the lower esophagus
downward (Fig.9.2b). The mechanical arm of the
right hand replaced the needle holder, 2-0 nonabsorbable thread was interrupted and sutured three
to four times to reconstruct the esophageal hiatus,
and the assistant needle holder was placed at the
esophageal hiatus after suturing, so that it could
pass smoothly through the suction apparatus
(Fig.9.2c). The ventral esophagus was preserved
for more than 2cm, and the esophagus was xed
with the diaphragmatic crus on both sides
(Fig.9.2d, e). The master knife was assisted by
an assistant to wrap the gastric fundus around the
lower esophageal segment 360° posterior to the
esophagus with 2-0 nonabsorbable sutures with
three needles (Nissen fundoplication, Fig.9.2f).
After exploration of the abdominal cavity no
active bleeding, abdominal wall puncture point
no bleeding, withdraw the robot system, close the
abdomen. There is no need to place abdominal
drainage tube.
9.6 Technical Points andSkills
When treating pediatric HH with da Vinci robotic
surgery system, due to the frequent separation
and cutting of tissue, the left arm is connected
with Maryland bipolar separation forceps and the
right arm is connected with ultrasonic knife.
Maryland bipolar separation forceps can pull
blunt tissue and perform electrocoagulation.
Ultrasonic knife can quickly cut tissue and perform electrocoagulation to reduce the interference of bleeding to the visual eld. When
dissociating the adhesive tissue around the lower
segment of the esophagus, we should pay atten-
tion that the separation depth should not be too
deep, we can remove part of the hernia sac to
avoid blocking the eld of vision, but it is not
necessary to completely dissociate and remove
the hernia sac to avoid damage to the esophageal
wall, vagus nerve, and mediastinal pleura. When
the hernia is tightened, the last needle should be
closely coordinated with the assistant, and it is
appropriate for the assistant to hold the attractor
or clamp to pass smoothly. Overloosening can
easily lead to esophageal hiatal hernia recurrence
and esophageal stricture, so experienced physicians should be used as assistants. At the same
time, because the chief surgeon is far away from
the operating table, the assistant should be prepared for thoracotomy or laparotomy at any time,
such as massive bleeding during the operation, no
visual eld, or unable to nd the location of the
bleeding. The assistant must quickly complete
emergency operations such as withdrawal from
the robot, thoracotomy, laparotomy, and so on.
According to the guidelines for the diagnosis and
treatment of HH issued by the American
Association of Gastrointestinal Endoscopic
Surgeons in 2013, for some patients with HH of
type I and II, the clinical symptoms are more
likely to be caused by reux, and anti-reux surgery is more effective than herniorrhaphy [8].
Some scholars have proposed that the mode of
operation should be selected according to the
preoperative clinical symptoms and examination
results of gastroesophageal reux and its degree
[9]. At present, the main anti-reux procedures
include Nissen’s operation, touch’s operation, or
Thal’s operation, but the choice of anti-reux
operation is still controversial [10–13]. It has
been reported that the three procedures are safe
and effective. Nissen is a widely accepted gastric
fundoplication, but the incidence of postoperative esophageal and cardiac stricture is higher
than that of other surgical methods. Some studies
have found that although the incidence of dysphagia after Toupet fundoplication decreased signicantly in the short term, the difference
decreased signicantly with the prolongation of
postoperative recovery period, and there was no
signicant statistical difference in the long-term
effect. Our view is that according to the degree of
9 Robot-Assisted Laparoscopic Repair ofHital Hernia
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57
dissociation of the gastric body during the operation, we choose the anti-reux operation, the gastric body wrapping the esophagus is more
relaxed, we choose Nissen, and when the gastric
body wraps the esophagus more tightly, we
choose Toupet. In Nissen operation, 1–2 needles
should be xed to the anterior wall of the esophagus to prevent the folded cardia from sliding up
and down along the esophagus and cardia when
the gastric fundus is wrapped around the esophagus. If vagus nerve injury is suspected during
operation, pyloroplasty can be performed at the
same time to prevent postoperative gastric dilatation and disturbance of gastric emptying.
9.7 Post-Operation
Complications
Patients with hiatal hernia routinely fasted for
2–3days after operation, and were treated with
intravenous uid replacement at the same time.
After anal exhaust and defecation, they ate gradually. It was necessary to observe whether there
were symptoms of dysphagia and vagus nerve
injury after eating. The common complications
after robotic esophageal hiatal hernia surgery
include: (1) esophageal injury: esophageal perforation caused by excessive deep injury to the
esophageal wall during the operation, which can
be repaired under microscope if it is found in
time during the operation, and severe esophageal
injury needs to be repaired by open surgery in
time; (2) vagus nerve injury: dissociation too
close to the side of the esophagus may lead to
vagus nerve injury. If it is suspected that vagus
nerve injury should be performed with pyloroplasty, it is necessary to prolong the indwelling
time of gastric tube and fasting time after operation; (3) dysphagia: it may be caused by tissue
edema at the gastroesophageal junction, which is
usually relieved within a few days to weeks after
operation, or dysphagia caused by esophageal
stricture caused by esophageal hiatus suture or
gastric fundus bypass. If this happens, you can
try to dilate the esophagus by balloon, but if the
dilatation is ineffective, you need another operation to relieve the esophageal stricture; (4) post-
operative recurrence and gastroesophageal
reux: too short abdominal esophagus, partial
gastric fundus folding, and not tight enough
esophageal hiatus may cause postoperative gastroesophageal reux, which can be relieved with
growth and development, and a few need reoperation [3]. The postoperative recurrence rate of
esophageal hiatal hernia is 0.98%–4%, and
recurrent surgery can also be performed under
laparoscopy [14].
9.8 Comparisons
withConventional
Laparoscopic Surgery
Since the rst laparoscopic anti-gastroesophageal
reux surgery was completed by Bammer etal. in
1991, it has been widely accepted by surgeons
and patients [9] and has become the standard procedure for the treatment of pediatric HH [15].
Laparoscopic surgery has obvious advantages
over open surgery in postoperative infection,
incidence of small intestinal obstruction, hospital
stay, fasting time, dry retching, and so on.
However, the operation time and postoperative
recurrence rate were higher than those of open
surgery (the difference was not statistically signicant). However, laparoscopic surgery also has
some shortcomings, such as two-dimensional
visual eld, poor sense of space, insufcient
operational stability and accuracy due to the
amplication of instrument angle and natural
tremor, and the greater risk of accidental injury.
In addition, the doctor’s learning curve is longer
[16]. In recent years, Leonardo da Vinci robotic
surgery system has been more and more used in
the eld of minimally invasive surgery. In 2004,
Hanly et al. reported robot-assisted HH repair
and Nissen fundoplication for the rst time [17].
Subsequently, more and more studies have conrmed that robotic HH surgery has the advantages of safety and effectiveness, less trauma,
rapid postoperative recovery, and low recurrence
rate [18–20]. Tian Wen etal. successfully implemented the rst robotic HH operation in China in
2015 [21]. da Vinci robot system has the advantages of high-denition three-dimensional imag-
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J. Yu and Y. Gao
ing vision, 7-degree-of-freedom movement of the
wrist of the manipulator, tremor ltering, and
more reasonable ergonomic design [22]. It has
achieved good therapeutic results in the elds of
general surgery, obstetrics and gynecology, urology, cardiovascular surgery, thoracic surgery, and
so on. However, Leonardo da Vinci robot surgery
is mainly concentrated in general hospitals, and it
is seldom used in the eld of pediatric surgery
[23–25]. At present, there is no report of Leonardo
da Vinci robot surgery system in the treatment of
esophageal hiatal hernia in children. The
temperature of Leonardo da Vinci robot lens is
about 50°C, which makes the operation eld not
easy to blur, the smoke produced by electrocoagulation interferes with the eld of vision very
little, and shortens the time of operation.
Moreover, the chief surgeon can adjust the lens
independently to avoid the prolongation of operation time and the increase of operation risk
caused by uncoordinated cooperation with assistants and improper operation. The 3D imaging
system makes it possible to provide ultra-highdenition vision, and the surgical eld has a
three-dimensional sense of hierarchy, which
makes some ne anatomical structures clearer,
especially when separating the tissue structures
around the esophageal wall, it can clearly distinguish the vagus nerve and short gastric vessels,
reduce the chance of accidental injury, avoid gastroparesis caused by vagus nerve injury, and contribute to the rapid recovery of gastric function
after operation. The closed Leonardo da Vinci
robot surgery system has obvious advantages in
suture, its robotic arm system has high degree of
freedom and accurate positioning, and can be
sutured and knotted from different angles, which
makes the suture and knotting in the narrow
space easier to operate and more safe, shorten the
operation time, and improve the quality of the
operation.
References
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5. Cheng C, Wu Y.Advances of laparoscopic fundoplication for children with congenital esophageal hiatal
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gastroesophageal reux disease in infants and children. Surg Endosc. 2007;21:167–74.
7. Mertens AC, Tolboom RC, Zavrtanik H, et al.
Morbidity and mortality in complex robot-assisted
hiatal hernia surgery: 7-year experience in a high- volume center. Surg Endosc. 2019;33:2152–61.
8. Zhang C, Li J, Ke L, et al. Interpretation of 2013
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Surgeons guidelines for the diagnosis and treatment of
esophageal hiatal hernia (I). Chin J Gastroesophageal
Reux Dis. 2015;2:6–9.
9. Lobe TE, Schropp KP, Lunsford K. Laparoscopic
Nissen fundoplication in childhood. J Pediatr Surg.
1993;28:358–61.
10. Fontaumard E, Espalieu P, Boulez J. Laparoscopic
Nissen-Rossetti fundoplication. First results. Surg
Endosc. 1995;9:869–73.
11. Ashcraft KW, Goodwin CD, Amoury RW, etal. Thal
fundoplication: a simple and safe operative treatment for gastroesophageal reux. J Pediatr Surg.
1978;13:643–7.
12. Horvath KD, Jobe BA, Herron DM, etal. Laparoscopic
Toupet fundoplication is an inadequate procedure for
patients with severe reux disease. J Gastrointest
Surg. 1999;3:583–91.
13. Su F, Zhang C, Ke L, etal. Efcacy comparison of
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14. Stefanidis D, Hope WW, Kohn GP, etal. Guidelines
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15. Garvey EM, Ostlie DJ. Hiatal and paraesophageal
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16. Soliman BG, Nguyen DT, Chan EY, et al. Robotassisted hiatal hernia repair demonstrates favorable
short-term outcomes compared to laparoscopic hiatal
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17. Hanly EJ, Talamini MA.Robotic abdominal surgery.
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18. Vasudevan V, Reusche R, Nelson E, etal. Robotic
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19. Brenkman HJ, Parry K, van Hillegersberg R, et al.
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Laparoendosc Adv Surg Tech A. 2016;26:465–9.
20. Tolboom RC, Broeders IA, Draaisma WA. Robotassisted laparoscopic hiatal hernia and antireux surgery. J Surg Oncol. 2015;112:266–70.
21. Tian W, Xi H, Wei B, etal. Robotic-assisted repair
of esophageal hiatal hernia combined with fundoplication: a report of two cases. Chin J Pract Surg.
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22. O'Connor SC, Mallard M, Desai SS, et al. Robotic
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Robotic-Assisted Plication of
https://t.me/medicina_free
Diaphragmatic Eventration
ZhengTan andTingHuang
10
10.1 Introduction
Diaphragmatic eventration (DE) is a congenital
anomaly and is caused by diaphragmatic abnormalities or partial diaphragms due to phrenic nerve
palsy. The incidence rate of congenital diaphragmatic eventration is about 0.05%, it is more common in males than in females [1]. Early diagnosis
and repair of the diaphragm can prevent gastrointestinal disorders, reduce recurrent respiratory
tract infections, and improve quality of life [2, 3].
Thoracoscopic diaphragmatic folding is a
classic operation for the treatment of diaphragmatic eventration [4]. In recent years, with the
rapid development of robot technology, many
studies have reported that robotic-assisted surgeries are safe and feasible for pediatric cases.
However, very few pediatric thoracic robotic
cases have been described, and most roboticassisted surgery in children is urological surgery
[5, 6]. No pediatric robotic-assisted diaphragmatic surgery has been reported.
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_10.
Z. Tan (*) · T. Huang
Department of Thoracic Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: tanzheng@zju.edu.cn; 6512045@zju.edu.cn
In our center, we successfully operated on
four cases of robotic-assisted thoracoscopic diaphragmatic folding. This chapter mainly shares
and summarizes the experience of roboticassisted thoracoscopic diaphragmatic folding.
10.2 Indications
andContraindications
Robotic-assisted thoracoscopic surgery (RAT) has
certain advantages. Almost all the indications and
contraindications are consistent with thoracoscopic
surgery. Due to our experience, we recommend
that the patient should be at least 7months old or
weigh at least 8kg, but the operation requirements
of pediatric RATs are clear, strict, and objective.
The indications and certain conditions are affected
by the accumulation of personal RAT experience
and grasp the impact of the scope of indications.
Indications: (1) relative to the normal position,
the diaphragm moved upward to more than 3 ribs;
(2) the inated diaphragm causes obvious compression on the affected side of the lung, and there are
obvious respiratory distress symptoms such as
shortness of breath and asthma; (3) frequent pulmonary infection, hypoxemia and even abnormal
respiratory movement; (4) conservative treatment
was ineffective. During the follow-up, the diaphragm continued to lift, and the became worse;
worsened; (5) accompanied by gastrointestinal
obstruction symptoms such as gastric volvulus or
acute intestinal obstruction; (6) newborns and
© 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_10
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