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Z. Tan and T. Huang
infants with respiratory distress, repeated episodes
of hypoxia or inability to evacuate the ventilator [7].
Contraindications: (1) abnormal coagulation
function and bleeding tendency; (2) severe infection; (3) systemic organ failure and unstable vital
signs unable to tolerate the operation; (4) diagnosed with neuromuscular disease; (5) weight
less than 8 kg or age less than 6 months, for children with these relative contraindications, a careful preoperative discussion by experienced
clinicians is required to assess the suitability of
da Vinci surgery.
10.3 Preoperative Preparation
First, related examinations are consummated,
and the diagnosis is conrmed. The preoperative
preparation of Da Vinci-assisted thoracoscopic
diaphragmatic folding includes gastrointestinal
preparation, psychological preparation, and
blood preparation. Intestinal preparation included
eating digestible food, preoperative enema, preoperative fasting for 8 hours and being water-free
for 2 hours before surgery. Appropriate uid
replacement was performed before the operation.
On the day of the operation, a glycerine enema
can be given according to defecation and abdominal distention, and gastrointestinal decompression can be carried out before the operation.
Psychological preparation includes preoperative
doctor–patient communication and nursing education so that the guardian can understand the
operation process, possible complications and
perioperative preventive measures to reduce the
anxiety of the family and children. For blood
preparation, with the maturity of diaphragmatic
folding in recent years, intraoperative blood
transfusion is rarely needed. However, due to the
risk of injury to large blood vessels, heart and
lung in the chest, red blood cells and plasma still
need to be prepared routinely before operation.
Diaphragmatic folding surgery is a type I incision
that generally does not require the use of antibiotics before the operation. For children with infection, relevant antibiotics can be used according to
the pathogen, and surgical treatment can be carried out after the inammation is controlled.
10.4 Position andDocking
The patient was placed in a lateral position, with
the affected side upward and the head low feet at
a high tilt (approximately 10-20°) (Fig. 10.1).
The ports were asymmetrically placed as
described below: (1) 8 mm 30-degree camera in
the 3th intercostal space (ICS) on the midaxillary
line connect to the arm 2; (2) arm 1 connect with
the trocar through the fth ICS on the preaxillaris
line with the distance 5-6 cm with camera port,
sometimes the port may be lateral 1 cm the preaxillaris line; (3) arm 3 through the seventh ICS on
the posterior axillary line with the distance of 5-6
cm with camera port, also the port can be lateral
1-2 cm the posterior axillary line, respectively; (4)
auxiliary Trocar (5 mm) was placed at the fourth
intercostal level between the axillary midline and
the clavicular midline. Due to the small chest
space of children, to achieve sufcient distance,
the robot operation holes are not in line with the
camera hole. We should keep the distance more
than 3 cm between the robot operation hole and
Fig. 10.1 The layout of the trocar for da Vinci diaphragmatic folding surgery. Points 1, 2 and 3 are the positions
of DaVinci Trocar holes, and point 4 is the auxiliary hole.
Line a: the midaxillary line; line b: the preaxillaris line;
line c: the posterior axillary line; star mark: surface projection of the surgical area
10 Robotic-Assisted Plication of Diaphragmatic Eventration
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the camera hole to avoid collision and damage of
the robotic arm. The specic port position will be
appropriately adjusted according to the actual
situation.
Docking: (1) adjust the child’s position to head
down and foot up (note: this step is important, and
the patient’s position cannot be adjusted after
installation unless a da Vinci eleven integrated
operating table is congured); (2) establish pneumothorax by means of the Da Vinci trocar; (3) set
the main machine “pelvic surgery” mode, leaving
arm 4 empty and arm 2 attached to a camera trocar,
determine the operative eld using the main view
lens, and press the “aim” button to adjust the other
robotic arms; (4) arm 1 and arm 3 were attached to
the trocar at points 2 and 3, respectively. The
instrument was mounted under the supervision of
a main viewer; (5) put the needle holder and gripper into trocar 1 and trocar 3, respectively.
10.5 Surgical Steps
Endotracheal intubation under beroptic guidance
allows one-lung ventilation to be achieved. Carbon
dioxide (CO2) was insufated into the chest to
maintain positive pressure, and the lung collapsed.
If one-lung ventilation is not tolerated, we choose
two-lung ventilation, but the pressure will be
increased. After the reduction was completed, the
redundant diaphragm was pulled plicated. Then, it
was sutured intermittently with 2-0 nonabsorbable
suture (Fig.10.2). A chest tube was always placed
and then removed after 1-3 days.
D
F
Fig. 10.2 The redundant diaphragm was pulled plicated, then sutured intermittently with 2-0 non-absorbable suture
(a–d)
E
G
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Z. Tan and T. Huang
10.6 Technical Points andSkills
The narrow intercostal space and thoracic cavity
make the distance between the port holes small,
so the manipulator easily collides inside and outside the thoracic cavity, which increases the difculty of the operation. We used the sequential
expansion method to place the trocar: rst, a 5
mm trocar was placed, and then an 8 mm trocar
was placed to gradually increase the intercostal
space. The asymmetrically layout trocar makes
the distance between the anterior arm port (or
posterior arm port) and camera port different,
which breaks through the limit of the intercostal
space and chest space and avoids collision with
the manipulator.
Due to the lack of force feedback and the
absence of instruments specically for younger
children, clinicians need to pay attention to the
following points: (1) body position (Nonda Vinci
integrated surgical bed): The body position
should be head-low and foot-high, with the foot
side elevated by approximately 10°-20° to prevent the robot arms from squeezing the head and
shoulder of the patient. The 30° camera was
turned upward while suturing the edge of the diaphragm. The ordinary bed height must be
adjusted before docking; (2) reduced grasping
and pulling of the diaphragm; (3) choose an
appropriate hole position and the depth of trocar
into the patient.
lung injury, especially in newborns and young
infants. The tissues and organs of newborns and
infants are fragile, which easily causes unnecessary damage during the operation.
In the initial period, robot installation always
takes a long time, which causes hypercapnia and
increases the risk of anesthesia [8, 9].
10.8 Comparisons
withConventional
Thoracoscopic Surgery
The robot has a wider visual angle and a 3-D
visual eld, which increased magnication and
sharpness, greatly increasing the surgical accuracy and reducing tissue damage. Its design is
ergonomic, so the operator can work in a relaxed
environment, reduce fatigue and concentrate
more [10]. However, it also has limitations: lack
of tactile feedback, nonbedside operation and
limited working space due to the large size of the
instrument, especially for small infants. The
RATS approach offers an easier learning curve
option for minimally invasive diaphragm plication [11]. Future studies are needed to judge the
benets of the RATS approach in children.
10.9 Case Presentations
andVideo
10.7 Postoperative Complications
Almost all complications are similar to those of
traditional thoracoscopic surgery, including pleural effusion, palindromia, tissue and organ bleeding, pneumothorax, chylothorax, atelectasis, and
A boy 11 months, 9.5 kg, a right diaphragm elevation was found for 2 months.
For robotic-assisted diaphragmatic folding,
the setup time was 20 mins, and the operation
time was 45 mins. The chest tube was removed
30 hours after the operation. The postoperative
hospital stay was 4 days (Fig.10.3).
10 Robotic-Assisted Plication of Diaphragmatic Eventration
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4. Liu JB, Yan XG, Chen G, et al. Comparative study
5. Fuchs ME, DaJusta DG. Robotics in pediatric urology.
6. Ferrero PA, Blanc T, Binet A, et al. The potential and
7. Section of Endoscopic Surgery, Branch of Pediatric
8. Bishay M, Giacomello L, Retrosi G, et al.
Fig. 10.3 Right diaphragm elevation
9. Bishay M, Giacomello L, Retrosi G, et al. Decreased
References
1. Deslauriers J. Eventration of the diaphragm. Chest
Surg Clin N Am. 1998:8:315–30.
2. Özkan S, YaziciÜ, Aydin E, et al. Is surgical plication
necessary in diaphragm eventration? Asian J Surg.
2016;39:59–65.
3. Ouyang H, Wu XC, Ding S, et al. Diaphragm plication for the treatment of diaphragmatic paralysis
10. Al-Bassam A. Robotic-assisted surgery in chil-
11. Stuart CM, Wojcik BM, Gergen AK, et al. A compari-
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in infants after surgical correction for congenital
heart diseases. Chin J Clin Thorac Cardiovasc Surg.
2014;21:220–223.
of open and thoracoscopic repair for congenital diaphragmatic eventration in children. Chin J Pediatr
Surg. 2014;35:39–42.
Int Braz J Urol. 2020;46:322–7.
the limitations of esophageal robotic surgery in children. Eur J Pediatr Surg. 2022;32:170–6.
Surgery, Chinese Medical Association. National consensus in China on surgery for diaphragmatic eventration in children. Section of Cardiothoracic Surgery.
Chin J Pediatr Surg. 2018;39:645–9.
Hypercapnia and acidosis during open and thoracoscopic repair of congenital diaphragmatic hernia
and esophageal atresia: results of a pilot randomized controlled trial. Annals of Surgery, 2013;258:
895–900.
cerebral oxygen saturation during thoracoscopic
repair of congenital diaphragmatic hernia and esophageal atresia in infants. J Pediatr Surg. 2011;46:
47–51.
dren: advantages and limitations. J Robotic Surg.
2010;4:19–22.
son ofshort-term outcomes followingrobotic-assisted
vs. open transthoracic diaphragm plication. J Robot
Surg. 2023;17(4):1787–96.
Robotic-Assisted Ligation of
https://t.me/medicina_free
ThePatent Ductus Arteriosus
LiyangYing andXiwangLiu
11
11.1 Introduction
Patent ductus arteriosus (PDA) is a common congenital cardiac anomaly. Without treatment, PDA
leads to an increase in continuous pulmonary
blood ow and left ventricular preload. It is necessary to treat PDA through surgical intervention
[1].
With advances in surgical techniques and peri-
operative management strategies over the past
decades, minimally invasive endoscopic surgery
has been extensively developed in all disciplines.
Endoscopic technology reduced the incidence of
complications after the operation and the length
of hospital stay. Recently, robotic-assisted surgery systems have helped to overcome the limitations of conventional endoscopic tools [2].
Robotic surgery for PDA closure with roboti-
cally assisted instrumentation provides accurate
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_11.
three-dimensional vision, intelligent tremor ltering, and motion correction [3]. The recent use
of robotic surgical assistance was technically
feasible in pediatric patients [4]. Compared with
traditional thoracoscopic surgery, new-generation Da Vinci robot-assisted thoracoscopic surgery excels in procedures in the small chest of
children. This makes it possible for Da Vinci
robots to be widely used in children’s surgery.
Areas that are more easily reached with the newest generation robotic articulations, such as the
foramen of Bochdalek. This is the most important factor for PDA closure in children [5].
Robot-assisted surgery has been proven to be
superior to traditional surgery, even to the thoracoscopic approach for PDA closure [6, 7]. The
current diameter of the robotic system trocar
limits the progress of its application in children.
There are still some limitations for PDA closure
by the robotically assisted surgical system in
children. Undoubtedly, robotic surgery will prevail with technological improvements in children in the future.
L. Ying (*)
Department of Cardiovascular Surgery, Children’s
Hospital of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: yingliyang_1980@zju.edu.cn
X. Liu
Department of Cardiac and Thoracic Surgery,
Children’s Hospital of Zhejiang University School of
Medicine, Hangzhou, China
e-mail: Liuxw@zju.edu.cn
© 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_11
11.2 Indications
andContraindications
Indications: age >1 year old, weight >10 kg,
tubular PDA.
Contraindications: age <1 year old,
weight <10 kg, window PDA, and thoracic
deformity.
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L. Ying and X. Liu
Note: to date, few patients have undergone
PDA ligation by Da Vinci robots. The indications
and contraindications of this surgery are still relative. It is undeniable that the indications for PDA
ligation using robotics will expand.
11.3 Preoperative Preparation
All children underwent chest X-ray and chest CT
scans to exclude chest and lung malformations.
ECG examination was performed to exclude
complicated arrhythmias. Other necessary preoperative routine examinations. Fasting and water
deprivation for 6h and anesthesia contraindications were excluded.
11.4 Position andDocking
The children were generally anesthetized and
administered an orotracheal tracheal cannula.
The endotracheal tracheal cannula was placed
into the right-side main bronchus, and then the
right lung was subjected to single lung ventilation. In all patients, arterial blood pressure was
monitored. In addition, central catheterization of
the internal jugular vein was established for
administering liquids and medications. The child
patient was in the right lying position, and the
right armpit was appropriately raised. The position was xed on the chest and back. The anterior
superior iliac spine and shoulder seam were xed
with 4 cm cloth tape (Fig.11.1a).
It is very important to place the system cart in
a suitable location for robotic ligation of PDA. It
is best to put the robot on the right side of the
operation table near the child’s head end. The
robot instrument arms were placed on the head
side of the patient. The assistant surgeon is on the
right side of the operation table, near the tail. The
nurse stands on the left side of the operation table
(Fig.11.1b).
When the ports are placed, proper robot arm
angles and depth should be considered. The arterial duct is on the left side of the upper mediastinum. Therefore, the robot instrument arms are
placed on the left side of the chest with or without
the auxiliary hole (Fig.11.1c).
There are several experiences for arranging
the hole. First, the mirror hole is laid in the fth
intercostal space of the axillary midline, and the
operation hole is placed in the sixth intercostal
space of the scapular midline and the fourth intercostal space of the axillary front. The ancillary
trocar is in the seventh rib gap of the axillary
front for traction exposure of the PDA and for
ligation (Fig.11.1d).
The scope faces the target anatomical area.
This area is not necessarily a pathological location. It is the farthest point of the surgical work
area. For PDA patients, it is the left subclavian
artery or left pulmonary apex (Fig.11.1e). After
the scope arm is located, the instrument arms are
positioned (Fig.11.1f).
Figure 11.1g shows the relative position of
the robot instrument arms on the patient. When
the patient is older than 10 years, it is best to
move the scope hole and the right instrument
arm hole up one intercostal space. Therefore,
the combination of rib spaces may be 4, 4, 5 or
4, 5, 6in different patients. The pressure of articial pneumothorax was maintained at 4–8
mmHg.
ab
cd
ef
gh
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Fig. 11.1 Position and docking of the surgery. (a)
Surgical position for ligation of PDA by Da Vinci robots;
(b) layout of the intraoperative operating table; (c) schematic diagram of robot arm placement during surgery; (d)
the position of the trocar hole; (e) targeting point of the
surgical work area; (f) the positioned instrument arms
before surgery; (g, h) the relative position of the robotic
trocar on the patient
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L. Ying and X. Liu
11.5 Surgical Steps
When the surgery began, the assistant surgeon
assisted the chief surgeon in pulling open the left
side lobar lung to expose the PDA. The surgeon
pulls the lens closer to the PDA (Fig.11.2).
When the position of the arterial catheter is
exposed well, the chief surgeon incisions the visceral pleura and aortic external with electrocoagulation along the aorta from the origin part of
the left subclavian artery. The chief surgeon
exposes the full view of the PDA gently using the
mechanical arms. The upper and lower windows
are separated carefully. See the schematic diagram in Fig.11.3.
The assistant handed a No. 7 silk thread to the
surgeon. The length of the silk thread is about
6–8 cm according to the PDA.The master surgeon placed the silk thread above the arterial
catheter. The position of the silk thread is just on
the left subclavian artery to ensure that it can be
seen by the surgeon and can be easily obtained.
The assistant opened the mesentery to expose the
arterial catheter, taking care not to pinch the
vagus nerve (Fig.11.4).
The surgeon operates the instrument arm to
bypass the PDA from the lower window to the
upper window. When doing this, the surgeon
ensured that the PDA was not pulled or raised
(Fig. 11.5). Then, the silk thread is ligated.
Additionally, make sure the thread is knotted in
place to avoid pulling the PDA. According to
experience, it is best to tighten the wire knot at
the upper and lower windows of the PDA
(Fig.11.6). After nishing 3 knots, the assistant
helped the surgeon cut the tail line short. The
second silk thread also passes the PDA as the
rst step. The silk thread knot is tensioned. The
second knot was not tied to the rst knot, and
the vagus nerve and recurrent laryngeal nerve
Fig. 11.2 The assistant surgeon pulled the left side lobar lung to expose the patent ductus arteriosus
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Fig. 11.3 The chief surgeon exposed the upper and lower windows of the patent ductus arteriosus
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Fig. 11.4 The assistant surgeon assisted the chief surgeon in exposing the patent ductus arteriosus
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L. Ying and X. Liu
Fig. 11.5 The chief surgeon bypassed the patent ductus arteriosus using No. 7 silk
Fig. 11.6 The silk thread was ligated
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