Robotic-assisted versus laparoscopic splenectomy in children: a costeffectiveness study.

Laparoscopic elective splenectomy is considered as a safe surgical treatment of spleen non-traumatic blood disorders. However, robotic assisted splenectomy is becoming a promising alternative, although there are scarce studies in pediatric patients. Our aim is to compare the effectiveness and associated costs of both procedures in children. A single-institution retrospective study was performed among consecutive children undergoing splenectomy between 2004 and 2021, who were divided according to the surgical approach: LAS group (laparoscopic splenectomy) and RAS group (robotic assisted splenectomy). Demographics, clinical features, intraoperative blood loss, surgery time, length of hospital stay (LOS), postoperative complications, need for postoperative blood transfusion, readmission rate and economic data were compared. A total of 84 patients were included (23 LAS group; 61 RAS group), without demographic or clinical differences between them. RAS patients presented lower intraoperative blood loss (42 ± 15 vs. 158 ± 39 ml; p < 0.021) and shorter surgery time (135 ± 39 vs. 182 ± 68 min; p = 0.043), with no differences in median LOS (3 days in both groups). No intraoperative complications or conversion was reported. Five postoperative complications were observed: 4 in LAS patients (17.4%) versus only one in RAS (1.6%; p = 0.021). One reintervention was required in LAS group due to hemoperitoneum 12 h after splenectomy. RAS patients had lower postoperative blood transfusion requirements (1.6% vs. 13.0%; p = 0.025) and lower readmission rate (3.3 vs. 17.4%; p = 0.042). No differences were observed when comparing the median economic costs ($25,645 LAS vs. $28,135 RAS; p = 0.215). Robotic assisted splenectomy may be considered as a safe and feasible option in children compared to the traditional laparoscopic approach. Level of evidence: III.

Simultaneous Robotic-Assisted Splenectomy and Cholecystectomy in Children: Is It Safe and Effective?

Background: Hematologic conditions such as hereditary spherocytosis, sickle cell disease, and idiopathic thrombocytopenic purpura are frequently linked to cholelithiasis. In instances where symptoms are present, simultaneous cholecystectomy and splenectomy are commonly recommended. Our aim was to assess the outcomes of robotic-assisted procedures conducted for simultaneous surgical issues involving the spleen and gallbladder in pediatric patients. Materials and Methods: We have made a simultaneous retrospective study of children with hereditary hematological diseases who underwent combined robotic-assisted splenectomy and cholecystectomy at our institution from January 2010 to December 2021. Demographics, clinical features, intraoperative data, length of hospital stay, postoperative complications, and follow-up outcomes were analyzed. Results: A total of 11 patients (6 male; 5 female) were included, with a mean age of 13.9 ± 4.4 years (range 8-17). Hereditary spherocytosis was the most common disease (7 cases), followed by sick cell disease (4 cases), with associated symptomatic gallbladder litiasis in all of them. Both operations were carried out using the da Vinci® Surgical Si System in a single docking robotic platform (four robotic arms). Median total surgery time was 145 minutes (Q1-Q3: 115-162). Minimal intraoperative bleeding was recorded (mean 45 ± 15 mL), with no intraoperative complications or conversion. Median length of hospital stay was 3 days (Q1-Q3: 2-4). There were no cases of surgical wound infections or postoperative bleeding documented. Conclusion: Simultaneous robotic-assisted splenectomy and cholecystectomy can be considered safe and feasible interventions in children with hematological diseases that affect both the spleen and the gallbladder. However, further research is needed to enhance the existing evidence and establish a standardized approach.

Robotic-assisted vs. Laparoscopic Heller's Myotomy for Achalasia in Children.

INTRODUCTION: Robotic-assisted Heller-Dor procedure has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia in children. Our aim is to compare the effectiveness, safety and associated costs between both procedures. METHODS: A retrospective single center study was conducted among consecutive children operated for achalasia (Heller-Dor operation) between 2005 and 2021, who were divided into two groups according to the surgical approach: laparoscopic (LAP-group) or robotic (ROB-group). Demographics, clinical features, surgery time, length of hospital stay (LOS), postoperative complications, long-term outcomes and economic data were compared between both groups. RESULTS: A total of 24 patients were included (12 in LAP-group; 12 in ROB-group), with no demographic or clinical differences between them. ROB-group patients presented lower intraoperative blood loss (23 ± 15 vs. 95 ± 15 ml; p < 0.001), shorter surgery time (178 ± 25 vs. 239 ± 55 min; p = 0.009) and shorter LOS, with a median of 2 days (Q1-Q3: 2-3) when compared to LAP-group (4 days [Q1-Q3:3-5]; p = 0.008). Three post-operative complications were reported, all in LAP-group (2 esophageal perforations and 1 esophageal tightness). After a median follow-up of 11 years, ROB-group patients presented fewer recurrences (0 vs 5; p = 0.039), less reintervention rate (0 % vs 41.7 %; p < 0.039) and lower associated economic costs (28,660$ vs. 60,360$; p < 0.001). CONCLUSION: This is the first comparative study of robotic and laparoscopic treatment of achalasia in children. Initial outcomes of robotic-assisted Heller-Dor procedure suggests some intraoperative (less blood loss and surgical time) and postoperative advantages (fewer complications and reinterventions). However, long-term studies with larger numbers of patients are needed. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: III.

Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study.

INTRODUCTION: Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children. METHODS: A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared. RESULTS: A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52 ± 19 vs. 145 ± 69 mL; p < 0.021), shorter surgery time (135 ± 39 vs. 179 ± 68 min; p = 0.009) and shorter length of hospital stay (median 3 days [2-4] vs. 5 days [3-7]; p = 0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p = 0.192) and lower overall associated economic costs (25 800$ vs. 45 500$; p = 0.012). CONCLUSION: Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.

Surgical Treatment of Bilateral Tubo-Ovarian Abscess in a Pre-Coitarchal Female.

Tubo-ovarian abscess (TOA) is a complication of pelvic inflammatory disease that is most commonly seen in sexually active females and seldom in pre-coitarchal adolescents. Initial treatment is generally parenteral antibiotics but often requires more invasive surgical procedures. We present the case of a 12-year-old, non-sexually active adolescent, with bilateral TOA who ultimately underwent a sterilizing bilateral salpingectomy and appendectomy for treatment.

Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes.

PURPOSE: To describe the long-term outcomes of the robotic Soave pull-through (RSPT) procedure for Hirschsprung's disease (HSCR) in children younger than 12 months. METHODS: A prospective observational study was conducted on HSCR patients under 12 months of age who underwent RSPT at our institution between 2011 and 2020. Data regarding demographics, clinical features, technical details, operative time, hospital stay, postoperative complications, and long-term outcomes were prospectively collected. RESULTS: A total of 15 patients (9 male; 6 female) were included, with a median age at surgery of 4 months (interquartile range 3-6), and a mean weight of 6.8 ± 1.3 kg. Twelve patients suffered from rectosigmoid aganglionosis and three from long HSCR (extending up to the hepatic flexure). The mean total operative time was 240 ± 72 min. The median hospital stay was 3 days (interquartile range 3-4). Partial anastomosis dehiscence was observed in one patient, requiring reoperation on the 4th postoperative day. With a median follow-up of 79 months (interquartile range 45-115), no fecal incontinence or mild soiling were observed. Constipation occurred in two patients and mild enterocolitis in one case. CONCLUSION: RSPT procedure for Hirschsprung's disease in children younger than 12 months is a safe and effective procedure, with few complications and satisfactory long-term continence outcomes.

Education and training in pediatric robotic surgery: lessons learned from an inaugural multinational workshop.

The introduction of robotic surgery into clinical practice brings new and specific needs for education and training. Application to the pediatric setting comes with unique considerations, warranting dedicated training resources that are accessible. A pediatric robotic surgery workshop was convened to address initial education and training requirements. The event was designed to offer an exposure rich environment for delegates to familiarize and learn basic principles in a maximally efficient manner. Pre- and post-workshop survey responses were evaluated to reflect on the quality of the educational experience and scope for improvement. Feasibility and sustainability of such events was further evaluated by reviewing various challenges encountered. A total of 29 surgeons participated in the workshop, with 7 countries represented. The majority of delegates (94 %) indicated they were "very satisfied" with the overall program. Delegates almost unanimously expressed preference and satisfaction for hands-on content. Qualitative feedback favored a stepwise and modular workshop structure, transitioning from didactic teaching to progressively more advanced training. At the basic and intermediate level, this style of event is able to satisfy initial training and educational needs. Feasibility and sustainability of such events is highly dependent on infrastructure resources that have numerous barriers to accessibility.

Papillary thyroid cancer in identical adolescent twins with osteogenesis imperfecta and Hashimoto's thyroiditis: is there a genetic link?

The relationship between Hashimoto's thyroiditis (HT) and papillary thyroid cancer (PTC) remains controversial. Researchers have identified multiple genes that could put patients with HT at risk for PTC. None are related to osteogenesis imperfecta (OI). We present identical twin sisters with OI who developed PTC in the setting HT.

The use of robotics in pediatric surgery: my initial experience.

Robotic assisted minimal invasive surgery (RMIS) is a new resource popular in some surgical specialties but not yet in pediatric surgery. There are numerous advantages of robotic surgical technology in adult patients well documented in the literature. The purpose of this study is to define the feasibility, safety, and benefits of RMIS in pediatric patients in my initial learning experience. In a period of 24 months, all consecutive abdominal RMIS were reviewed. Chart revision was conducted retrospectively. Demographic data were collected in each patient. Other data reviewed were indications for surgery, surgical procedures, complication rate, and conversion rate to open procedure. Four arms robotic equipment was used in all cases with 3 (5 mm) reusable robotic ports and a single (12 mm) disposable port. A total of 102 consecutive abdominal RMIS were performed in 77 pediatric patients. All cases were performed by the same pediatric surgeon in a teaching institution. The average patient age was 6.2 years (ranged from 4 months to 18 years) with 16 patients <1 year of age. The smallest patient was 4 kg. No cases required conversion to open technique. However, one case was converted to laparoscopy because of mesenteric bleeding. There were five intraoperative complications in three patients: minor bleeding (2), suture orogastric tube (1), and gastric opening (2) with repair. Postoperative complications were noted in four patients: mild dysphagia (2) and Nissen wrap breakdown (2). Although the use of RMIS in pediatric patients is still controversial, it is feasible and safe to perform robotic surgery in children with a low complication rate. In addition, excellent visualization with outstanding maneuverability of instruments is of great benefit. These benefits may offset the increased cost of robotic technology especially in technically complex surgical cases.

A novel technique for the surgical treatment of achalasia in children: evaluated with postoperative esophageal manometry.

INTRODUCTION: The current surgical treatment for achalasia in the pediatric population is the laparoscopic Heller myotomy with or without a fundoplication. Although medical management with serial dilations and botulism toxin injections may offer short-term benefits, surgical therapy offers definitive treatment. In this article, we propose a modified surgical technique that avoids pitfalls associated with the standard procedure and evaluated our results with postoperative manometry. METHODS: Charts were reviewed for all patients having undergone the proposed surgical procedure. Seven patients underwent postoperative manometry, while 12 answered a short questionnaire. RESULTS: While manometry showed a statistically significant reduction of lower esophageal sphincter tone, from a mean preoperative lower esophageal sphincter (LES) of 56.1 mm Hg (SD = 8.88, 95% CI = 50.36-61.93) to mean postoperative LES tone of 11.69 mm Hg (SD = 11.69, 95% CI = 3.287-20.08; P < 0.0001), peristalsis was not consistently affected, although a trend toward improvement was noted. Symptoms related to dysphagia were noted in 42% of patients postoperatively but were mild, while all patients showed improved feeding tolerance and weight gain. Interestingly, patients with a postoperative LES pressure <12 mm Hg were more likely to have no symptoms, although this LES pressure was arbitrarily chosen and the study was not powered to detect this outcome (chi-square = 3.73, df = 1; P < 0.053). CONCLUSIONS: The proposed surgical technique for the treatment of achalasia in children was successful at improving feeding and weight gain and attaining normal postoperative LES tone; however, underlying esophageal dysmotility persisted.

A pure Sertoli cell tumor of the ovary in a 10-year-old female.

STUDY OBJECTIVE: To document an unusual presentation of a pure Sertoli Cell tumor. DESIGN: Case report. RESULTS: We present a 10-year-old female who presented with abdominal pain and diarrhea with no symptoms of puberty. Surgical exploration revealed a metastatic pure Sertoli Cell tumor, which was treated with resection and chemotherapy. CONCLUSION: Sertoli cell tumors are rare occurrences and should be considered in the differential diagnosis for a prepubescent girl with an abdominal mass.