Pediatric Robot Surgery with the Da Vinci Surgical System by Dr. Thomas Lendvay, MD

Pediatric Robot Surgery with the Da Vinci Surgical System

By Dr. Thomas Lendvay, MD

Member, Medical Robotics Magazine Board of Editorial Advisors

Since the introduction of a commercially available surgical robot in 2001, the number of patients undergoing robotic surgery has exploded in the US. The surgical robot is an adjunct to existing laparoscopic surgery (keyhole surgery) and enables the surgeon to move instruments with more degrees of freedom than a human hand. The principles involve a surgical console where the surgeon sits and controls robotic instruments that are placed through small incisions in the patients’ cavities (chest, abdomen, neck, etc.). The surgeon has a 3-D view of the operative field through a visor on the console that projects images form two stereoscopic cameras placed within the patient. The robot dampens natural human tremor and allows for motion scaling for more precise movements (e.g. if the surgeon moves her hands 3 cm through space, the robot will only move the instruments one cm through the patient. The advantages to patients is that they avoid having large surgical incisions and they experience less post-operative pain while receiving surgery that recreates open surgical success.

Initially, the robot’s use was limited to adults because many thought that the robot was too bulky for operating on children, but the delicate robotic movements are ideal for the reconstructive surgeries children require. To date, the robot has been used to fix many types of birth defects in children and is used to remove poorly functioning or cancerous organs. The areas of pediatric surgery, urology, cardiothoracic surgery, and neurosurgery have embraced robotic technology. Doctors at Children’s Hospital and Regional Medical Center in Seattle, WA have used the robot to repair birth defects in the genito-urinary system, the intestinal tract, and the lungs. Some of the more common procedures performed include repair of congenitally obstructed kidneys (pyeloplasty), refluxing urinary systems (where urine goes backwards from the bladder to the kidney), duplicated kidney systems, repair of gastro-esophageal reflux in children, and removal of abnormal lung masses. The robot has also been used to repair children born with ambiguous genitalia (removal of female internal organs in genetically male boys) and has been used to create urinary channels in spina bifida patients so that they can better empty their bladders. Children as young as 5 months old and as small as 20 lbs. have successfully undergone robotic surgery.

The major advantages to robotic surgery in the future will be in surgical education and ensuring that patients receive the finest care from the most skilled surgeons yielding the best outcomes. Through improved resident education, the robot will allow learners to rapidly acquire the skills needed to perform safe and effective surgery with faster learning curves than open or conventional laparoscopy.

In April, Children’s became one of only a handful of pediatric institutions nationwide to incorporate the da Vinci® robotic system into minimally invasive surgery. Robotic-assisted laparoscopic (RAL) surgery has penetrated adult urology, general surgery, cardiac surgery, and gynecology. Many people, however, have reported that robotic surgery is not applicable to children before adolescence due to the smaller working spaces and the robot’s size. At Children’s Hospital and Regional Medical Center, we are using the robot to assist in performing urinary tract reconstruction formerly difficult with pure laparoscopy. We have performed over 20 robotic surgeries including extravesical ureteral reimplantation, pyeloplasty, ureteropyelostomy, nephrectomy, and Mitrofanoff and ACE procedures. We have operated on children less than 10 kg and under one year of age. Our goal is to determine if patient outcomes can be improved with the use of RAL. Laparoscopy has been shown to reduce post-operative pain and lessen hospital stays in adults, but little literature has focused on these advantages in children. Few surgeons perform complex urinary tract reconstructions on infants and toddlers because fine suture material is required for delicate anastomoses and smaller working spaces overstep the limitations of pure laparoscopic equipment and techniques. The robot, however, allows for increased precision and articulation required for complex reconstructions in small children.

In the Fall we will begin our first prospective study with the robot comparing RAL extravesical ureteral reimplants with open extravesical reimplants. Our primary study end-point will analyze post-operative pediatric pain scores. In addition, we will compare narcotic requirements, operative times, length of hospital stays, and surgery outcomes. We will also collaborate with pediatric urologists from the University of Connecticut to assess RAL pyeloplasty outcomes in children less than 4 years of age, a particular age group of patients thought not to be candidates for RAL due to patient size.

In addition to my clinical research endeavors, I will be focusing on advancing robotics in the realm of surgical simulation. CPR, PALS, ATLS, and ACLS are all examples of medical simulation training modules which focus on first teaching disease didactics and subsequently recognizing and applying appropriate interventions. Historically, surgical training has been based on the doctrine, “See one, do one, teach one.” Although current and past surgical training has remained relatively unchanged, demands from clinicians, the public, and the government to improve patient outcomes have encouraged us to re-evaluate our training techniques. Airline pilots spend hundreds of hours in flight simulators before they ever get into a cockpit. This type of training will be applied to surgical residencies in the future. The models for surgical simulation have become evident in teaching basic laparoscopy but the techniques in pure laparoscopy, especially suturing, are associated with a slow learning curve. We are working with a surgical simulation company in Seattle to validate a virtual reality da Vinci® robot simulator. In addition, I am collaborating with the University of Washington Biorobotics and Engineering department in their goal to create a dual trainer-trainee robot consul to teach robotic techniques with immediate trainer oversight, much like in a cockpit.

Through collaboration with the ISIS (Institute for Surgical and Interventional Simulation) Center at the University of Washington, Dr. Sangte Park and I will be developing surgical simulation curricula to help instruct residents on safe and efficient practices for bedside procedures. The first simulation module we plan to develop is a percutaneous suprapubic tube (SPT) placement module for the management of acute urinary retention. When surveyed, residents reported that a simulation module to train SPT placement would have benefited them and most respondents reported knowing of patients who suffered morbidity from inadequate placement or positioning of these tubes. We plan to develop a prototype virtual reality suprapubic tube placement module with haptic feedback to help urology residents learn how to minimize morbidity and understand the indications for such tubes. Once designed, this module could be adapted to training Emergency Medicine and Pediatrics residents on how to safely perform suprapubic bladder aspiration for pediatric fever work-ups, as well as be adapted for other percutaneous needle insertion/catheter placement techniques such as thoracentesis. Hospitals around the country are moving towards individual procedure credentialing and will require that residents have completed appropriate didactics and simulation before performing procedures on actual patients. Similar to general surgery and anesthesiology who have designed mannequin-based central venous line placement simulators incorporating ultrasound (US) guidance, our simulator will use US to mitigate patient morbidity. The University of Washington’s ISIS Center has a cooperative relationship with the University of British Columbia and McGill University in Canada to share simulation modules and residents/medical students for validation studies. Through additional collaborations with faculty at Emory University and the University of Minnesota, we will have a robust resident population to evaluate and ensure statistical power for any validation studies.

Medical training is now based on learners achieving goals laid out within the Clinical Core Competencies. Each resident must reach these goals before advancement and we have been tasked with ensuring that the public has confidence in our surgical skills. Training our future clinicians through discrete curriculum-based surgical simulation modules demonstrates our unending pursuit to improve patient outcomes.

Dr. Thomas Lendvay is an attending pediatric urologist at Seattle Children’s Hospital and is an assistant professor at the University of Washington, Department of Urology. His clinical and research focus is on minimally invasive surgery using laparoscopy and telerobotic surgical technologies. He has spear-headed the newly developed robotics program at Children’s and collaborates with the Biorobotics engineering department at UW relating to clinical applications of new telerobotic technologies. Additionally, he is a member Expert of the ISIS (Institute for Surgical and Interventional Simulation) center at UW to help advance surgical education for medical students and residents through simulation curriculum and is involved in the development of a virtual reality percutaneous catheter placement simulator. Through his work with the Biorobotics lab, he plans to be involved in an upcoming NASA Extreme Environment Mission Operations (NEEMO 12) demonstration of remote telerobotic surgery to be performed from Seattle to a submerged space station of the coast of Florida this Spring. Dr. Lendvay has also published this year on outcomes and practice patterns for the management of vesicoureteral reflux disease and the management of incontinence in spina bifida patients using multi-center databases.