Magnus Anderberg

Paediatric robotic surgery in clinical practice: a cost analysis.

BACKGROUND Since 2006 we have used robotic assistance when performing minimally invasive laparoscopic fundoplications in children. We compared the costs of robotic surgery with the costs for open and laparoscopic surgery to test our hypothesis that the increased costs of the new technology are acceptable. METHOD Costs were calculated using the regional hospital prices for our first 14 fundoplications in children, performed with the aid of the da Vinci Surgical System from Intuitive Surgical. We compared these costs with those of our ten latest fundoplications performed using open and laparoscopic surgery, respectively. There were no differences in the demographic data, work-up or indications for surgery between the three groups of children. RESULTS The mean cost of robotic surgical fundoplications (EUR 9 584) was 7% higher than the mean cost of laparoscopic surgery (EUR 8 982) and 9% lower than the mean costs for open surgical procedures (EUR 10 521). These differences can be explained by the increased cost of robotic instruments (EUR 2 081 per operation). The duration of the operation and the duration of in-hospital stay are comparable to those of laparoscopic surgical interventions. The time required for the operative intervention was considerably longer than for the open surgical procedure; the duration of the in-hospital stay was only half of that of the open surgical procedure. The patients seemed to benefit from the use of robotic instruments with less morphine (as a marker of less postoperative pain) and a shorter hospital stay. CONCLUSION The introduction of robotic assistance into surgical practice involves increased in-hospital costs, mainly because of the cost of the new instruments. This increase in cost can be offset by the shorter hospital stay compared to open surgery. After laparoscopic surgery the hospital stay is about the same as after operations performed with robotic assistance. Cheaper instruments and shorter operating time will make robotic surgery cost efficient in the future. The benefit for the patients is less trauma due to the use of minimally invasive surgery and a shorter hospital stay. Thus, the higher initial costs may be considered worthwhile.

Morgagni Hernia Repair in a Small Child Using da Vinci Robotic Instruments - A Case Report

BACKGROUND The recently introduced use of robotic surgery in minimally invasive surgery procedures facilitates several steps in the operative procedure. We report the first case of a robot-assisted laparoscopic repair of a Morgagni hernia using the da Vinci Surgical System from Intuitive Surgical (Sunnyvale, CA, USA) in a 7.8 kg 18-month-old child. METHODS Four trocars were used to gain access to the abdomen. The robot-enhanced instruments were used to close the hernia defect with interrupted, absorbable sutures, using intracorporeal knot tying. RESULTS The operation was completed laparoscopically without a patch. The total setup time for the robotic system was 35 minutes including draping. The operating time at the robotic console was 80 minutes. The child tolerated an oral intake the day after surgery and was discharged home on the third postoperative day. CONCLUSION Robot-assisted laparoscopic Morgagni hernia repair is feasible in small children.

Prolonged Use of Proton Pump Inhibitors as Stricture Prophylaxis in Infants with Reconstructed Esophageal Atresia.

Introduction Proton pump inhibitors (PPIs) are used as prophylaxis, guarding against anastomotic stricture (AS) in the aftermath of reconstructed esophageal atresia (EA). The incidence of stricture formation was studied in this setting, comparing outcomes of 3‐ and 12‐month PPI prophylactic regimens. Patients and Methods Patient characteristics (gestational age, birth weight, prevalence of chromosomal aberrations, and other malformations), as well as rates of survival, AS formation, and required balloon dilation, were recorded in the following therapeutic subsets: (1) all infants undergoing primary surgical anastomosis for EA in years 2010–2014 and given postoperative PPI prophylaxis for 12 months and (2) all infants similarly treated for EA in years 2001–2009 but given postoperative PPI prophylaxis for 3 months only. Duration of follow‐up was 1 year in each group. Results Patient characteristics and survival rates in 12‐month (n = 33) and in 3‐month (n = 30) treatment groups did not differ significantly. The prevalence of AS was 42%/43% in each group (12 months, 14/33; 3 months, 13/30; p = 1). Median number of dilations required was 3 (range, 1–9) per patient in each group (p = 0.69). Median age at initial dilation was 163 days and 63 days in 12‐ and 3‐month groups, respectively (p = 0.04). Conclusion Development of AS in the first year after reconstruction of EA was not reduced by prolonged PPI prophylaxis (12 vs. 3 months), but initial balloon dilation procedures were performed later in infants who were treated longer.

A literature review of the outcomes after robot-assisted laparoscopic and conventional laparoscopic Nissen fundoplication for gastro-esophageal reflux disease in children.

Robot‐assisted surgery is a promising technical innovation. Given the similarities between laparoscopic and robot‐assisted surgery it is unlikely that randomized controlled trials would be conducted to disclose any differences between these two technical instruments. Thus, skepticism remains due to lack of any definitive conclusions in the literature.

Robot-Assisted Laparoscopic Hemihysterectomy for a Rare Genitourinary Malformation with Associated Duplication of the Inferior Vena Cava - A Case Report.

Anderberg M et al. Robot-Assisted Laparoscopic Hemihysterectomy for Rare Genitourinary Malformation ... Eur J Pediatr Surg 2010; 20: 206 – 208 Introduction & Complex non-communicating M ü llerian / Wolffi an malformations are rare and a strict classifi cation from an embryological point of view is sometimes diffi cult [1, 2] . For unknown reasons laterally distributed malformations are more often right-sided [14] . Diagnosis is often delayed due to the rarity of the condition but symptoms typically include increasingly severe dysmenorrhoea. A thorough preoperative investigation is mandatory to rule out other anomalies and to plan a correct surgical approach. Typically, the didelphic uterus is associated with an obstructed hemivagina and almost invariably an ipsilateral renal agenesis [9, 14] . These patients can be successfully treated by resection of the vaginal septum [7, 9] . Alternatively, a unicornuate uterus with a rudimentary horn, which covers a wide range of anatomic variability, requires a hemihysterectomy and sometimes an adnexectomy [8, 9] . These patients are reported to have ipsilateral renal agenesis in 38 % of cases [9] . The rationale for a hemihysterectomy in the case of a rudimentary horn is to alleviate dysmenorrhoea, to prevent an intracornual pregnancy and to possibly prevent endometriosis caused by refl ux of viable endometrial cells. The rationale for removing the ispilateral fallopian tube is to avoid an ectopic implantation fertilised via the communicating hemiuterus. We present here a case of left sided noncommunicating hemiuterus, a large haemato-oophorosalpinx, ipsilateral renal agenesis and associated inferior vena cava duplication with a high division and aberrant courses of the external iliac and hypogastric veins. Since October 2005, the Departments of Obstetrics and Gynaecology and Paediatric Surgery at Lund University Hospital have been using the da Vinci system (da Vinci ® Surgical System, Intuitive Surgical Inc, CA, USA) to perform robot-assisted surgical interventions. Since then, robotassisted surgery has been performed on more than 400 patients, providing extenRobot-Assisted Laparoscopic Hemihysterectomy for a Rare Genitourinary Malformation with Associated Duplication of the Inferior Vena Cava – A Case Report

Outcome after Computer-Assisted (Robotic) Nissen Fundoplication in Children Measured as Pre- and Postoperative Acid Reducing and Asthma Medications Use.

PURPOSE This study aims to report the clinical outcome of computer-assisted fundoplication (CAF) in children. METHODS As our center changed policy to using computer-assisted surgery only, a prospectively studied cohort of 40 children underwent CAF, during the period from January 2006 through May 2013. The collected data include patient demographics and postoperative complications as well as medication, 24-hour pH measurements and DeMeester scores before and after surgery. RESULTS In the studied group, the median percentage of the duration of the 24-hour pH < 4 decreased postoperatively from 11 (range, 5-39) to 1% (range, 0-12) (p < 0.001); the DeMeester score decreased from 40 (range, 17-137) to 5 (range, 1-42) (p < 0.001). All 40 patients required antireflux medication before the fundoplication. This number decreased significantly to 8 (20%) after the fundoplication (p < 0.001). Before the fundoplication, 22 children (55%) were using asthma medication and 12 (30%) after the fundoplication (p = 0.04). CONCLUSIONS The CAF significantly reduced the acid reflux from the stomach to the esophagus and the use of antireflux as well as asthma medication during the median observation period of 5 years. The evidence of advantages compared with conventional laparoscopic fundoplication remain to be confirmed.

Robot-assisted radical cystoprostatectomy in a small child with rhabdomyosarcoma: a case report

We report the first case of a robot-assisted radical cystoprostatectomy in a 22-month-old boy with embryonal rhabdomyosarcoma in his urinary bladder. Treatment according to international protocol CWS-2002 P (Cooperative Weichteilsarkom Studie) was given prior to surgery. The da Vinci S Surgical System from Intuitive Surgical (Sunnyvale, CA, USA) was used to laparoscopically remove the urinary bladder and prostate radically. The surgical procedure performed and the postoperative course were uneventful. This technique is safe and feasible also in small children. It seems to have advantages over open surgery and no disadvantages. We recommend this technique for further use.

Faster acquisition of laparoscopic skills in virtual reality with haptic feedback and 3D vision

Abstract Background: The study investigated whether 3D vision and haptic feedback in combination in a virtual reality environment leads to more efficient learning of laparoscopic skills in novices. Material and methods: Twenty novices were allocated to two groups. All completed a training course in the LapSim® virtual reality trainer consisting of four tasks: ‘instrument navigation’, ‘grasping’, ‘fine dissection’ and ‘suturing’. The study group performed with haptic feedback and 3D vision and the control group without. Before and after the LapSim® course, the participants’ metrics were recorded when tying a laparoscopic knot in the 2D video box trainer Simball® Box. Results: The study group completed the training course in 146 (100–291) minutes compared to 215 (175–489) minutes in the control group (p = .002). The number of attempts to reach proficiency was significantly lower. The study group had significantly faster learning of skills in three out of four individual tasks; instrument navigation, grasping and suturing. Using the Simball® Box, no difference in laparoscopic knot tying after the LapSim® course was noted when comparing the groups. Conclusions: Laparoscopic training in virtual reality with 3D vision and haptic feedback made training more time efficient and did not negatively affect later video box-performance in 2D.

Single-Port Laparoscopy-Assisted Appendectomy in Children : A Method Described

Single-incision laparoscopic appendectomy (SILA) has gained popularity in children, and several different techniques have been described, including intracorporeal and extracorporeal techniques and single-channel and multi-channel single-port techniques. However, there has been a concern that exteriorizing an infected appendix through the umbilical channel would increase the risk of postoperative wound infections. This report aims to describe a technique for single-port laparoscopy-assisted appendectomy (SPLAA) using an operative laparoscope and conventional laparoscopic instruments, as well as a VersaStep™ sheath to protect the wound edge while removing the appendix from the abdomen.

Pre- and Postoperative Vomiting in Children Undergoing Video-Assisted Gastrostomy Tube Placement

Background. The aim of this study was to determine the incidence of pre- and postoperative vomiting in children undergoing a Video-Assisted Gastrostomy (VAG) operation. Patients and Methods. 180 children underwent a VAG operation and were subdivided into groups based on their underlying diagnosis. An anamnesis with respect to vomiting was taken from each of the childrens parents before the operation. After the VAG operation, all patients were followed prospectively at one and six months after surgery. All complications including vomiting were documented according to a standardized protocol. Results. Vomiting occurred preoperatively in 51 children (28%). One month after surgery the incidence was 43 (24%) in the same group of children and six months after it was found in 40 (22%). There was a difference in vomiting frequency both pre- and postoperatively between the children in the groups with different diagnoses included in the study. No difference was noted in pre- and postoperative vomiting frequency within each specific diagnosis group. Conclusion. The preoperative vomiting symptoms persisted after the VAG operation. Neurologically impaired children had a higher incidence of vomiting than patients with other diagnoses, a well-known fact, probably due to their underlying diagnosis and not the VAG operation. This information is useful in preoperative counselling.