Pediatric Robotic-Assisted Surgery: Too Early an Assessment?

Abstract

Alexander PopeNew technologies have defined the pace of medical progress in recent years and continue to challenge our ability to assess their safety, efficacy, and value, particularly for children.1 Robotically assisted surgery has rapidly taken hold in several areas of adult surgical practice and is beginning to emerge in pediatric surgery. In their report, vanHaasteren et al2 attempt to assess the current utility and role of pediatric robotic surgery. The authors' conclusions are that this technology seems to be safe and effective but that there is no substantive evidence that this technology is superior to open or conventional laparoscopic surgery. The authors also indicate that the current robotic system is not cost-effective in most applications. Should we abandon this technology for pediatric surgical applications? I suspect that would be premature and likely to prevent some children from receiving the benefits of what may prove to be a positive new paradigm in surgery.One important element to consider in evaluating both this report and robotic surgical technology is in the title: “early assessment.” It can be difficult to know when in the development of a new medical technology it is appropriate to assess this technology. Similar to children, new technologies do not spring forth in mature form but, rather, require time for development and refinement. This has been the case for surgery over the millennia and has been clearly seen in the evolution of laparoscopic surgery in the last 2 decades. The current DaVinci surgical system (Intuitive Surgery, Sunnyvale, CA) was designed for adults yet has been made to work for children, including infants, with technical success. These adaptations require more time, effort, and experience to employ. Already the system has been modified with smaller, 5-mm working instruments, which reduces the size of the port sites. Newer versions of the system are more flexible in positioning constraints, facilitating use in the small patient. The individual instruments, however, remain large and relatively crude. It will continue to evolve, however, as long as there is interest in using this technology.There is also procedural evolution that has been occurring steadily to permit progressively more complex surgeries to be performed, which has increased efficiency.3,4 The learning curve for laparoscopic procedures performed with robotic assistance is much faster than that with conventional laparoscopic procedures. This quality has facilitated the utilization of laparoscopic procedures that were technically feasible with conventional laparoscopy yet were rarely performed because of the challenging learning curve. Adult practice often entails repeating a single operation, whereas in pediatric practice many various procedures are performed by a single surgeon, which limits the ability to efficiently develop the skills of conventional laparoscopy.At present, it may be premature to make any definitive assessment of robotic surgical technology for children. The reported case series have been preliminary, serving the purpose of setting benchmarks of performance and dissemination of methodology, and will act as an impetus for further technologic and procedural evolution. It will be necessary, in time, to more stringently assess these methods. If too much time passes, it may be difficult to effectively assess robotic surgery in that there will be fewer practitioners of conventional open or laparoscopic techniques, and patients may be reluctant to undergo those procedures if they are perceived as archaic.There are other significant challenges to the type of rigorous assessment that vanHaasteren et al have indicated should be used. Performing a prospective randomized, controlled trial for surgical procedures is exceptionally difficult.5 Blinding is nearly impossible, and real ethical concerns must be addressed. These studies are even more difficult in children. It is also difficult to know what outcome paramet