Clinical application and evaluation of robot-assisted surgery in children

Abstract

Minimally invasive surgery (MIS) in children is epitomised by delicate and complex reconstructive procedures undertaken on diminutive anatomy within constrained operative workspaces. Conventional MIS equipment imposes restrictions on a surgeon’s ability that may limit the eligibility, safety and effectiveness of keyhole surgery in paediatric settings. Enhancements provided by medical robotics may restore and augment operative capabilities to overcome these limitations. This thesis represents a detailed healthcare technology assessment of robotic technologies in paediatric MIS.

Systematic review of the first decade of clinical adoption identifies a progressive diffusion pattern. Fundoplication and pyeloplasty procedures stand out as dominant target applications. Meta analyses of comparative effectiveness literature for these procedures identified outcomes to be either comparable or marginally better, but at higher financial cost. An international survey was conducted to understand perceptions of paediatric surgeons towards robotic technologies. To address a deficiency in dedicated education resources, an inaugural European workshop was hosted. Large prospective fundoplication and pyeloplasty series were then analysed to determine multi-dimensional learning curves.

Other features of robots in paediatric surgery were explored in further detail, specifically dextrous ‘wristed’ instruments and haptic feedback loss. In a pre-clinical randomised study of robotic versus non-robotic instruments a threshold workspace size of <200cm3 was identified for which existing larger robotic instruments are less well suited for advanced bimanual tasks. Investigation of in vivo suture damage revealed that experience-related factors compensate for haptic loss. A force-sensing paediatric laparoscopy simulator was developed and validated to provide a platform for compensatory haptic skills to be acquired.

Overall, first-generation robotic systems can safely be used to perform all paediatric procedures currently undertaken with conventional MIS techniques. However, cost-effectiveness is not sustainable in most healthcare settings. If genuinely disruptive clinical improvements are to be achieved, creative new procedural approaches need to be considered that are facilitated by purpose-designed technology. To pursue this agenda, the application of two novel single-shaft flexible robotic system prototypes are investigated for future roles in advancing surgical care in children.