Mayo Clinic- Rochester, Department of Urology, 200 1st Street SW, Rochester, MN 55905, United States.
J Pediatr Urol. 2023 Aug;19(4):426.e1-426.e4. doi: 10.1016/j.jpurol.2023.03.038. Epub 2023 Apr 5.
In the past two decades, technology has advanced to augment an already minimally-invasive approach in laparoscopic surgery. Robotic-assisted laparoscopic platforms have now evolved to its 4th-generation product: a single-port system, first cleared through the FDA for urologic procedures last year. A single, 2.5 cm incision allows for placement of a port that admits a fully-wristed camera as well as three fully-wristed instruments, all controlled by the surgeon at the console.
We sought to document the feasibility of the single-port (SP) robotic platform in the first clinical series of pediatric patients, reporting use of this system for dismembered pyeloplasty and Mitrofanoff. Secondary aims were to report intraoperative details and perioperative outcomes.
Seven patients underwent surgery using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). Six patients, two girls and 4 boys, were diagnosed with ureteropelvic junction obstruction and underwent SP robotic-assisted dismembered pyeloplasty while one male patient with neurogenic bladder underwent SP robotic-assisted Mitrofanoff procedure. Patient's ages ranged from 22 months to 14 years. A 2.5-cm incision was made within the Pfannenstiel line in HIdES fashion for the pyeloplasties, while the previous gastrostomy tube site was used for the Mitrofanoff. Through this incision a 25-mm multichannel port was placed. The 12 × 10-mm articulating robotic camera and two 6-mm articulating robotic instruments were utilized.
All surgeries were completed successfully through the single port without intraoperative complications, need for separate ports, or conversion. Median operative time was 120 min, and all patients were dismissed in less than 24 h, taking only acetaminophen and ibuprofen for pain control. There was no issue with instrumentation in older patients; however, shorter working distance in the 22-month-old pyeloplasty limited wristing of the instruments.
We report the first cases utilizing the SP robotic platform in children. Despite their smaller size and limited workspace, we had no issues with instrument clashing or triangulation in older patients, completing the procedures in a similar timeframe as multiport robotic platforms. Use of the SP platform is not recommended if working distance will be < 10 cm from the end of the port as instrument movement is prohibitive. The HIdES approach of placing the port in the Pfannenstiel line gave additional working distance and kept the incision below the swimsuit line for excellent cosmesis (Figure 1). Further study with additional cases will compare this approach with standard multiport robotics to analyze and compare operative data and outcomes.
在过去的二十年中，技术的进步使得腹腔镜手术中的微创方法得到了增强。机器人辅助腹腔镜平台现已发展到第四代产品：单端口系统，该系统去年首次通过 FDA 批准用于泌尿科手术。一个 2.5 厘米的单一切口可容纳一个端口，该端口可容纳全腕关节的摄像头和三个全腕关节的器械，所有器械均由控制台的外科医生控制。
我们旨在记录单端口（SP）机器人平台在儿科患者的首个临床系列中的可行性，报告使用该系统进行离断性肾盂成形术和 Mitrofanoff 的情况。次要目标是报告手术过程中的细节和围手术期的结果。
七名患者使用达芬奇 SP 手术系统（直觉外科公司，加利福尼亚州森尼韦尔）进行手术。六名患者，两名女孩和 4 名男孩，被诊断为肾盂输尿管连接部梗阻，并接受了 SP 机器人辅助离断性肾盂成形术，而一名患有神经源性膀胱的男性患者则接受了 SP 机器人辅助 Mitrofanoff 手术。患者年龄从 22 个月到 14 岁不等。在 HIdES 方式下，在 Pfannenstiel 线内做 2.5 厘米的切口进行肾盂成形术，而 Mitrofanoff 则使用之前的胃造口管部位。通过这个切口放置一个 25 毫米的多通道端口。使用 12×10 毫米的铰接式机器人摄像头和两个 6 毫米的铰接式机器人器械。
所有手术均通过单端口成功完成，无术中并发症、无需单独端口或转为开放手术。中位手术时间为 120 分钟，所有患者在 24 小时内出院，仅需服用对乙酰氨基酚和布洛芬来控制疼痛。在年龄较大的患者中，器械没有问题；然而，在 22 个月大的肾盂成形术中，较短的工作距离限制了器械的腕部运动。
我们报告了在儿童中首次使用 SP 机器人平台的病例。尽管他们的体型较小，工作空间有限，但在年龄较大的患者中，我们没有遇到器械碰撞或三角化的问题，手术时间与多端口机器人平台相似。如果端口末端的工作距离<10 厘米，则不建议使用 SP 平台，因为器械的移动会受到限制。将端口放置在 Pfannenstiel 线中的 HIdES 方法提供了额外的工作距离，并将切口保持在泳衣线以下，以获得极佳的美容效果（图 1）。进一步的研究将通过更多病例比较这种方法与标准的多端口机器人，分析和比较手术数据和结果。
