The development of surgical robotics is a dynamic process, a constant interplay between clinical need and technologic capability. As both of these factors are constantly changing, it is unlikely that the form the surgical robot takes today will be the form it takes in 20 years. In many aspects, the technology has progressed beyond perceived clinical need. This has created a novel challenge for the surgeon — to determine whether a technologic innovation with apparent benefit has meaningful clinical application. This process has defined the in corporation of robotic technologies into many surgical disciplines, including gynecologic, cardiothoracic, urologic, abdominal, and pediatric surgeries. In whatever way this interplay of technology and clinical need progresses, surgeons are left with the task of guiding its impact on patient care.

The term robot is a misnomer when describing this surgical device. Derived from the Czech robota meaning “drudgery,” this term implies autonomous function, which most surgical robots do not have. Instead, they are better described as computerassisted telemanipulators, implying that they are subject to human control. The complexity of surgical procedures does not currently allow for devices that work entirely autonomously. Nevertheless, the term robot has added a flare of futurism to the endeavor and has been the one most commonly used in the literature.

The rapid co-evolution of instrumentation and surgical technique has allowed for an ever-growing number of pediatric procedures to be performed using minimal access surgery (MAS). Presently, patients of any size or age (i.e., from fetus to adolescent) can benefit from MAS. This chapter discusses current applications of MAS in infants and children and explores new developments and future directions in the field. Throughout this chapter, the term MAS is defined as procedures that are performed with tiny (≤12-mm) incisions, those performed percutaneously, or those performed endoluminally. It encompasses the field of robotic surgery and image-guided therapy. Common synonyms are laparoscopic surgery (abdominal MAS), thoracoscopic surgery (thoracic MAS), videoscopic surgery, and endosurgery.

WHY MINIMAL ACCESS PEDIATRIC SURGERY?

To date, there is only one randomized controlled trial of MAS in the pediatric population; however, many large retrospective studies in adults have demonstrated decreased postoperative pain, earlier return to feeds, shorter hospital stays, and improved cosmetic results when compared with open surgery. Despite these advantages, a number of concerns limited early widespread adoption of minimal access techniques in children. Appropriately sized instruments were slow to develop as the manufacturers focused on the adult population. The cost of these instruments was believed to be too high and the length of setup too long. Further, perioperative pain and stress have historically been underappreciated in children, and the benefit of smaller incisions was not seen to be substantial as many pediatric surgeons believed they had already made “small incisions.”