Despite numerous advantages, thoracoscopic esophageal anastomosis is challenging. The spatial constraints of the thoracic cavity combined with surgeon tremor, large translated motions at the instrument tips, and a decreased view of the operative field increased not only the risk of injury to surrounding organs, but also the difficulty of suturing and knot-tying tasks . In addition, the location of the lesion itself and the thoracoscopic rigid equipment made the operations not in accordance with ergonomic considerations, and finally made the surgeon extremely exhausted.
Theoretically, robotic surgery system possesses superior techniques and friendly design concept over standard thoracoscopic rigid instruments. The articulating instruments with 7 degrees of freedom permit suturing in locations that are difficult to reach, and make dissection around the surgical target at adequate angles. In addition, 3-dimension camera is controlled by the surgeon oneself and internal articulation of the instruments allows the surgeon eye–hand integration to perform flexible and precise maneuvers comfortably . Moreover, stable view and tremor filtration technique is especially helpful for esophageal anastomosis.
However, additional hurdles would come when current robot surgery system was applied: unavoidable instruments collision and inserting huge trocars through the tiny intercostal space. Initially, the minimum distance required between ports is 8 cm and 5–6 cm for later generation robots . Previously, patient’s weight below 4 kg could get irreparable collided for thoracic robotic procedures . According to our experience, in neonates weighing over 3 kg, the width of the hemithorax is only around 7 cm, roughly meeting the requirement. Since the distance between ports cannot reach that requirement, we developed an asymmetric ports distribution technique (Fig. 3A): the distance between the right and the camera ports was only 3 cm, while the distance between the left and the camera was 5 cm. During operation, the instruments remoted by the right hand only maneuvered with the inner-articulating part to avoid robotic arms collisions outside. The motion on the narrow side (right side) was slightly restricted sometimes, but no severe external arms collisions took place. To get enough freedom, the requisite internal length of the instruments is 5.61 cm to keep the articulating instruments functional . Additional solution was that placing the trocars outside of the patient after instruments introduction to provide the instruments an extra 1.5–2.0 cm of maneuverability .
Obviously, it was difficult to insert 12 mm and 8 mm trocars into the intercostal space in neonates . It is possible for the huge trocars to cause rib fracture. We applied a Step procedure firstly used in cannula making in anorectal plasty for high ARM . By dilating the intercostal space gradually, the huge trocars were place on the chest wall successfully. None case got real fracture or postoperative thoracic deformity.
It is acknowledged that the convincingness of this study is limited for series size (only 2 cases). Efforts are still needed to summarize global cases in perspective manner using the next-generation robotic surgery system. As Cundy reviewed, robotic surgery is an expanding and diffusing innovation in pediatric surgery . Taking advantage of the robotic surgery system and finding ways to overcome obstacles can benefit patients finally.
To conclude, Step procedure and asymmetric ports distribution were effective in neonatal thoracic robotic procedures. Stable view and tremor filtration made the esophageal anastomosis more concise. However, there were constant complaints regarding the size of the instruments and trocars.