A review of robotic-assisted mediastinal surgery in the pediatric population

Introduction

Advances in minimally invasive surgical techniques have greatly decreased the morbidity associated with large open procedures. Robotics represents a transformative advancement in minimally invasive surgery and has been rapidly integrated into adult surgical practice (1). While the integration of robotic-assisted surgery in the pediatric population has been slower, current trends indicate that pediatric robotic-assisted surgery is a growing field (1). With this increase in utilization, there is growing evidence in the literature demonstrating the safety of robotic surgery in children (1). Numerous studies describe the benefits of robotic surgery compared to conventional laparoscopy or thoracoscopy, including improved visualization, three-dimensional imaging, greater dexterity, a shorter learning curve, and better control within smaller working spaces (1-3). Although most of these studies have been conducted in the adult population, the benefits of robotic surgery are often translatable to pediatric patients. Robotic-assisted surgery offers distinct advantages in the thoracic cavity and mediastinum where the limited working domain demands enhanced visualization and instrument articulation and is quickly becoming the standard of care in adult thoracic surgery.

Gaining surgical access to the thoracic cavity has long been a challenge for thoracic surgeons, as traditional open approaches through thoracotomies and sternotomies are highly morbid. These incisions are associated with high post-operative pain levels and carry a greater risk of post-operative complications including pneumonia, atrial fibrillation, prolonged air leaks, need for transfusion, and death when compared to minimally invasive approaches (4). In the pediatric population, these incisions also carry additional musculoskeletal concerns including the risk of developing scoliosis and acquired thoracic dystrophy (5). Conventional video-assisted thoracic surgery (VATS) provides a limited visual field and requires rigid instruments, limiting dexterity and precision (6). Robotic-assisted surgery allows surgeons to overcome the limitations of conventional VATS while maintaining the benefits of a minimally invasive approach.

Within thoracic surgery, mediastinal resections are particularly well suited to a robotic approach. The robotic platform offers precise fine motor control in a narrow and confined operative field, while avoiding the morbidity of a sternotomy or thoracotomy (6). Pediatric surgeons frequently encounter benign and malignant mediastinal pathology which may require biopsy or resection, and thoracoscopic minimally invasive resection techniques have been increasingly utilized (7). Table 1 includes a list of common pediatric mediastinal pathologies divided by compartment and their typical treatments.

With the growth of robotic surgery within the pediatric population, one would expect that pediatric mediastinal surgery would follow a similar trajectory; however, there have been few studies commenting on the feasibility and safety of robotic-assisted surgery in the pediatric population. In this review, we will outline the scope of literature currently available on pediatric robotic-assisted mediastinal surgery with the goal of clarifying the feasibility and safety of this approach, as well as examining opportunities for future investigation (Table 2). For the sake of this review, we define the pediatric population as all patients ≤18 years old. To review this topic efficiently and effectively, we will first examine the approach to robotic-assisted mediastinal surgery by mediastinal compartment, focusing primarily on the anterior and posterior compartments, including pathology, technique and outcomes. Figure 1 provides a graphical representation of the differences in robotic port positioning for anterior mediastinal surgery compared to middle and posterior mediastinal surgery. Of note, robotic cardiac surgery is being conducted within the middle mediastinum; however, literature surrounding this topic in the pediatric population is extremely limited and therefore will not be discussed in this review. We will then discuss robotic-assisted surgery versus VATS in this population and, finally, analyze potential drawbacks to robotic-assisted mediastinal surgery within the pediatric population.

Figure 1 Graphical diagram indicating typical port placement for robotic-assisted mediastinal surgery in the anterior compartment versus the middle and posterior compartments.

Anterior mediastinum

The anterior mediastinum is defined anteriorly by the sternum and posteriorly by the anterior margin of the pericardium (20). Pediatric pathology within this compartment encompasses both benign and malignant processes. Malignant pathologies include both Hodgkin and non-Hodgkin lymphoma (20). Benign lesions typically include mature teratomas, thymic hyperplasia, thymic cysts, and ectopic thyroid tissue (20). Not all anterior mediastinal masses require resection; in fact, lymphoma, the most common anterior mediastinal mass in the pediatric population, is typically treated with chemotherapy without the need for resection. Diagnosis is typically accomplished with image-guided core needle biopsy rather than excisional biopsy. The comprehensive work-up and medical management of pediatric mediastinal pathology is complex and beyond the scope of this review, however, we will examine the feasibility and safety of the robotic-assisted approach to pediatric mediastinal pathology requiring operative intervention.

Approach

Patient positioning is tremendously important in robotic surgery and becomes even more critical when operating in a small area like the mediastinum. Positioning for an anterior mediastinal procedure differs from that of a posterior or middle mediastinal procedure. For anterior mediastinal procedures, patients are typically placed in the supine position with a roll placed under the shoulders, as illustrated in Figure 2. The arms are padded and dropped below the level of the thorax. The procedure is typically conducted with two working ports triangulated to the lesion (7). Once access has been obtained, the tumor is dissected circumferentially through a combination of blunt dissection and energy attempting to resect the mass as a single unit. Several studies outline the outcomes for pediatric patients undergoing robotic-assisted anterior mediastinal resections and are outlined here.

Figure 2 Example of supine positioning for anterior mediastinal mass with working ports at the third and sixth intercostal spaces, the camera port in the fifth intercostal space, and an accessory port in the eighth intercostal space as indicated by the white circles. Figure redrawn and adapted from Okazaki et al. (21), which is distributed under the Creative Commons Attribution (CC BY) license.

Blanc et al. evaluated robotic surgery in pediatric oncology over a 4-year period (14). Their study captured three patients with thymic pathologies [one patient with thymoma, one with myasthenia gravis (MG) and one with Multiple Endocrine Neoplasia Type 1], representing the only anterior mediastinal pathologies in the study. All three patients underwent successful robotic thymectomies without complications. However, it should be noted that the thymoma patient required reoperation as they initially underwent a partial thymectomy with the presumed diagnosis of teratoma (14). Final pathology revealed thymoma necessitating completion thymectomy. This reoperation was also successfully completed robotically without complication (14). Unfortunately, anterior mediastinal pathology represented a small percentage of the study’s cohort (4%), and the authors did not include length of stay (LOS), operative approach, or operative times specifically for these patients.

Hartwich et al. conducted a retrospective descriptive study, focusing specifically on robotic-assisted thymectomies for MG in the pediatric population (10). Their study consisted of nine patients ranging from 2 to 15 years old who underwent robotic-assisted thymectomy for MG (10). All thymectomies were performed via a left-sided approach utilizing two 5-mm working ports and an 8.5- or 12-mm camera port (10). Of the nine patients in the study, only one suffered a complication: a small residual pneumothorax, which was successfully managed with supplemental oxygen only (10). The average postoperative LOS was 1.1 days, and the average operative time was 160.1 minutes (10).

Grasso et al. published a case report describing a robotic-assisted thymectomy for juvenile MG in a 12-year-old male (12). They utilized a left-sided approach with two 8-mm working ports and an 8-mm camera port (12). They reported no complications. Operative time was 90 minutes; the patient had his chest tube removed on postoperative day 2 and was discharged on postoperative day 4 (12).

Hanke et al. published a case report describing a robotic thymectomy in a 10-year-old male for a thymolipoma (17). They utilized a left sided approach with three 8-mm working ports, a 12-mm assistant port, and a 5-mm camera port (17). There were no postoperative complications, and the patient was discharged on postoperative day three (17).

Meehan and Sandler conducted a case-series which further details the utility of pediatric robotic-assisted surgery within the mediastinum (8). Their study included five pediatric patients, ranging from 2 to 17 years old, who underwent robotic-assisted resection of a mediastinal tumor (8). Of these five patients, three had anterior mediastinal masses, and two had posterior mediastinal masses (8). Pathology for the patients with anterior mediastinal pathology included a 16-year-old female with a mediastinal fluid collection of unknown etiology, an 11-year-old male with a germ cell tumor adherent to the superior vena cava (SVC) and phrenic nerve, and a 17-year-old female with a mature teratoma adhered to the aortic arch and left lung (8). Each of these patients underwent a robotic-assisted mediastinal resection without complication and the average LOS was two days (8).

Each of these studies highlights the safety and feasibility of a robotic approach to the anterior mediastinum in children, with several studies reporting that the improved visualization and articulating instruments offered significant advantages over the traditional VATS approach (8,10,12,14,17). The Hartwich et al. study also demonstrated a progressive decline in operative time corresponding to the number of times the procedure was performed, suggesting a rapid learning curve with the robotic platform (10).

Middle mediastinum

The middle mediastinum is bound anteriorly by the anterior margin of the pericardium and posteriorly by a line approximately 1-cm posterior to the anterior margin of the thoracic vertebral bodies (20). Pediatric pathology within this compartment can be divided into vascular and non-vascular lesions. The utilization of a robotic approach to vascular lesions, which include aortic arch, pulmonary artery, and SVC anomalies, is limited in the pediatric population (20). While reports such as the case report by Ohye et al. and the study by Suematsu et al. illustrate a robotic approach to vascular ring repair in children, for the sake of this review, we will not focus on vascular lesions (22,23). Non-vascular lesions primarily include foregut duplication cysts (bronchogenic, esophageal, and neuroenteric cysts); however, lymphadenopathy can also present as middle mediastinal lesions (20).

Approach

Due to the similarities in surgical approach to middle and posterior mediastinal pathology, more details on the approach will be provided in the posterior mediastinal section. Briefly, the patient is typically positioned in the semi-prone or lateral decubitus position with two working ports triangulated to the lesion (7). Robotic-assisted resections of middle mediastinal pathologies have been described, however, the literature surrounding this topic is limited to primarily case reports.

Obasi et al. published a case report in which they described the robotic resection of esophageal duplication cysts in two patients (9). Their cases included a 12-year-old female and a 15-year-old male, both of whom underwent successful robotic-assisted resection of esophageal duplication cysts utilizing a left-sided approach with three working ports and a camera port (9). There were no complications reported, and they had an average LOS of 1.5 days (9).

Shu et al. published another case report out of China detailing a robotic-assisted resection of an esophageal duplication cyst in an 8-year-old male (19). They utilized a right-sided approach with two working ports and a camera port (19). Total operative time was 135 minutes; there were no complications and LOS was six days (19).

Toker et al. reported a case of an 8-year-old female who underwent a robotic-assisted resection of a bronchogenic cyst via a left sided approach with two working ports and a camera port (11). Total operative time was 62 minutes; there were no reported complications, and the patient was discharged on postoperative day 2 (11).

While limited in quantity, these cases help to illustrate the feasibility and safety of a robotic approach to the middle mediastinum in the pediatric population. In each of these studies, the authors reported that the robotic platform offered distinct advantages over the traditional VATS approach, including superior visualization, greater range of motion, and more precise movements (9,11,19).

Posterior mediastinum

The posterior mediastinum is defined anteriorly by an imaginary line 1-cm posterior to the anterior border of the thoracic vertebral bodies and posteriorly by the paravertebral gutters (20). Most posterior mediastinal pathology in the pediatric population is neurogenic in origin, including neuroblastoma, ganglioneuroblastoma, ganglioneuroma, schwannoma, and neurofibroma, with neuroblastoma being the most common posterior mediastinal pathology in this population (6,20). The posterior mediastinum is a challenging operative location due to its proximity to multiple important structures including the great vessels and spine. Care must be taken in approaching the posterior mediastinum and its approach robotically differs from an anterior mediastinal approach. While the majority of posterior mediastinal lesions resected using a robotic approach are benign, some low and intermediate risk neuroblastomas without evidence of vascular invasion (L1 tumors) may also be amenable to this minimally invasive technique.

Approach

Unlike robotic anterior mediastinal procedures, patients are typically placed in the semi-prone or lateral decubitus position for posterior mediastinal approaches (7). This technique typically utilizes two working ports that are placed under direct visualization, triangulated based on the location of the lesion. The ports can be placed as in Figure 3, or in the same manner as a robotic lobectomy, depending on the lesion being resected and the goals of the operation (7). If necessary, an additional robotic arm can be utilized to retract the lung to aid in visualization. Port placement may need to be adjusted in cases where the pathology resides high in the mediastinum near the apex. For pathology in this location, we recommend utilizing port placement similar to that of a complete robotic portal lobectomy, with the camera port in the mid-axillary line at the seventh or eighth intercostal space, and two or three working ports placed along the same intercostal space in the anterior and posterior axillary lines as in Figure 4. Dissection of the lesion occurs similarly, with a combination of blunt dissection and energy used to circumferentially dissect the mass as a single unit.

Figure 3 Example of lateral decubitus positioning for middle or posterior mediastinal resection with two working ports at the fourth and eighth intercostal spaces and a camera port at the sixth intercostal space, indicated by white circles. An accessory port at the eighth intercostal space is indicated by the gray circle. Figure redrawn and adapted from Okazaki et al. (21), which is distributed under the Creative Commons Attribution (CC BY) license.

Figure 4 Example of port placement for pathology located high in the middle or posterior mediastinum with two working ports placed in the anterior and posterior axillary lines of the seventh intercostal space, a camera port placed in the mid-axillary line of the seventh intercostal space, and an accessory port placed by triangulating with the camera and working ports. All ports are indicated by white circles.

Minimally invasive resection of posterior mediastinal pathology is considered the gold standard in the adult population, with comparable rates of survival and symptom improvement in comparison to the open approach, along with considerable improvements in overall morbidity (6). While there are no trials directly comparing robotic surgery with either VATS or the open approach, it is widely believed that the robotic approach further simplifies the procedure, particularly in areas of the thoracic cavity where working space is limited (6). While there is a consensus favoring the utility of robotic resections in the adult population, literature discussing the matter in the pediatric population is sparse. Despite limitations in the quantity of publications, the existing literature reveals favorable outcomes with robotic utilization in this patient population.

Meehan and Sandler’s case series also included the robotic resection of two posterior mediastinal masses (8). The first case was a 2-year-old female with a ganglioneuroblastoma adherent to the azygous vein and SVC; the second involved a 4-year-old boy with a ganglioneuroma (8). In both cases, the lesions were successfully resected robotically without complication, and the patients had an average LOS of 1.4 days (8).

Blanc et al. also included twelve posterior mediastinal resections in their review (14). Pathology included four neuroblastomas [International Neuroblastoma Risk Group (INRG) stage L1-M], three ganglioneuroblastomas, three ganglioneuromas, and two mature teratomas (14). Notably, one of the patients undergoing resection of a neuroblastoma required conversion to the open approach due to difficulties with dissection secondary to a narrow operative field (14). Additionally, one patient developed a pneumothorax on postoperative day one which required chest tube placement (14). No other complications were noted. Unfortunately, this study does not discuss the mediastinal patients specifically, making it difficult to draw conclusions on these patients as they represent a small percentage of the total cohort.

Nemoto et al. present a case report of a 15-year-old with a ganglioneuroma (13). This case was complicated by the tumor anatomy as the arteries feeding the tumor and the artery of Adamkiewicz (the major arterial supply for the lower two-thirds of the spinal cord) both arose from the ninth intercostal artery (13). They were able to selectively divide the tumor feeding arteries robotically while preserving the artery of Adamkiewicz and ninth intercostal artery and vein, facilitating complete tumor resection without complication (13).

Two additional case reports out of Japan illustrate the feasibility of a robotic approach to the pediatric posterior mediastinum. Ochi et al. describe the robotic-assisted resection of a neuroblastoma in a 28-month-old, pushing the limits of patient size in robotic surgery (16). The original INRG classification was stage metastasis (M), as the patient presented with multiple bone and bone marrow metastases (16). The patient underwent neoadjuvant chemotherapy and autologous peripheral blood stem cell transplant prior to surgical intervention at 35-months and weighing 11 kg (16). They utilized a left sided approach with two 8-mm working ports and a 12-mm assistant port (16). The resection was successfully conducted robotically without complication; however, the authors do not comment on the operative time or LOS (16).

Kaneda et al. published a report in which they discuss the resection of a ganglioneuroma in an 8-year-old male weighing 22.5 kg, utilizing a single left sided subcostal port (18). The resection was successfully carried out robotically without complication (18). Operative time was 250 minutes; the patient’s chest tube was removed on postoperative day 1 and he was discharged on postoperative day 3 (18). The single subcostal port utilized by these authors offers a unique approach which may further increase the feasibility of robotic mediastinal surgery in children (18). This approach avoids the use of the intercostal spaces which are narrow in the pediatric population and raises logistical concerns for robotic mediastinal surgery in this population. This topic will be discussed in greater detail later in this review.

Each of these publications lays the foundation for the safety and efficacy of a robotic approach to the posterior mediastinum in the pediatric population. The authors collectively cited the improved maneuverability and flexibility offered by the robotic platform as being integral to facilitating a meticulous minimally invasive dissection (8,13,14,16,18).

Robotic-assisted surgery versus VATS

Two retrospective studies have examined the feasibility and effectiveness of robotic surgery in pediatric mediastinal pathology. The first study is a single institution study out of Beijing conducted by Zeng et al. (15). The study totaled 149 pediatric patients, ranging from 6-months to 16-years old with an average weight of 23.6 kg (range: 8.0–72.0 kg), who underwent robotic-assisted mediastinal mass resection over a 2-year period (15). Of the 149 patients in the study, there were zero mortalities and only four patients (2.7%) required conversion to thoracotomy (15). The authors noted no serious complications, and no cases of recurrence or need for a secondary operation (15). The mean operative time for these patients was 106.7 minutes, and the average LOS was 7.2 days (15).

The second study was conducted by Sun et al. and was also designed as a single institution study; however, their study provides a true comparative analysis between open, thoracoscopic, and robotic approaches for pediatric mediastinal resection (24). Their study comprised 184 children with an average age of 5.9 years (range: 6-months to 16-years) and an average weight of 23.6 kg (range: 8.0–72.0 kg), who underwent mediastinal tumor resection over a 10-year period and retrospectively compared outcomes based on surgical approach (24). Assessed outcomes included conversion rates, intraoperative and postoperative complications, estimated operative blood loss, chest tube duration, operative duration, postoperative analgesia requirements, LOS, and cost (24).

The study found no statistically significant difference in conversions rates (4.76% vs. 10.71%), operative duration (106.5 vs. 122.5 vs. 111.5 minutes) or postoperative complications rates (7.14% vs. 10.71% vs. 18.18%) between robotic-assisted, VATS and open surgery (24). Additionally, there were no cases of perioperative mortality helping to further demonstrate the safety and feasibility of this approach (24). They also showed that robotic-assisted surgery was associated with shorter chest tube duration (2.0 vs. 3.50 vs. 7.00 days), shorter LOS (5.00 vs. 5.50 vs. 8.00 days), reduced intraoperative blood loss (5.00 vs. 10.00 vs. 30.00 mL) and lower postoperative analgesia requirements (13.47 vs. 16.86 vs. 18.68 mg) when compared to VATS and open surgery (24). However, they also found that robotic surgery accrued the highest overall cost ($8,442.67 vs. $5,725.25 vs. $5,901.33) (24).

While the study by Zeng et al. does not offer a control group for outcome comparisons, they draw similar conclusions to the study conducted by Sun et al. regarding the utility of a robotic approach to the pediatric mediastinum (15,24). Both studies acknowledge that thoracoscopic mediastinal surgery has had positive results, however, both cite limited flexibility of thoracoscopic instruments as a challenge, particularly when circumnavigating mediastinal tumors (15,24). Zeng et al. go on to conclude that a robotic approach to the pediatric mediastinum offers the following advantages: alignment of hand motion with robotic motion which eliminates the reverse movement seen in thoracoscopic surgery; elimination of hand tremors, further improving operative stability; improved visualization due to increased magnification and three-dimensional fields; and improved surgeon ergonomics (15). The outlined benefits of robotic surgery derived from both studies converge on a central theme of improving the precision and safety of the operation. Improvement in operative safety and precision is always important; this fact becomes even more apparent in the pediatric mediastinum—a small, confined anatomic space that contains many important neurovascular structures—making both thoracoscopic and open resection in this area technically difficult and risky (15).

While these studies outline several positive aspects of pediatric robotic mediastinal surgery, Zeng et al. acknowledge that appropriate patient selection is necessary for successful outcomes (15). The primary factor impacting feasibility of a robotic approach was the need for adequate intercostal space for trocar placement (15). The diameter of robotic trocars is 8-mm, therefore children with an intercostal space <8-mm would be poor candidates for a robotic approach (15). While different studies have made claims about the optimal age and weight in which robotic thoracic surgery is feasible in children, this study found that children older than 6-months and weighing more than 8 kg was sufficient (15).

These studies are novel in their evaluation of robotic-assisted mediastinal surgery in the pediatric population both studies, however, they have several limitations. First, the retrospective single institution nature of these reports limits their ability to make claims about the population at large and leads to potential selection bias (15,24). Second, while the short-term outcomes have been promising, long-term follow-up was not conducted, therefore no conclusions can be made about the long-term impact of a robotic approach in this population based on these studies (15,24). Furthermore, while they represent the largest studies conducted regarding this topic to date, both are limited by their sample size (15,24). The Sun et al. study is severely limited in its statistical power when making comparisons between robotic, thoracoscopic and open approaches limiting the ability to draw definitive conclusions from this report (24). Finally, while Zeng et al. infer benefits of a robotic approach, their study lacks a control group and therefore no direct comparisons between robotic outcomes versus traditional VATS approaches can be made (15). Despite their limitations, these studies represent the most comprehensive studies of the feasibility and safety of robotic-assisted mediastinal surgery in the pediatric population and clearly show the robotic approach to be a safe and feasible option.

Delgado-Miguel et al. have published a recent meta-analysis reviewing robotic-assisted thoracic surgery in children as a whole (25). While their meta-analysis goes beyond the scope of this review in discussing pediatric robotic-assisted thoracic surgery outside of the mediastinum, their study does include robotic-assisted mediastinal surgery within this population. This study represents the first meta-analysis addressing the topic of robotic-assisted thoracic surgery in the pediatric population and provides valuable weight to the feasibility and safety of robotic-assisted mediastinal surgery in this population (25). While their analysis was not specifically aimed at evaluating the feasibility and safety of robotic-assisted surgery in the pediatric mediastinum, the authors proposed that the advantages of robotic-assisted surgery may be especially useful in the cervicomediastinal area (25). Similar to previous studies, they cited the flexibility of robotic instruments, improved visualization and elimination of tremors as the primary factors in improving surgical safety (25).

While this meta-analysis is extremely beneficial in synthesizing the available data on robotic-assisted pediatric thoracic surgery, it does have limitations. The most evident limitation stems from the study’s design. Due to the data available in the literature, the meta-analysis relies solely on non-blinded retrospective analyses, opening this study to the same biases previously discussed (25). Despite limitations in the available data the authors concluded that pediatric robotic-assisted thoracic surgery was safe and feasible across a wide variety of thoracic pathologies including mediastinal pathologies (25).

Limitations of pediatric robotic-assisted mediastinal surgery

The literature surrounding robotic-assisted surgery in this population does reveal some limitations. The primary limitation is robotic instrument and port size, which has already been briefly discussed, and has been cited by many of the studies in the literature (7,8,15). This limitation is derived from the fact that smaller patients have smaller thoracic cavities as well as narrower intercostal spaces making the 8- and 12-mm robotic ports difficult to place. It should be noted that several studies in this review, including the studies by Meehan and Sandler, Hartwich et al., and Hanke et al., utilized 5-mm robotic ports (8,10,17). The 5-mm robotic port is only produced for the Da Vinci Si robot and is not available for the newer Da Vinci models, Xi or DV5. Due to the limited working space in the pediatric population, the lack of availability of the 5-mm port for newer robotic platforms may have slowed the growth of robotic surgery in children. One way to circumvent this problem is to avoid the intercostal spaces completely utilizing a single port subcostal or subxiphoid incision as was utilized by Kaneda et al. (18). While there are theoretical benefits to this approach, this technique has not been widely described and therefore the applicability of this technique to a larger population is uncertain.

Aside from port diameter, the length of the port itself provides another limitation. Robotic instruments work by maneuvering around a focal point, which ideally should be centered at the chest wall to allow for complete instrument deployment and full range of motion (7). Due to the small intrathoracic volume in pediatric patients, there is a smaller working space which may not allow for full instrument deployment, limiting the benefits of robotic-assisted surgery. While somewhat counterintuitive, this problem can be circumvented by utilizing longer ports (8). Longer ports allow the surgeon to move the robotic focal point such that it lies external to the patient and artificially increases the available working space, increasing the feasibility of robotic-assisted surgery in children (8).

The loss of haptic feedback when operating on a robotic platform has also been cited as a limitation of robotic surgery (8). While the loss of haptic feedback initially seems concerning, the improved visualization and recognition of visual cues of tension help to mitigate this limitation, with one of the authors noting that no injuries or complications occurred as a direct result of this limitation (8). Still, the loss of tactile sensation when operating in such an important and narrow area does serve as a concern, particularly for surgeons without prior robotic experience who heavily rely on tactile cues when operating.

Finally, while not unique to this population, the cost associated with robotic surgery has been cited as an additional limitation to its utilization in this population (8). As evidenced by the study conducted by Sun et al., robotic surgery in its current state is significantly more expensive than traditional VATS and open surgery (24). For robotic mediastinal surgery to be truly feasible in the pediatric population, its higher inpatient costs must be offset by improved postoperative outcomes and shorter lengths of stay.

Due to the scarcity of literature available on this topic and the absence of studies evaluating the long-term outcomes of pediatric patients undergoing robotic mediastinal surgery, it is difficult to conclude if this approach is truly cost-effective. However, studies have been conducted regarding the cost-effectiveness of robot-assisted surgeries for other pediatric conditions. One such study was conducted by Huang et al. and looked at the cost-effectiveness of robotic surgeries across four pediatric surgical conditions (choledochal cyst, Hirschsprung’s disease, vesicoureteral reflux, and congenital hydronephrosis) (26). They found that while robotic-assisted surgeries accrued a higher inpatient cost than conventional laparoscopy, the robotic-assisted approaches had better postoperative outcomes making them cost-effective overall (26). They found that the greatest benefit was for patients with complex diseases and long operative times (26). Therefore, if robotic-assisted mediastinal surgery follows the same paradigm as has been outlined previously, one would expect that a robotic approach would ultimately be cost-effective. However, without further investigation, one cannot definitively comment one way or another.

Review strengths and limitations

While we feel that this review summarizes the available literature about robotic-assisted mediastinal surgery in the pediatric population, we recognize its limitations. Firstly, while our review portrays a standardized position and operative approach, the reality is that there are subtle differences in positioning and technique described in the literature that are not outlined here. Secondly, we recognize that the scarcity of true comparative studies within the literature significantly limits the ability to truly evaluate the efficacy of robotic mediastinal surgery compared with open or thoracoscopic techniques in this population. Finally, while we believe that this review serves as an introduction to a rather niche topic and summarizes the available literature on the topic, it is meant to serve as a foundational synthesis with the goal of determining the feasibility and safety of robotic-assisted mediastinal surgery in the pediatric population.

Conclusions

Robotic mediastinal surgery represents a safe, feasible, and increasingly versatile approach for the management of diverse pediatric mediastinal pathologies requiring resection. As robotic experience expands and technology continues to evolve, the robotic platform has demonstrated clear technical and ergonomic advantages that may translate into improved precision, enhanced visualization, and greater dexterity within the confines of the mediastinal space. Our review highlights that these benefits are applicable across a broad pediatric age spectrum and across procedures of varying complexity. Despite these promising findings, high-quality comparative data remain limited. Future studies are essential to evaluate long-term clinical outcomes and comprehensive cost-effectiveness in comparison with VATS and open approaches for similar pathologies. In summary, while current evidence supports the safety and feasibility of the robotic approach, further rigorous investigation is necessary to fully optimize its integration into pediatric surgical practice.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-71/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-71/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Navarrete Arellano M, Garibay González F. Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries. Front Pediatr 2019;7:200. [Crossref] [PubMed]
2. Köckerling F. Robotic vs. Standard Laparoscopic Technique - What is Better? Front Surg 2014;1:15.
3. Hong Z, Sheng Y, Cui B, et al. A comparative study of robotic surgery and thoracoscopic surgery for mediastinal cysts. BMC Surg 2023;23:102. [Crossref] [PubMed]
4. Villamizar NR, Darrabie MD, Burfeind WR, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 2009;138:419-25. [Crossref] [PubMed]
5. Lawal TA, Gosemann JH, Kuebler JF, et al. Thoracoscopy versus thoracotomy improves midterm musculoskeletal status and cosmesis in infants and children. Ann Thorac Surg 2009;87:224-8. [Crossref] [PubMed]
6. Kumar A, Asaf BB. Robotic thoracic surgery: The state of the art. J Minim Access Surg 2015;11:60-7. [Crossref] [PubMed]
7. Svetanoff WJ, Bergus KC, Xia J, et al. Robotic-assisted resection of mediastinal tumors in pediatric patients. Semin Pediatr Surg 2023;32:151262. [Crossref] [PubMed]
8. Meehan JJ, Sandler AD. Robotic resection of mediastinal masses in children. J Laparoendosc Adv Surg Tech A 2008;18:114-9. [Crossref] [PubMed]
9. Obasi PC, Hebra A, Varela JC. Excision of esophageal duplication cysts with robotic-assisted thoracoscopic surgery. JSLS 2011;15:244-7. [Crossref] [PubMed]
10. Hartwich J, Tyagi S, Margaron F, et al. Robot-assisted thoracoscopic thymectomy for treating myasthenia gravis in children. J Laparoendosc Adv Surg Tech A 2012;22:925-9. [Crossref] [PubMed]
11. Toker A, Ayalp K, Grusina-Ujumaza J, et al. Resection of a bronchogenic cyst in the first decade of life with robotic surgery. Interact Cardiovasc Thorac Surg 2014;19:321-3. [Crossref] [PubMed]
12. Grasso F, De Leonibus L, Bertozzi M, et al. Robotic-assisted thoracoscopy thymectomy for juvenile myasthenia gravis. Journal of Pediatric Surgery Case Reports 2020;62:101541.
13. Nemoto Y, Kuroda K, Mori M, et al. Robot-assisted thoracoscopic resection of a posterior mediastinal tumor with preserving the artery of Adamkiewicz. Surg Case Rep 2022;8:129. [Crossref] [PubMed]
14. Blanc T, Meignan P, Vinit N, et al. Robotic Surgery in Pediatric Oncology: Lessons Learned from the First 100 Tumors-A Nationwide Experience. Ann Surg Oncol 2022;29:1315-26. Erratum in: Ann Surg Oncol 2021;28:901.
15. Zeng Q, Chen C, Zhang N, et al. Robot-assisted thoracoscopic surgery for mediastinal tumours in children: a single-centre retrospective study of 149 patients. Eur J Cardiothorac Surg 2023;64:ezad362. [Crossref] [PubMed]
16. Ochi T, Koga H, Ueno H, et al. Successful all robotic-assisted excision of highly malignant mediastinal neuroblastoma in a toddler: A case report. Asian J Endosc Surg 2023;16:542-5. [Crossref] [PubMed]
17. Hanke R, Emr B, Taylor M, et al. Robotic resection of a giant thymolipoma in a pediatric patient. J Surg Case Rep 2024;2024:rjae691. [Crossref] [PubMed]
18. Kaneda S, Kawaguchi K, Ito A, et al. Subcostal approach using the single-port robotic system for a giant ganglioneuroma in a child. JTCVS Tech 2025;32:141-3. [Crossref] [PubMed]
19. Shu B, Zhang S, Gao J, et al. Robotic-assisted thoracoscopic surgery for esophageal duplication cyst in a child: a rare case report and literature insight. Front Pediatr 2025;13:1679015. [Crossref] [PubMed]
20. Jaggers J, Balsara K. Mediastinal masses in children. Semin Thorac Cardiovasc Surg 2004;16:201-8. [Crossref] [PubMed]
21. Okazaki M, Shien K, Suzawa K, et al. Robotic Mediastinal Tumor Resections: Position and Port Placement. J Pers Med 2022;12:1195. [Crossref] [PubMed]
22. Ohye RG, Devaney EJ, Graziano J, et al. Amplatzer closure of atrial septal defect and da Vinci robot-assisted repair of vascular ring. Pediatr Cardiol 2004;25:548-51. [Crossref] [PubMed]
23. Suematsu Y, Mora BN, Mihaljevic T, et al. Totally endoscopic robotic-assisted repair of patent ductus arteriosus and vascular ring in children. Ann Thorac Surg 2005;80:2309-13. [Crossref] [PubMed]
24. Sun M, Guo S, Wang C, et al. Comparison of open, thoracoscopic, and robotic approaches for pediatric mediastinal tumor resection. J Robot Surg 2025;20:81. [Crossref] [PubMed]
25. Delgado-Miguel C, Camps J, Garavis Montagut I, et al. Robotic-assisted thoracic surgery in children: A systematic review and meta-analysis. J Pediatr Surg 2026;61:162840. [Crossref] [PubMed]
26. Huang J, Huang Z, Mei H, et al. Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions. Surg Endosc 2023;37:8404-20. [Crossref] [PubMed]