Robotic surgery in Hirschsprung disease: a unicentric experience on 31 procedures

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We report the results of a 5-year unicentric experience. Materials and methods - All consecutive HSCR patients older than 12 months who underwent a surgical procedure with robotic approach between September 2017 and August 2022 were prospectively included. We collected data regarding demographics, extent of aganglionosis, associated anomalies, indications to surgery, and a number of perioperative data such as surgical details, intraoperative and perioperative complications, length of surgery, length of hospital stay, and functional outcome. Results - A total of 28 patients underwent 31 robotic procedures during the study period. Median age at surgery was 82 months. Eleven primary Totally Robotic Soave Pull-Through, 12 redoes, 5 innervative mapping, 2 redundant rectal pouch excision and 1 Miles’ procedures have been performed. Median console time was 145 minutes. No conversion to either laparoscopy nor to laparotomy was required. Median length of hospital stay was 6 days. Two patients experienced complications requiring reiterative surgery. One patient experienced mild postoperative enterocolitis. Normal continence was achieved by 70% of patients after a median of 16 months postoperatively (80% for primary pull-throughs, 55% for redoes). Conclusions - To conclude, robotic surgery for older HSCR patients proved to be feasible, safe, and effective. Patients with complex surgical requirements seem to benefit most from this promising approach. Provided the economic burden is addressed and solved, robotic surgery will represent an excellent alternative for the surgical treatment of HSCR to serve the best for our patients. Hirschsprung Robotics Soave Endorectal Redo Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Since early 2000 minimally invasive surgery gained popularity in the treatment of Hirschsprung’s disease (HSCR) with good results and the well-known advantages of minimally invasive surgery [ 1 , 2 ]. With the exception of a single experience in adults, dating back to 2013, robotic surgery in HSCR has been first reported in children by our group in 2017 and later on with an extended series, in 2020. We could confirm safety and feasibility of totally robotic Soave procedure (TRSPT) in HSCR along with its promising results in terms of functional outcome [ 3 , 4 ]. Given the versatility of robotics in children [ 5 ], indications have been subsequently extended to other procedures performed in HSCR patients and we now routinely resort to robotic approach for various procedures, including redo pull-throughs [ 6 ]. This paper aims at reporting the results of our unicentric experience with robotic surgery applied to pediatric HSCR patients in order to address indications and possibly suggest specific recommendations in such a dedicated and rare setting. Materials And Methods All consecutive HSCR patients who underwent a surgical procedure with robotic approach at the Umberto Bosio Center for Digestive Diseases, The Children Hospital, Alessandria, between September 2017 and August 2022 (5 years) have been prospectively included. Ethical Committee approval was obtained on June 15, 2017, ID ASO. CHIRT.17.01. Inclusion and exclusion criteria Inclusion criteria were: 1) acceptance to participate to the study by parents and patients; 2) reliable HSCR diagnosis; 3) Robotic approach performed at the Umberto Bosio Center for Digestive Diseases with the Da Vinci Si platform; 4) patients older than 1 year at surgery; 5) follow up available on July 30 th , 2022 Exclusion criteria were: 1) unclear and/or unreliable HSCR diagnosis; 2) lack of follow up data; 3) refusal to participate Confirmation of HSCR diagnosis In case of patients undergoing a primary pull-through, two experienced pathologists (PN and SC) confirmed the diagnoses on rectal suction or surgical biopsies (based on age) performed in our Center and stained with enzymohistochemestry as previously reported [7]. In case of patients already operated on elsewhere who presented with persistent obstructive symptoms, both pathologists re-assessed the slides belonging to previous samples stained with conventional histology, enzymohistochemestry or immuno-histochemistry in order to confirm the exact HSCR diagnosis. Diagnostic workup After confirming the diagnosis of HSCR, each patient underwent a comprehensive diagnostic workup including barium enema, clinical phenotype assessment (kidney and urinary tract and cardiac ultrasound scans and audiometry), as reported in our previous reports [8,9], molecular genetics and all further investigation according to specific clinical features. Collected data A number of data have been collected prospectively according to data protection Act. Those included demographic data, extent of aganglionosis, associated anomalies, indications to surgery (primary or redo and indications for redoing), and a number of perioperative data such as surgical details, intraoperative and perioperative complications, length of surgery, length of hospital stay, and functional outcome. Follow up protocol Postoperatively, follow up was performed in an outpatient setting after 1 month, 3 months, 6 months, 12 months, 18 months, and then yearly based on patients’ clinical conditions. Presence of constipation, enterocolitis occurrences (HAEC), continence, and perianal excoriations have been assessed. Definitions [8] Extent of Aganglionosis Classic HSCR – Aganglionosis extending up to the splenic flexure Long HSCR – Aganglionosis extending beyond the splenic flexure but confined within ascending colon Ultralong HSCR or TCSA – Aganglionosis extended to the terminal ileum with variable small bowel involvement Continence – Continence was assessed in patients older than 4 years of age, without intellectual disability and a minimum 6 months of follow up according to modified Wingspread scoring system. Continence was graded into Excellent, Good, Fair and Poor [10]. Enterocolitis (HAEC) – Defined according to Pastor criteria [11] and graded according to Elhalabi criteria (mild, moderate, severe) [12] Constipation – According to Rome IV criteria [13,14] Perineal rash – severe perineal excoriation that interferes with a normal quality of life lasting longer than 6 weeks and requiring medications or change of diet Statistical Analysis Descriptive statistics were reported as absolute frequencies and percentages. Median and ranges were used to describe semiquantitative and quantitative variables. Mean and standard deviation were used to report continuous variables. Two tailed Fisher’s exact test was used to compare categorical variables. Unpaired t test was used to compare continuous variables. A p lower than 0.05 was considered to be statistically significant. Results Demography and phenotype A total of 28 HSCR patients underwent 31 robotic procedures during the study period. Male to female ratio was 4.6:1. Median age at surgery was 82 months (ranging between 12 months to 17 years). Nineteen patients suffered from Classic HSCR, 7 from Long HSCR, 2 from TCSA. No familial cases were recorded. Thirteen associated anomalies were detected in 11 patients (39%) including 4 Down Syndrome, 2 congenital anomalies of the kidney and urinary tract, 1 Ondine’s Course, 1 Brugada’s syndrome, 1 congenital heart disease, 1 cerebral palsy, 1 congenital immune deficiency, 1 skeletal abnormality, and 1 eosinophilic colitis. Surgical procedures Totally Robotic Soave Pull-Through (TRSPT) - A total of 11 patients underwent a TRSPT, including 2 TCSA, 1 Long HSCR and 8 Classic HSCR Redo Totally Robotic Soave Pull-Through (Redo TRSPT) – A total of 12 patients underwent a Redo TRSPT, including 2 Long HSCR and 9 Classic HSCR Robotic innervative mapping – A total of 5 patients underwent innervative mapping, including 1 Long HSCR and 4 Classic HSCR Redundant Rectal Pouch Excision – A total of 2 patients underwent a Robotic Redundant Rectal Pouch Excision, both suffering from Long-HSCR Robotic Proctocolectomy and Miles’ procedure – One patient with complete anal canal fibrosis and severe stricture due to multiple perianal abscesses underwent radical proctocolectomy and modified Miles’ procedure. Surgical Details (robotic platform Da Vinci Si) TRSPT and Redo TRSPT (23 procedures – Figure 1a and 1b) – Those procedures have been performed according to our previous reports [3,4] regardless of the presence of a stoma or extent of aganglionosis as the pelvis and rectal dissection represented the focus and goal of robotic surgery. A stoma was already in place in 4 patients and was maintained to protect the anastomosis up to 6 weeks postop. A protective stoma was fashioned at time of surgery in a further 6 patients with the same timing for subsequent closure. Based on those data, a total of 10 patients (45%) received a stoma as part of the treatment (4 TRSPT and 6 redo TRSPT). Robotic Innervative mapping (5 procedures – Figure 2) – These procedures consisted in identification of the peritoneal reflection, freeing of a few centimeters of the rectum extraperitoneal rectum, seromuscular biopsy taken at the reflection, 5 cm above and a further 5 cm above in order to provide mapping of the last 10 intrabdominal centimeters of colon. In case of suspected complex innervative issue, two further biopsies were taken at the transverse colon and at the caecum. All biopsy sites were closed back with interrupted Prolene 4-0 sutures and a final hydrostatic check of the seal of the enterotomies was performed before dedocking. Redundant Rectal Pouch Excision (2 procedures – Figure 3) – Procedures have been performed in patients who previously underwent a Duhamel technique. The procedures consisted in 4 major steps: 1) identification of the redundant rectal pouch behind the bladder, which was straightened and made evident thanks to a probe inserted through the anus; 2) blunt dissection of the rectal pouch with the aid of monopolar cautery, down to the retrorectal colo-rectal anastomosis; 3) division of the redundant pouch with a linear stapler; 4) reinforcement of the stapling-line with a running Prolene 4-0 suture and subsequent reapproximation of the parietal peritoneum in order to extraperitonealize the surgical field in case of leakage to avoid abdominal diffusion of possible infection. A drain was left in place at the end of the procedure just before dedocking. Radical proctocolectomy and modified Miles’ procedure (1 procedure – Figure 4) – The procedure has been performed in a patient who previously experienced two pull-through procedures (Duhamel and Swenson) and subsequently developed severe anal fibrosis, multiple recurrent perianal abscesses and anastomotic retraction. The procedure consisted in robotic radical proctocolectomy resembling the technical features of both TRSPT and redo TRSPT. The colon that was previously pulled-through (right ascending colon) was isolated downwards to the elevator ani (1-2 cm above the dentate line) with a delicate and extremely demanding dissection due to severe pericolic fibrosis and an evident “frozen pelvis”. Transanal distal dissection allowed the removal of the colon. A previously fashioned ileostomy was left in place as definitive stoma. The anus was closed in layers with three consecutive pure-string sutures and a drain was left from above (Figure 4). Clinical details (overall series) Length of surgery – Surgery lasted a median of 345 minutes (225 to 645 minutes). Console time – Console time lasted a median of 145 minutes (90 to 300 minutes). Length of stay – Median length of hospital stay was 6 days (4 to 20 days) Length of follow up – Median length of follow up was 12 months (2 to 47 months) Age at follow up – Median age at follow up was 6.25 years (2 to 20 years) Outcome (overall series) Intraoperative complications - Two patients experienced mucosal tearing during endorectal dissection with subsequent fecal contamination of surgical field. One of these patients, who had a stoma already fashioned preoperatively, maintained the stoma in place for 6 weeks to promote healing and avoid anastomotic leakage. None further intraoperative complications have been experienced. No conversion to either laparoscopy nor to laparotomy was required. Postoperative complications – Six patients experienced postoperative complications (severe perianal rash in 2, bowel obstruction in 2, anastomotic leakage in 1 and residual innervation issue in 1). Two of them required some sort of surgical treatment, namely 1 redo pull-through and 1 lysis of peritoneal adhesions and temporary stoma fashioning. Adequacy of biopsies for innervative mapping – All biopsies proved sampled with robotic approach proved to be adequate for both diagnosis and exclusion of innervative issues. HAEC – one out of 23 patients who could be assessed on this regard experienced mild postoperative HAEC Constipation – three out of 23 patients who could be assessed on this regard experienced constipation requiring medical treatment with softeners Continence – continence could be assessed in 16 patients with a median age of 7.7 years (4.9 to 19.7 years) after a median follow up of 16 months (4 to 47 months). Eleven patients scored excellent to good (69%). Below the continence scores according to surgical procedure TRSPT – Excellent to good in 4/5 (80%) Redo TRSPT – Excellent to good in 5/9 (55%) Redundant rectal pouch excision – Excellent to good in 2 (100%) Discussion To the best of our knowledge this is the largest series addressing the use of robotic surgery for the treatment of HSCR. The results of our series confirmed what previously suggested by our group [3,4] regarding safety and feasibility. We could also demonstrate the intriguing versatility of the Da Vinci Si robotic system as HSCR patients could undergo a variety of different surgical procedures ranging from diagnostic biopsies for innervative mapping to primary therapeutic or complex reconstructive procedures. Minimally invasive colonic mapping in HSCR has been first reported by Mazziotti and Carvalho in 2001 [15,16] with good results but in a relatively small series of patients. Later on, in 2021, Bogusz et al reported similar results and outcome in a slightly larger series [17]. These authors reported safety and reliability of a minimally invasive approach for the diagnosis of intestinal innervative issues in HSCR. In accordance with what previously published, our series of patients confirmed how helpful minimally invasive surgery is in the diagnostic workup of HSCR patients who experience postoperative obstructive symptoms. In particular, we could demonstrate that the robotic system is versatile, safe, and effective in harvesting adequate size biopsies with minimal to no risk of postoperative complications, leakage in particular. In fact, we showed that enterotomy closure with interrupted sutures is straightforward, safe and effective with the possibility of early discharge, minimal postoperative requirements and the possibility to reestablish rectal irrigation short after surgery. Biopsy size and depth, which represent a critic aspect of adequate colonic biopsies, proved to be consistently adequate thanks to the magnification and 3D vision thus increasing the likelihood of adequate sampling (Figure 2). Even if innervative mapping proved to benefit from this approach, the biggest advantages of robotics should be more evident for procedures involving deep pelvic structures. In fact, Hebra in 2011 and Rickey in 2013 proved that the use of Da Vinci robotic system is feasible and safe for both infants and adults with HSCR [18,19]. Of note, the authors performed a Swenson procedure and not to a Soave endorectal pull-through, in infants [18]. Both papers confirmed safety and feasibility of robotics for complex reconstructive surgeries in HSCR suggesting the possibility for a larger adoption of robotics in pediatric surgical practice. This is confirmed by the results of our series of patients who underwent complex pelvic reconstructive procedures. The first reported series of Totally Robotic Soave Pull-Through (TRSPT) has been published by our group in 2017 [4]. Since then, we increased the number of patients who underwent TRSPT primary and redo procedures [3]. Our series now counts a total of 23 procedures, performed in children older than 12 months, with intriguing results. Duration of surgery proved to be longer compared to what observed in conventional laparoscopic or open approaches, with console-time lasting an average of 2 hours. Interestingly, surgery proved to last longer in primary TRSPT compared to redo TRSPT. Also, complication rate proved to be reasonable with most issues occurring in patients undergoing multiple reiterative procedures. Even if these differences and trends proved not to be statistically significant, the shorter length of surgery observed in redo TRSPT suggested that magnification, 3D view, and increased dexterity of robotic arms could be particularly helpful in dissecting tissues in delicate and deranged regions with fibrosis and inflammation, as found in previously operated HSCR patients. If we consider that our series of HSCR patients included only those older than 12 months of age at surgery (median close to 7 years), functional outcome proved to be promising with a very low rate of constipation and postoperative HEAC and an intriguing 80% of excellent to good continence for primary TRSPT after a median of 1 year postoperatively. The enthusiastic outcome reported in a recent publication by Delgado and co-workers addressing infants younger than 12 months [21] suggests that robotic approach could represent a valid alternative for all HSCR patients. As expected and previously reported [20], continence proved to be worse in those patients who underwent a redo TRSPT. Anyway, it is well-known that continence normalization can be observed up to 4 years postoperatively [20] so we still expect an improvement that will be addressed in the long term. The versatility of robotic surgery applied to HSCR patients was confirmed by the possibility to perform unconventional or uncommon procedures such as the excision of the redundant rectal pouch or the radical proctocolectomy with Miles’ procedure. Both proved to be feasible and safe with reasonable length of surgery and excellent postoperative recovery (Table 1). This aspect has been confirmed by the absence of complications in this specific subset of patients who underwent surgery with minimal requirements, short hospitalization ad rapid recovery of daily activities. Technical advantages of robotic surgery over laparoscopy have been already addressed, yet it is difficult to report a superiority of one approach over the other with relation of the overall outcome. This is due to the combination small series of patients and relatively low complication rates observed in most pediatric surgical fields. These issues make it difficult to detect statistically significant differences and identify suitable subgroups of patients, risk factors, and correct indications. Previous publications demonstrated that in face of similar outcomes, length of surgery and costs of robotic surgery are so high to limit its spread and routine use in pediatric surgical practice [5,22,23]. Our study have several limitations: 1) we could not compare the results of this series with laparoscopic or laparotomic ones given a number of selection bias, including age range and clinical features of patients; 2) even if larger than others, this series remain too small to address any statistical aspect with regard to outcome measures; 3) the DaVinci Si surgical system has now been overcome by the Xi version that improved most of technical aspects and limitation of the platform making our results only partially reproducible. Based on these considerations, we could not address the question regarding the superiority of robotic approach over laparoscopy for HSCR patients. Anyway, we could speculate that a specific subgroup of them could benefit from the advantages of robotic systems. Older and plurioperated patients undergoing complex pelvic reconstructions are those who seem to benefit most from this approach. The increased dexterity improves daintiness of tissue handling, reliability of enterotomy suture-closure, and magnification to perform adequate size biopsies. This suggests that also innervative mapping might benefit from a robotic approach, but larger series and possible randomized trials are needed to address this specific aspect. To conclude, robotic surgery in older HSCR patients proved to be feasible, safe, and effective. In particular, older children with previously operated deep pelvis and complex surgical requirements seem to benefit most from this promising approach. Provided the economic burden is addressed and solved, robotic surgery will represent an excellent alternative for the surgical treatment of HSCR to serve the best for our patients. Statements And Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. GM,ME, EF, and MPD drafted the paper; SC revised all histology and confirmed the diagnosis and possible need for redoing due to innervative issues; TM and VB participated in enrolling the patients; JB and AT performed all preoperative radiological investigations required to determine the need for surgery; APP conceived the study and performed all surgical procedures; all Authors revised and approved the final version of the paper. References Georgeson KE. Laparoscopic-assisted pull-through for Hirschsprung's disease. Semin Pediatr Surg. 2002 Nov;11(4):205 – 10. doi: 10.1053/spsu.2002.35350. PMID: 12407501. Georgeson KE, Robertson DJ. Laparoscopic-assisted approaches for the definitive surgery for Hirschsprung's disease. Semin Pediatr Surg. 2004 Nov;13(4):256 – 62. doi: 10.1053/j.sempedsurg.2004.10.013. PMID: 15660319. Pini Prato A, Arnoldi R, Dusio MP, Cimorelli A, Barbetta V, Felici E, Barbieri P, Barbero S, Carlini C, Petralia P, Mattioli G, Roveta A, Maconi A. 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Table Table 1 – Overall clinical features, surgical details, and outcome of 28 HSCR patients who underwent 31 robotic surgical procedures Surgery (n = 31) M:F ratio Median age (yrs) Median console time (min) Median H stay (days) Complications Postop issues Continent (%) TRSPT (11) 2.7:1 2.5 (1 to 17.8) 180 (120 to 300) 6 (4 to 20) 1 cuff stricture 1 constipation 80% Redo TRSPT (12) 5:1 7.7 (4.4 to 16.1) 148 (90 to 300) 7 (4 to 9) 1 anastomotic leak 1 innervative issue 1 HAEC 2 constipation 56% Innervative mapping (5) 4:1 8.5 (4.6 to 17.7) 60 (35 to 90) 4 (3 to 5) None None n.a. Pouch excision (2) n.a. 9.4 (4.7 to 14.2) 163 (145 to 180) 9 (5 to 13) 1 transient ileus None 100% Miles’ (1) n.a. 16.7 210 5 None None n.a. Legend – TRSPT = Total Robotic Soave Pull-Through; yrs = years; min = minutes; H = hospital; HAEC = Hirschsprung Associated Enterocolitis; n.a. = not applicable Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 09 Oct, 2022 Reviews received at journal 28 Sep, 2022 Reviewers agreed at journal 14 Sep, 2022 Reviewers agreed at journal 14 Sep, 2022 Reviewers invited by journal 13 Sep, 2022 Editor assigned by journal 13 Sep, 2022 Submission checks completed at journal 12 Sep, 2022 First submitted to journal 11 Sep, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2053506","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":135924468,"identity":"9657063b-36ce-48e5-a8e5-77882d435778","order_by":0,"name":"Giulia Mottadelli","email":"","orcid":"","institution":"Azienda Ospedaliera SS. 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Antonio e Biagio e Cesare Arrigo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Enrico","middleName":"","lastName":"Felici","suffix":""},{"id":135924476,"identity":"ec56c7a5-a75f-4da8-b2b7-e0dcdb259d72","order_by":5,"name":"Tiziana Milanese","email":"","orcid":"","institution":"Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tiziana","middleName":"","lastName":"Milanese","suffix":""},{"id":135924477,"identity":"a4df2b12-b13a-46bd-9589-103526bbd7cf","order_by":6,"name":"Vincenza Barbetta","email":"","orcid":"","institution":"Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vincenza","middleName":"","lastName":"Barbetta","suffix":""},{"id":135924479,"identity":"2e325f91-1e4f-474f-96d4-329ccbd5231f","order_by":7,"name":"Bakeine James","email":"","orcid":"","institution":"Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bakeine","middleName":"","lastName":"James","suffix":""},{"id":135924482,"identity":"bedc6934-722c-493c-bad7-b58abc07e65d","order_by":8,"name":"Augusta Tentori","email":"","orcid":"","institution":"Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Augusta","middleName":"","lastName":"Tentori","suffix":""},{"id":135924484,"identity":"4d981b94-04dd-4a00-8ab9-930bbaa4622c","order_by":9,"name":"Alessio Pini Prato","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYFACxgaGhAowy4DhAZDkA4kQ1nIGqiUBSLIxMDYS0gPU1YaihYA1/LOb2x48nGdjb87evPED0IXybAzM7Q/waZG4c7DdIHFbWuLOnmPFEkAXGrYRdNiNxDaJxG2HEwxu5BhIJLaBHElAizxYy5zD9gb33xj/SPzHYE9QiwFYS8Nhxg03eMyADIZEgloM7xxsk0g4BvJLWplFwjGJ5DZmxsYZ+LTI3W5/JvmjBhRihzff+FBjY9vP3v7gAz4tDBIwF8K5zHjVY2oZBaNgFIyCUYAJACM4TDoJu0waAAAAAElFTkSuQmCC","orcid":"","institution":"Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Alessio","middleName":"Pini","lastName":"Prato","suffix":""}],"badges":[],"createdAt":"2022-09-11 10:44:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2053506/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2053506/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":26470072,"identity":"68caf137-5da5-40b8-bd9b-e9ddabcfb0da","added_by":"auto","created_at":"2022-09-14 20:50:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":594700,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1a shows a primary totally robotic Soave pull-through. The picture shows a nearly completed dissection just before moving to the transanal approach to complete the procedure. Figure 1b shows a redo totally robotic Soave pull-through performed in a patient suffering from a partially twisted endorectal pull-through performed years before. The pictures demonstrated the 270 degree twisting of the colon that is being dissected from the rectal cuff.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2053506/v1/cd6bea7347d7950f9366f9a9.png"},{"id":26469030,"identity":"3c74f115-44d8-4f98-aaaf-250b7a9d344c","added_by":"auto","created_at":"2022-09-14 20:45:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":841121,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2 shows a seromuscular biopsy performed to determine the length of residual dysganglionosis in a patient with confirmed transition zone pull-through at full-thickness rectal biopsy.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2053506/v1/95a1aa5c6a3ea9dd6bfb47a8.png"},{"id":26469028,"identity":"64ba1537-6bd3-4b14-aaaa-8135ad49663f","added_by":"auto","created_at":"2022-09-14 20:45:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":936878,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 3 shows the excision of the redundant rectal pouch after a previous Duhamel procedure. The linear stapling device is used to complete the excision after meticulous dissection of the pouch.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2053506/v1/47eaed028fb52d02f475156e.png"},{"id":26469027,"identity":"25868375-8bc0-4109-9182-660154b9c448","added_by":"auto","created_at":"2022-09-14 20:45:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":519381,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 4 shows the anus closed in layers at the very end of the Miles’ procedure performed to deal with a severe pelvi/perineal fibrosis after multiple procedures performed in a male patient with HSCR. A further redo was not feasible and the previously pulled-through colon had to be removed to get rid of the continuous discharge related to a severe diversion colitis.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2053506/v1/9c97800d7c35243160cfa80b.png"},{"id":26471606,"identity":"a210c228-79ae-44c4-ae5e-e9ea6c6a4815","added_by":"auto","created_at":"2022-09-14 20:55:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4963611,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2053506/v1/972f06cc-be0d-448d-bf97-58647937448e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic surgery in Hirschsprung disease: a unicentric experience on 31 procedures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince early 2000 minimally invasive surgery gained popularity in the treatment of Hirschsprung\u0026rsquo;s disease (HSCR) with good results and the well-known advantages of minimally invasive surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. With the exception of a single experience in adults, dating back to 2013, robotic surgery in HSCR has been first reported in children by our group in 2017 and later on with an extended series, in 2020. We could confirm safety and feasibility of totally robotic Soave procedure (TRSPT) in HSCR along with its promising results in terms of functional outcome [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Given the versatility of robotics in children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], indications have been subsequently extended to other procedures performed in HSCR patients and we now routinely resort to robotic approach for various procedures, including redo pull-throughs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This paper aims at reporting the results of our unicentric experience with robotic surgery applied to pediatric HSCR patients in order to address indications and possibly suggest specific recommendations in such a dedicated and rare setting.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eAll consecutive HSCR patients who underwent a surgical procedure with robotic approach at the Umberto Bosio Center for Digestive Diseases, The Children Hospital, Alessandria, between September 2017 and August 2022 (5 years) have been prospectively included. Ethical Committee approval was obtained on June 15, 2017, ID ASO. CHIRT.17.01.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eInclusion and exclusion criteria\u003c/u\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eInclusion criteria\u003c/u\u003e were: 1) acceptance to participate to the study by parents and patients; 2) reliable HSCR diagnosis; 3) Robotic approach performed at the Umberto Bosio Center for Digestive Diseases with the Da Vinci Si platform; 4) patients older than 1 year at surgery; 5) follow up available on July 30\u003csup\u003eth\u003c/sup\u003e, 2022\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eExclusion criteria\u003c/u\u003e were: 1) unclear and/or unreliable HSCR diagnosis; 2) lack of follow up data; 3) refusal to participate\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eConfirmation of HSCR diagnosis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIn case of patients undergoing a primary pull-through, two experienced pathologists (PN and SC) confirmed the diagnoses on rectal suction or surgical biopsies (based on age) performed in our Center and stained with enzymohistochemestry as previously reported [7]. In case of patients already operated on elsewhere who presented with persistent obstructive symptoms, both pathologists re-assessed the slides belonging to previous samples stained with conventional histology, enzymohistochemestry or immuno-histochemistry in order to confirm the exact HSCR diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDiagnostic workup\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAfter confirming the diagnosis of HSCR, each patient underwent a comprehensive diagnostic workup including barium enema, clinical phenotype assessment (kidney and urinary tract and cardiac ultrasound scans and audiometry), as reported in our previous reports [8,9], molecular genetics and all further investigation according to specific clinical features.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCollected data\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA number of data have been collected prospectively according to data protection Act. Those included demographic data, extent of aganglionosis, associated anomalies, indications to surgery (primary or redo and indications for redoing), and a number of perioperative data such as surgical details, intraoperative and perioperative complications, length of surgery, length of hospital stay, and functional outcome.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFollow up protocol\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePostoperatively, follow up was performed in an outpatient setting after 1 month, 3 months, 6 months, 12 months, 18 months, and then yearly based on patients\u0026rsquo; clinical conditions. Presence of constipation, enterocolitis occurrences (HAEC), continence, and perianal excoriations have been assessed.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDefinitions [8]\u003c/u\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eExtent of Aganglionosis\u003c/u\u003e\n \u003col\u003e\n \u003cli\u003e\u003cem\u003eClassic HSCR\u0026nbsp;\u003c/em\u003e\u0026ndash; Aganglionosis extending up to the splenic flexure\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eLong HSCR\u003c/em\u003e \u0026ndash; Aganglionosis extending beyond the splenic flexure but confined within ascending colon\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eUltralong HSCR or TCSA\u003c/em\u003e \u0026ndash; Aganglionosis extended to the terminal ileum with variable small bowel involvement\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cu\u003eContinence\u003c/u\u003e\u003cem\u003e\u0026nbsp;\u0026ndash;\u0026nbsp;\u003c/em\u003eContinence was assessed in patients older than 4 years of age, without intellectual disability and a minimum 6 months of follow up according to modified Wingspread scoring system. Continence was graded into Excellent, Good, Fair and Poor [10].\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eEnterocolitis (HAEC)\u003c/u\u003e \u0026ndash; Defined according to Pastor criteria [11] and graded according to Elhalabi criteria (mild, moderate, severe) [12]\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eConstipation\u003c/u\u003e \u0026ndash; According to Rome IV criteria [13,14]\u003c/li\u003e\n \u003cli\u003e\u003cu\u003ePerineal rash\u003c/u\u003e \u0026ndash; severe perineal excoriation that interferes with a normal quality of life lasting longer than 6 weeks and requiring medications or change of diet\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eStatistical Analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were reported as absolute frequencies and percentages. Median and ranges were used to\u0026nbsp;describe semiquantitative and quantitative variables. Mean and standard deviation were used to report continuous variables.\u0026nbsp;Two tailed Fisher\u0026rsquo;s exact test was used to compare categorical variables. Unpaired t test was used to compare continuous variables. A p lower than 0.05 was considered to be statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eDemography and phenotype\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA total of 28 HSCR patients underwent 31 robotic procedures during the study period. Male to female ratio was 4.6:1. Median age at surgery was 82 months (ranging between 12 months to 17 years). Nineteen patients suffered from Classic HSCR, 7 from Long HSCR, 2 from TCSA. No familial cases were recorded.\u003c/p\u003e\n\u003cp\u003eThirteen associated anomalies were detected in 11 patients (39%) including 4 Down Syndrome, 2 congenital anomalies of the kidney and urinary tract, 1 Ondine’s Course, 1 Brugada’s syndrome, 1 congenital heart disease, 1 cerebral palsy, 1 congenital immune deficiency, 1 skeletal abnormality, and 1 eosinophilic colitis.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSurgical procedures\u003c/u\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eTotally Robotic Soave Pull-Through (TRSPT)\u003c/u\u003e - A total of 11 patients underwent a TRSPT, including 2 TCSA, 1 Long HSCR and 8 Classic HSCR\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRedo Totally Robotic Soave Pull-Through (Redo TRSPT)\u003c/u\u003e – A total of 12 patients underwent a Redo TRSPT, including 2 Long HSCR and 9 Classic HSCR\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRobotic innervative mapping\u003c/u\u003e– A total of 5 patients underwent innervative mapping, including 1 Long HSCR and 4 Classic HSCR\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRedundant Rectal Pouch Excision\u003c/u\u003e – A total of 2 patients underwent a Robotic Redundant Rectal Pouch Excision, both suffering from Long-HSCR\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRobotic Proctocolectomy and Miles’ procedure\u003c/u\u003e\u003cstrong\u003e–\u0026nbsp;\u003c/strong\u003eOne patient with complete anal canal fibrosis and severe stricture due to multiple perianal abscesses underwent radical proctocolectomy and modified Miles’ procedure.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eSurgical Details (robotic platform Da Vinci Si)\u003c/u\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eTRSPT and Redo TRSPT\u0026nbsp;\u003c/u\u003e\u003cem\u003e(23 procedures – Figure 1a and 1b)\u0026nbsp;\u003c/em\u003e– Those procedures have been performed according to our previous reports [3,4] regardless of the presence of a stoma or extent of aganglionosis as the pelvis and rectal dissection represented the focus and goal of robotic surgery. A stoma was already in place in 4 patients and was maintained to protect the anastomosis up to 6 weeks postop. A protective stoma was fashioned at time of surgery in a further 6 patients with the same timing for subsequent closure. Based on those data, a total of 10 patients (45%) received a stoma as part of the treatment (4 TRSPT and 6 redo TRSPT).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRobotic Innervative mapping\u0026nbsp;\u003c/u\u003e\u003cem\u003e(5 procedures – Figure 2)\u003c/em\u003e – These procedures consisted in identification of the peritoneal reflection, freeing of a few centimeters of the rectum extraperitoneal rectum, seromuscular biopsy taken at the reflection, 5 cm above and a further 5 cm above in order to provide mapping of the last 10 intrabdominal centimeters of colon. In case of suspected complex innervative issue, two further biopsies were taken at the transverse colon and at the caecum. All biopsy sites were closed back with interrupted Prolene 4-0 sutures and a final hydrostatic check of the seal of the enterotomies was performed before dedocking.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRedundant Rectal Pouch Excision\u0026nbsp;\u003c/u\u003e\u003cem\u003e(2 procedures – Figure 3)\u003c/em\u003e – Procedures have been performed in patients who previously underwent a Duhamel technique. The procedures consisted in 4 major steps: 1) identification of the redundant rectal pouch behind the bladder, which was straightened and made evident thanks to a probe inserted through the anus; 2) blunt dissection of the rectal pouch with the aid of monopolar cautery, down to the retrorectal colo-rectal anastomosis; 3) division of the redundant pouch with a linear stapler; 4) reinforcement of the stapling-line with a running Prolene 4-0 suture and subsequent reapproximation of the parietal peritoneum in order to extraperitonealize the surgical field in case of leakage to avoid abdominal diffusion of possible infection. A drain was left in place at the end of the procedure just before dedocking.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRadical proctocolectomy and modified Miles’ procedure\u0026nbsp;\u003c/u\u003e\u003cem\u003e(1 procedure – Figure 4)\u0026nbsp;\u003c/em\u003e– The procedure has been performed in a patient who previously experienced two pull-through procedures (Duhamel and Swenson) and subsequently developed severe anal fibrosis, multiple recurrent perianal abscesses and anastomotic retraction. The procedure consisted in robotic radical proctocolectomy resembling the technical features of both TRSPT and redo TRSPT. The colon that was previously pulled-through (right ascending colon) was isolated downwards to the elevator ani (1-2 cm above the dentate line) with a delicate and extremely demanding dissection due to severe pericolic fibrosis and an evident “frozen pelvis”. Transanal distal dissection allowed the removal of the colon. A previously fashioned ileostomy was left in place as definitive stoma. The anus was closed in layers with three consecutive pure-string sutures and a drain was left from above (Figure 4).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eClinical details (overall series)\u003c/u\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eLength of surgery\u003c/u\u003e – Surgery lasted a median of 345 minutes (225 to 645 minutes).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eConsole time\u003c/u\u003e– Console time lasted a median of 145 minutes (90 to 300 minutes).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eLength of stay\u003c/u\u003e– Median length of hospital stay was 6 days (4 to 20 days)\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eLength of follow up\u003c/u\u003e – Median length of follow up was 12 months (2 to 47 months)\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eAge at follow up\u003c/u\u003e– Median age at follow up was 6.25 years (2 to 20 years)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eOutcome (overall series)\u003c/u\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eIntraoperative complications\u003c/u\u003e- Two patients experienced mucosal tearing during endorectal dissection with subsequent fecal contamination of surgical field. One of these patients, who had a stoma already fashioned preoperatively, maintained the stoma in place for 6 weeks to promote healing and avoid anastomotic leakage. None further intraoperative complications have been experienced. No conversion to either laparoscopy nor to laparotomy was required.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003ePostoperative complications\u003c/u\u003e–\u0026nbsp;Six patients experienced postoperative complications (severe perianal rash in 2, bowel obstruction in 2, anastomotic leakage in 1 and residual innervation issue in 1). Two of them required some sort of surgical treatment, namely 1 redo pull-through and 1 lysis of peritoneal adhesions and temporary stoma fashioning.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eAdequacy of biopsies for innervative mapping\u003c/u\u003e\u003cem\u003e\u0026nbsp;–\u003c/em\u003e All biopsies proved sampled with robotic approach proved to be adequate for both diagnosis and exclusion of innervative issues.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eHAEC\u003c/u\u003e\u003cem\u003e\u0026nbsp;–\u003c/em\u003e one out of 23 patients who could be assessed on this regard experienced mild postoperative HAEC\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eConstipation\u003c/u\u003e\u003cem\u003e\u0026nbsp;–\u003c/em\u003e three out of 23 patients who could be assessed on this regard experienced constipation requiring medical treatment with softeners\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eContinence\u003c/u\u003e\u003cem\u003e\u0026nbsp;–\u003c/em\u003e continence could be assessed in 16 patients with a median age of 7.7 years (4.9 to 19.7 years) after a median follow up of 16 months (4 to 47 months). Eleven patients scored excellent to good (69%). Below the continence scores according to surgical procedure\u003col\u003e\n \u003cli\u003e\u003cu\u003eTRSPT\u003c/u\u003e\u003cem\u003e\u0026nbsp;– Excellent to good in 4/5 (80%)\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRedo TRSPT\u003c/u\u003e\u003cem\u003e\u0026nbsp;– Excellent to good in 5/9 (55%)\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eRedundant rectal pouch excision\u003c/u\u003e\u003cem\u003e\u0026nbsp;– Excellent to good in 2 (100%)\u003c/em\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge this is the largest series addressing the use of robotic surgery for the treatment of HSCR. The results of our series confirmed what previously suggested by our group [3,4] regarding safety and feasibility. We could also demonstrate the intriguing versatility of the Da Vinci Si robotic system as HSCR patients could undergo a variety of different surgical procedures ranging from diagnostic biopsies for innervative mapping to primary therapeutic or complex reconstructive procedures.\u003c/p\u003e\n\u003cp\u003eMinimally invasive colonic mapping in HSCR has been first reported by Mazziotti and Carvalho in 2001 [15,16] with good results but in a relatively small series of patients. Later on, in 2021, Bogusz et al reported similar results and outcome in a slightly larger series [17]. These authors reported safety and reliability of a minimally invasive approach for the diagnosis of intestinal innervative issues in HSCR. In accordance with what previously published, our\u0026nbsp;series of patients confirmed how helpful minimally invasive surgery is in the diagnostic workup of HSCR patients who experience postoperative obstructive symptoms. In particular, we could demonstrate that the robotic system is versatile, safe, and effective in harvesting adequate size biopsies with minimal to no risk of postoperative complications, leakage in particular. In fact, we showed that enterotomy closure with interrupted sutures is straightforward, safe and effective with the possibility of early discharge, minimal postoperative requirements and the possibility to reestablish rectal irrigation short after surgery. Biopsy size and depth, which represent a critic aspect of adequate colonic biopsies, proved to be consistently adequate thanks to the magnification and 3D vision thus increasing the likelihood of adequate sampling (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEven if innervative mapping proved to benefit from this approach, the biggest advantages of robotics should be more evident for procedures involving deep pelvic structures. In fact, Hebra in 2011 and Rickey in 2013 proved that the use of Da Vinci robotic system is feasible and safe for both infants and adults with HSCR [18,19]. Of note, the authors performed a Swenson procedure and not to a Soave endorectal pull-through, in infants [18]. Both papers confirmed safety and feasibility of robotics for complex reconstructive surgeries in HSCR suggesting the possibility for a larger adoption of robotics in pediatric surgical practice.\u003c/p\u003e\n\u003cp\u003eThis is confirmed by the results of our series of patients who underwent complex pelvic reconstructive procedures. The first reported series of Totally Robotic Soave Pull-Through (TRSPT) has been published by our group in 2017 [4]. Since then, we increased the number of patients who underwent TRSPT primary and redo procedures [3]. Our series now counts a total of 23 procedures, performed in children older than 12 months, with intriguing results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuration of surgery proved to be longer compared to what observed in conventional laparoscopic or open approaches, with console-time lasting an average of 2 hours. Interestingly, surgery proved to last longer in primary TRSPT compared to redo TRSPT. Also, complication rate proved to be reasonable with most issues occurring in patients undergoing multiple reiterative procedures. Even if these differences and trends proved not to be statistically significant, the shorter length of surgery observed in redo TRSPT suggested that magnification, 3D view, and increased dexterity of robotic arms could be particularly helpful in dissecting tissues in delicate and deranged regions with fibrosis and inflammation, as found in previously operated HSCR patients.\u003c/p\u003e\n\u003cp\u003eIf we consider that our series of HSCR patients included only those older than 12 months of age at surgery (median close to 7 years), functional outcome proved to be promising with a very low rate of constipation and postoperative HEAC and an intriguing 80% of excellent to good continence for primary TRSPT after a median of 1 year postoperatively. The enthusiastic outcome reported in a recent publication by Delgado and co-workers addressing infants younger than 12 months [21] suggests that robotic approach could represent a valid alternative for \u003cem\u003eall\u003c/em\u003e HSCR patients.\u003c/p\u003e\n\u003cp\u003eAs expected and previously reported [20], continence proved to be worse in those patients who underwent a redo TRSPT. Anyway, it is well-known that continence normalization can be observed up to 4 years postoperatively [20] so we still expect an improvement that will be addressed in the long term.\u003c/p\u003e\n\u003cp\u003eThe versatility of robotic surgery applied to HSCR patients was confirmed by the possibility to perform unconventional or uncommon procedures such as the excision of the redundant rectal pouch or the radical proctocolectomy with Miles\u0026rsquo; procedure. Both proved to be feasible and safe with reasonable length of surgery and excellent postoperative recovery (Table 1). This aspect has been confirmed by the absence of complications in this specific subset of patients who underwent surgery with minimal requirements, short hospitalization ad rapid recovery of daily activities.\u003c/p\u003e\n\u003cp\u003eTechnical advantages of robotic surgery over laparoscopy have been already addressed, yet it is difficult to report a superiority of one approach over the other with relation of the overall outcome. This is due to the combination small series of patients and relatively low complication rates observed in most pediatric surgical fields. These issues make it difficult to detect statistically significant differences and identify suitable subgroups of patients, risk factors, and correct indications. Previous publications demonstrated that in face of similar outcomes, length of surgery and costs of robotic surgery are so high to limit its spread and routine use in pediatric surgical practice [5,22,23].\u003c/p\u003e\n\u003cp\u003eOur study have several limitations: 1) we could not compare the results of this series with laparoscopic or laparotomic ones given a number of selection bias, including age range and clinical features of patients; 2) even if larger than others, this series remain too small to address any statistical aspect with regard to outcome measures; 3) the DaVinci Si surgical system has now been overcome by the Xi version that improved most of technical aspects and limitation of the platform making our results only partially reproducible.\u003c/p\u003e\n\u003cp\u003eBased on these considerations, we could not address the question regarding the superiority of robotic approach over laparoscopy for HSCR patients. Anyway, we could speculate that a specific subgroup of them could benefit from the advantages of robotic systems. Older and plurioperated patients undergoing complex pelvic reconstructions are those who seem to benefit most from this approach. The increased dexterity improves daintiness of tissue handling, reliability of enterotomy suture-closure, and magnification to perform adequate size biopsies. This suggests that also innervative mapping might benefit from a robotic approach, but larger series and possible randomized trials are needed to address this specific aspect.\u003c/p\u003e\n\u003cp\u003eTo conclude, robotic surgery in older HSCR patients proved to be feasible, safe, and effective. In particular, older children with previously operated deep pelvis and complex surgical requirements seem to benefit most from this promising approach. Provided the economic burden is addressed and solved, robotic surgery will represent an excellent alternative for the surgical treatment of HSCR to serve the best for our patients.\u003c/p\u003e\n"},{"header":"Statements And Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eGM,ME, EF, and MPD drafted the paper; SC revised all histology and confirmed the diagnosis and possible need for redoing due to innervative issues; TM and VB participated in enrolling the patients; JB and AT performed all preoperative radiological investigations required to determine the need for surgery; APP conceived the study and performed all surgical procedures; all Authors revised and approved the final version of the paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGeorgeson KE. Laparoscopic-assisted pull-through for Hirschsprung\u0026apos;s disease. Semin Pediatr Surg. 2002 Nov;11(4):205 \u0026ndash; 10. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/spsu.2002.35350. PMID: 12407501.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eGeorgeson KE, Robertson DJ. 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Enterocolitis associated with Hirschsprung\u0026apos;s disease: a clinical\u0026ndash;radiological characterization based on 168 patients. J Pediatr Surg 1995;30(1):76\u0026ndash;83. PubMed PMID: 7722836.\u003c/li\u003e\n \u003cli\u003eBenninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology. 2016 Feb 15. pii: S0016-5085(16)00182-7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.gastro.2016.02.016. PubMed PMID: 27144631.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eHyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Functional Disorders: Children and Adolescents. Gastroenterology. 2016 Feb 15:S0016-5085(16)00181-5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.gastro.2016.02.015. Epub ahead of print. PMID: 27144632.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eMazziotti MV, Langer JC. Laparoscopic full-thickness intestinal biopsies in children. J Pediatr Gastroenterol Nutr. 2001 Jul;33(1):54 \u0026ndash; 7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00005176-200107000-00009. PMID: 11479408.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eCarvalho JL, Campos M, Soares-Oliveira M, Estev\u0026atilde;o-Costa J. Laparoscopic colonic mapping of dysganglionosis. Pediatr Surg Int. 2001 Jul;17(5\u0026ndash;6):493\u0026ndash;5. PubMed PMID: 11527202\u003c/li\u003e\n \u003cli\u003eBogusz B, Smolec-Zamora M, Zając A, Mol A, G\u0026oacute;recki W. Laparoscopic histological mapping for the determination of the length of aganglionic segment in children with Hirschsprung disease. Adv Clin Exp Med. 2021 Mar;30(3):233\u0026ndash;237. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17219/acem/129575. PMID: 33757163.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eHebra A, Smith VA, Lesher AP. Robotic Swenson pull-through for Hirschsprung\u0026apos;s disease in infants. Am Surg. 2011 Jul;77(7):937\u0026ndash;41. PubMed PMID: 21944363.\u003c/li\u003e\n \u003cli\u003eRickey J, Robinson CC, Camps JI, Lagares-Garcia JA. Robotic-assisted Soave procedure in an 18-year-old man with adult short-segment Hirschsprung\u0026apos;s disease. Am Surg. 2013 Jun;79(6):E223-5. PubMed PMID: 23711253.\u003c/li\u003e\n \u003cli\u003ePini-Prato A, Mattioli G, Giunta C, Avanzini S, Magillo P, Bisio GM, Jasonni V. Redo surgery in Hirschsprung disease: what did we learn? Unicentric experience on 70 patients. J Pediatr Surg. 2010 Apr;45(4):747 \u0026ndash; 54. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpedsurg.2009.08.001. PMID: 20385282.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eDelgado-Miguel C, Camps JI. Robotic Soave pull-through procedure for Hirschsprung\u0026apos;s disease in children under 12-months: long-term outcomes. Pediatr Surg Int. 2022 Jan;38(1):51\u0026ndash;57. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00383-021-05018-6. Epub 2021 Sep 23. PMID: 34557957.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eBoia ES, David VL. The Financial Burden of Setting up a Pediatric Robotic Surgery Program. Medicina (Kaunas). 2019 Nov 14;55(11):739. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/medicina55110739. PMID: 31739631; PMCID: PMC6915423.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eDenning NL, Kallis MP, Prince JM. Pediatric Robotic Surgery. Surg Clin North Am. 2020 Apr;100(2):431\u0026ndash;443. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.suc.2019.12.004. Epub 2020 Feb 7. PMID: 32169188.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e \u0026ndash; Overall clinical features, surgical details, and outcome of 28 HSCR patients who underwent 31 robotic surgical procedures\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.720081135902637%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery (n = 31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.302231237322515%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM:F ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.460446247464503%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian age (yrs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.255578093306287%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian console time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.314401622718053%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian H stay (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.474645030425963%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.939148073022313%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostop issues\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.533468559837727%\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinent (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.720081135902637%\"\u003e\n \u003cp\u003e\u003cem\u003eTRSPT (11)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.302231237322515%\"\u003e\n \u003cp\u003e2.7:1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.460446247464503%\"\u003e\n \u003cp\u003e2.5 (1 to 17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.255578093306287%\"\u003e\n \u003cp\u003e180 (120 to 300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.314401622718053%\"\u003e\n \u003cp\u003e6 (4 to 20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.474645030425963%\"\u003e\n \u003cp\u003e1 cuff stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.939148073022313%\"\u003e\n \u003cp\u003e1 constipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.533468559837727%\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.720081135902637%\"\u003e\n \u003cp\u003e\u003cem\u003eRedo TRSPT (12)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.302231237322515%\"\u003e\n \u003cp\u003e5:1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.460446247464503%\"\u003e\n \u003cp\u003e7.7 (4.4 to 16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.255578093306287%\"\u003e\n \u003cp\u003e148 (90 to 300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.314401622718053%\"\u003e\n \u003cp\u003e7 (4 to 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.474645030425963%\"\u003e\n \u003cp\u003e1 anastomotic leak\u003c/p\u003e\n \u003cp\u003e1 innervative issue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.939148073022313%\"\u003e\n \u003cp\u003e1 HAEC\u003c/p\u003e\n \u003cp\u003e2 constipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.533468559837727%\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.720081135902637%\"\u003e\n \u003cp\u003e\u003cem\u003eInnervative mapping (5)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.302231237322515%\"\u003e\n \u003cp\u003e4:1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.460446247464503%\"\u003e\n \u003cp\u003e8.5 (4.6 to 17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.255578093306287%\"\u003e\n \u003cp\u003e60 (35 to 90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.314401622718053%\"\u003e\n \u003cp\u003e4 (3 to 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.474645030425963%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.939148073022313%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.533468559837727%\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.720081135902637%\"\u003e\n \u003cp\u003e\u003cem\u003ePouch excision (2)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.302231237322515%\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.460446247464503%\"\u003e\n \u003cp\u003e9.4 (4.7 to 14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.255578093306287%\"\u003e\n \u003cp\u003e163 (145 to 180)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.314401622718053%\"\u003e\n \u003cp\u003e9 (5 to 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.474645030425963%\"\u003e\n \u003cp\u003e1 transient ileus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.939148073022313%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.533468559837727%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.720081135902637%\"\u003e\n \u003cp\u003e\u003cem\u003eMiles\u0026rsquo; (1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.302231237322515%\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.460446247464503%\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.255578093306287%\"\u003e\n \u003cp\u003e210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.314401622718053%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.474645030425963%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.939148073022313%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.533468559837727%\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e \u0026ndash; \u003cem\u003eTRSPT\u003c/em\u003e = Total Robotic Soave Pull-Through; \u003cem\u003eyrs\u003c/em\u003e = years; \u003cem\u003emin\u003c/em\u003e = minutes; \u003cem\u003eH\u003c/em\u003e = hospital; \u003cem\u003eHAEC\u003c/em\u003e = Hirschsprung Associated Enterocolitis; \u003cem\u003en.a.\u003c/em\u003e = not applicable\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hirschsprung, Robotics, Soave, Endorectal, Redo","lastPublishedDoi":"10.21203/rs.3.rs-2053506/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2053506/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e – Robotic surgery has been increasingly applied to Hirschsprung patients with encouraging results. We report the results of a 5-year unicentric experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods\u003c/strong\u003e - All consecutive HSCR patients older than 12 months who underwent a surgical procedure with robotic approach between September 2017 and August 2022 were prospectively included. We collected data regarding demographics, extent of aganglionosis, associated anomalies, indications to surgery, and a number of perioperative data such as surgical details, intraoperative and perioperative complications, length of surgery, length of hospital stay, and functional outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e - A total of 28 patients underwent 31 robotic procedures during the study period. Median age at surgery was 82 months. Eleven primary Totally Robotic Soave Pull-Through, 12 redoes, 5 innervative mapping, 2 redundant rectal pouch excision and 1 Miles’ procedures have been performed. Median console time was 145 minutes. No conversion to either laparoscopy nor to laparotomy was required. Median length of hospital stay was 6 days. Two patients experienced complications requiring reiterative surgery. One patient experienced mild postoperative enterocolitis. Normal continence was achieved by 70% of patients after a median of 16 months postoperatively (80% for primary pull-throughs, 55% for redoes).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003e- To conclude, robotic surgery for older HSCR patients proved to be feasible, safe, and effective. Patients with complex surgical requirements seem to benefit most from this promising approach. Provided the economic burden is addressed and solved, robotic surgery will represent an excellent alternative for the surgical treatment of HSCR to serve the best for our patients.\u003c/p\u003e","manuscriptTitle":"Robotic surgery in Hirschsprung disease: a unicentric experience on 31 procedures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-14 20:45:47","doi":"10.21203/rs.3.rs-2053506/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-10-09T21:14:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-28T08:04:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e5f00e37-1724-42bc-90e3-f37833d3145a","date":"2022-09-14T20:42:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214417cc-123c-4578-bbd2-bb9abc982b4f","date":"2022-09-14T05:59:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-09-14T01:25:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-14T01:05:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-12T08:42:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2022-09-11T10:39:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"03612f7d-41d2-4ce3-9555-aed28280c3f5","owner":[],"postedDate":"September 14th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-31T03:29:14+00:00","versionOfRecord":[],"versionCreatedAt":"2022-09-14 20:45:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2053506","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2053506","identity":"rs-2053506","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}