Pediatric Robotic Surgery in the Philippines: Initial Experience and Early Outcomes

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We report the first Philippine series of pediatric robotic-assisted general surgery, describing early program implementation and 30-day outcomes in a public tertiary referral center. Methods: A retrospective descriptive case series was conducted of pediatric patients (less than 19 years-old) who underwent robotic-assisted surgery between September 2024 and October 2025. Demographic characteristics, operative metrics (docking time, console time, total operative time, and estimated blood loss), as well as short-term postoperative outcomes, were summarized descriptively. Results: Nine pediatric robotic procedures were performed using the da Vinci platform: four choledochal cyst excisions with hepaticoduodenostomy, two robotic-assisted anorectal pull-throughs for anorectal malformation, two total proctocolectomies (ulcerative colitis; familial adenomatous polyposis), and one ovarian oophorocystectomy. Age ranged from 2–16 years; the lowest weight was 12.7 kg. Median docking, console, and total operative times were 26 (10–45), 195 (70–480), and 272 (145–610) minutes, respectively. Median estimated blood loss was 60 (10–150) mL. There were no unplanned conversions or intraoperative complications. One postoperative complication occurred (chylous leak, Clavien–Dindo II) managed conservatively. No Clavien–Dindo ≥ III complications, mortality, or unplanned ICU admissions occurred; all patients completed 30-day follow-up. Conclusion: Pediatric robotic surgery was feasible with acceptable 30-day outcomes during early implementation in a resource-constrained public healthcare setting. Operative metrics and morbidity were within ranges reported in published pediatric robotic series. Continued case accrual and longer follow-up are required to evaluate functional outcomes, cost implications, and long-term program sustainability. pediatric robotic surgery pediatric minimally-invasive surgery choledochal cyst pediatric colorectal surgery anorectal malformation low-middle income country INTRODUCTION Minimally invasive techniques are now routinely used in many areas of pediatric surgery. In selected conditions, laparoscopic approaches are associated with faster recovery, less postoperative pain, and improved perioperative outcomes compared with open procedures. Despite these benefits, complex operations in children remain demanding. Small patient size, limited intra-abdominal working space, and reliance on straight laparoscopic instruments may complicate delicate reconstruction, particularly during deep pelvic or complex abdominal surgery. Robotic systems were developed to overcome some of these limitations by increasing instrument mobility and improving visual control during minimally invasive procedures.( 1 ) Early adoption of robotic technology in pediatric surgery occurred primarily within urologic procedures, with gradual expansion into general pediatric surgical applications. ( 1 , 2 ) Establishing a pediatric robotic program requires institutional investment, operating room workflow adaptation, team training, and structured case selection. Published implementation experiences emphasize that safe integration depends not only on technology acquisition but also on multidisciplinary coordination and progressive escalation of case complexity. In resource-limited healthcare systems, financial constraints and competing service priorities may delay adoption despite potential technical benefits. ( 3 , 4 ) Clinical experience with pediatric robotic surgery has expanded beyond urology to include selected hepatobiliary and colorectal procedures. In choledochal cyst excision, comparative analyses have demonstrated perioperative outcomes similar to laparoscopy, with safe reconstruction and acceptable morbidity profiles. ( 5 ) Robotic-assisted pull-through procedures for anorectal malformation have likewise been reported as technically feasible, particularly during deep pelvic dissection.( 6 ) Despite these encouraging findings, most published data originate from high-resource settings, and experience from low- and middle-income countries remains limited. Published data on pediatric robotic surgery from Southeast Asia are limited, and to date, no published pediatric robotic series has been reported from the Philippines. In 2024, University of the Philippines–Philippine General Hospital performed the country’s first general pediatric robotic operation—a robotic-assisted choledochal cyst excision in a 10-year-old child. This case series represents the first documented pediatric robotic surgery experience in the Philippines, focusing on feasibility, safety, and short-term outcomes. METHODS This study is a retrospective descriptive case series of pediatric patients who underwent robotic-assisted surgery at a public tertiary referral center in the Philippines following the introduction of a pediatric robotic surgery program. All consecutive patients aged < 19 years who underwent robotic-assisted surgery between September 2024 and October 2025 were included. There were no exclusion criteria. Demographic, clinical, and perioperative data were extracted from electronic medical records and operative logs by the primary investigator and cross-checked for accuracy prior to analysis. All patients were followed for a minimum of 30 days postoperatively and outpatient clinic records were reviewed. Operative and perioperative variables collected included the type of robotic procedure performed, robotic platform used, docking time, console time, and total operative time, estimated intraoperative blood loss, conversion to laparoscopic or open surgery, intraoperative and postoperative complications, time to full oral intake, duration of postoperative pain control, and postoperative length of hospital stay. Postoperative complications were classified according to the Clavien-Dindo classification and recorded within 30 days of surgery. All data were anonymized prior to analysis. Data were analyzed descriptively, with continuous variables reported as medians with ranges and categorical variables summarized as frequencies and percentages. No comparative statistical analyses were performed due to the descriptive nature of the study. This study was conducted in accordance with the STROCSS 2021 guidelines for reporting surgical case series. Ethical approval was obtained from the University of the Philippines Manila Research Ethics Board. RESULTS Overall Cohort Characteristics A total of nine pediatric patients underwent robotic-assisted surgical procedures during the study period. The cohort included 5 males and 4 females, with a median age of 6 years (range 2–16) and median weight of 19.5 kg (range 12.7–58.0). All procedures were performed electively at a public tertiary referral center using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA), the 8 cases in the da Vinci Si and one in the da Vinci Xi (total proctocolectomy). All procedures were performed by a single pediatric surgeon as the primary console operator. Surgical procedures included choledochal cyst excision (n = 4), robot-assisted anorectal pullthrough (RAARP) for anorectal malformation (n = 2), robotic total proctocolectomy for infantile inflammatory bowel disease and familial polyposis syndrome (n = 2), and robotic unilateral oophorocystectomy for ovarian teratoma (n = 1). All cases were completed robotically, with no unplanned conversions to laparoscopic or open surgery. Table 1 Baseline demographic characteristics Number of patients n: 9 Age (years) median: 6 (range: 2–16) Sex (male : female) 5 : 4 Weight (kg) median: 19.5 (range: 12.7–58) Type of surgical procedure choledochal cyst excision n: 4 anorectal pullthrough for anorectal malformation (RAARP) n: 2 total proctocolectomy n: 2 unilateral oophorocystectomy n: 1 Robotic choledochal cyst excision Four patients underwent robotic-assisted excision of choledochal cysts. All cases involved Todani type I cysts, with widest cyst diameters ranging from 14 to 53 mm. Patient ages ranged from 3 to 10 years, with weights between 14.2 and 38.0 kg. Three patients were female and one was male. Hepaticoduodenostomy was the biliary–enteric reconstruction performed in all four cases. All cases were performed robotically in the da Vinci Si system using three 8-mm ports, one 12-mm optical port and one 5-mm assist port. Docking time ranged from 10 to 45 minutes, console time from 210 to 480 minutes, and total operative time from 240 to 545 minutes. A reduction in docking time, console time, and total operative time was observed across sequential cases. Estimated intraoperative blood loss ranged from 25 to 150 mL, and no patient required intraoperative or postoperative blood transfusion. There were no recorded intraoperative complications and no conversions to laparoscopic or open surgery. Postoperative length of stay ranged from 5 to 8 days. Duration of intravenous analgesia ranged from 2 to 6 days. Only one patient required postoperative parenteral opioid administration. Time to full enteral feeding ranged from 3 to 6 days. No postoperative complications or reinterventions were recorded. All patients were reviewed at 30-day follow-up and were clinically well. Table 2 Operative and Postoperative Outcomes of Robotic Choledochal Cyst Excision (Individual Patient Data) Variable Case 1 Case 2 Case 3 Case 4 Age (years) / Sex 10 / F 6 / F 6 / F 3 / M Weight (kg) 38.0 19.5 18.3 14.2 Widest cyst diameter (mm) 45 53 25 14 Docking time (min) 45 30 20 10 Console time (min) 480 415 210 210 Total operative time (min) 545 485 250 240 Estimated blood loss (mL) 150 150 50 25 Postoperative length of stay (days) 7 7 8 5 Postoperative parenteral opioid use (# of doses) 0 4 0 0 Time to full enteral diet (days) 5 6 4 3 No intraoperative complications, conversions, or postoperative complications occurred. No intraoperative or postoperative blood transfusions were required. All patients were reviewed at 30-day postoperative follow-up without complications. Robot-assisted Anorectal pullthrough for Anorectal Malformation Two patients underwent RAARP for anorectal malformation with recto–bladder neck fistula, following prior diverting colostomies during infancy. Both patients were male, aged 2 and 8 years, with weights of 12.7 kg and 20.4 kg, respectively. The procedures were performed following the technique of laparoscopy-assisted anorectal pullthrough (LAARP) described by Georgeson et al. ( 7 ) Both procedures were done in the da Vinci Si system. Console times were 195 and 190 minutes, while total operative times were 272 and 240 minutes, respectively. There were no intraoperative complications and no conversions to laparoscopic or open surgery. Postoperative length of hospital stay was 7 and 8 days. Duration of postoperative parenteral analgesia was 3 days in both patients, with 1 and 2 doses of parenteral opioid administered, respectively. Time to full enteral feeding was 4 and 5 days. No postoperative complications or reinterventions were recorded. Both patients were reviewed at 30-day postoperative follow-up without complications. Table 3 Operative and Postoperative Outcomes of RAARP Variable Case 1 Case 2 Age (years) / Sex 2 / M 8 / M Weight (kg) 12.7 20.4 Krickenbeck classification of ARM Recto–bladder neck fistula Recto–bladder neck fistula Type of stoma Descending colostomy Transverse colostomy Docking time (min) 32 20 Console time (min) 195 190 Total operative time (min) 272 240 Estimated blood loss (mL) 50 25 Postoperative length of stay (days) 7 8 Postoperative parenteral opioid use (# of doses) 1 2 Time to full diet (days) 4 5 No intraoperative complications, conversions, or postoperative complications occurred. No blood transfusions were required. Both patients were reviewed at 30-day postoperative follow-up without complications. Robot-assisted total proctocolectomy Two male patients underwent robotic-assisted total proctocolectomy with straight ileoanal anastomosis (SIAA) and diverting ileostomy for infantile ulcerative colitis and familial adenomatous polyposis (FAP), respectively. Patients were aged 6 and 13 years, with weights of 18.5 kg and 24.4 kg, respectively. The first case of infantile ulcerative colitis was done in the da Vinci Si while the case of FAP was performed in the da Vinci Xi. Docking times were 30 and 16 minutes, console times were 145 and 429 minutes, and total operative times were 609 and 610 minutes, respectively. Estimated intraoperative blood loss was 60 mL and 80 mL, respectively. The patient with infantile ulcerative colitis underwent a combined robotic and laparoscopic approach in the da Vinci Si. The robotic portion was performed for the pelvic and left-sided colonic mobilization and laparoscopy was used in the right-sided colonic dissection. The patient with FAP underwent a pure robotic-assisted procedure in the newer da Vinci Xi system, which allowed multi-quadrant surgery with single docking. Postoperative length of hospital stay was 8 and 10 days, respectively. The patient with FAP developed a chylous leak noted in the peritoneal drain, which was managed conservatively and classified as Clavien–Dindo grade II. No reoperations were required. Duration of postoperative intravenous analgesia was 8 and 7 days. Only one patient received a single dose of parenteral opioid. Time to full enteral feeding was 4 and 5 days. Both patients were reviewed at 30-day postoperative follow-up without further complications. Robot-assisted unilateral oophorocystectomy One 16-year-old female patient underwent robotic unilateral oophorocystectomy for a right ovarian teratoma. The patient weighed 58 kg. Docking time was 26 minutes, console time was 70 minutes, and total operative time was 145 minutes. Estimated intraoperative blood loss was 10 mL. The procedure was completed robotically without complication or conversion. Postoperative length of hospital stay was 2 days. The patient was reviewed at 30-day postoperative follow-up without complications. Table 4 Operative and Postoperative Outcomes of Robotic Total Proctocolectomy and Oophorocystectomy Variable Case 1 Case 2 Case 3 Age (years)/ Sex 6/ M 13/ M 16/ F Weight (kg) 18.5 24.4 58 Diagnosis Infantile ulcerative colitis Familial adenomatous polyposis Right ovarian teratoma Procedure Total proctocolectomy, SIAA, ileostomy Total proctocolectomy, SIAA, ileostomy Right oophorocystectomy Docking time (min) 30 16 26 Console time (min) 145 429 70 Total operative time (min) 609 610 145 Estimated blood loss (mL) 60 80 10 Postoperative length of stay (days) 8 10 2 Postoperative parenteral opioid use (# of doses) 0 1 0 Time to full diet (days) 4 5 1 Complications None Chylous leak (Clavien-Dindo grade II) None Across the entire cohort of nine patients, there were no intraoperative complications and no unplanned conversions to laparoscopic or open surgery. One patient (11%) developed a postoperative complication classified as Clavien-Dindo grade II, which was managed conservatively without reoperation. There were no major postoperative complications (Clavien-Dindo grade III or higher) and no mortality. All patients were reviewed at 30-day postoperative follow-up without additional complications. Table 5 Summary Operative and Postoperative Outcomes for the Entire Cohort (n = 9) Variable Value Number of patients 9 Docking time (min) Median: 26 (range: 10–45) Console time (min) Median: 195 (range: 70–480) Total operative time (min) Median: 272 (range: 145–610) Estimated blood loss (mL) Median: 60 (range: 10–150) Postoperative length of stay (days) Median: 7 (range: 2–10) Conversions to lap/open 0 (0%) Intraoperative complications 0 (0%) Postoperative complications (overall) 1 (11%) Clavien-Dindo ≥ III complications 0 (0%) 30-day follow-up completed 9 (100%) DISCUSSION This report describes the first pediatric robotic surgery case series from the Philippines and presents the early clinical experience of a newly established program in a public tertiary referral center. Although robotic surgery is well integrated into pediatric practice in many high-income settings, published data from LMICs remain limited. In this initial cohort, all procedures were completed robotically without unplanned conversion, and no major perioperative complications occurred. Operative duration reflected the early phase of program implementation, yet perioperative outcomes were comparable to those reported in previously published pediatric series of robotic hepatobiliary and colorectal surgery. ( 3 , 5 , 6 , 8 – 10 ) These findings suggest that pediatric robotic surgery can be introduced safely in a resource-constrained setting with careful case selection and coordinated implementation. Feasibility and Safety The introduction of robotic-assisted surgery into pediatrics requires deliberate planning, team preparation, and careful case selection. In our program, the initial cases were intentionally chosen based on procedural familiarity. All index operations were procedures that the primary surgeon had previously performed laparoscopically with established experience. This approach was adopted to prioritize patient safety during the early phase of robotic integration and to limit technical variability unrelated to the platform itself. Adult robotic surgeons with established console experience were also present during the initial cases and served as proctors. Their involvement provided technical oversight and team support, particularly during docking, troubleshooting, and optimization of operative workflow. This structured introduction—built upon prior laparoscopic expertise and multidisciplinary mentorship—likely contributed to the absence of major intraoperative complications and the successful completion of all procedures without conversion. Similar experiences have been described during early program development in other centers. Pham et al. reported safe initial outcomes in a 39-case series of robotic choledochal cyst excisions in Vietnam, with no conversions or intraoperative complications.( 8 ) Systematic reviews of RAARP have likewise demonstrated feasibility with low perioperative morbidity in selected pediatric patients. ( 6 , 10 ) Longer operative times are expected during the early phase of adopting a new platform, particularly while the operating teams become accustomed to docking, port configuration, and console coordination. In our series, operative duration likely reflects this initial adjustment period. No major perioperative complications were observed. However, the small number of cases does not allow meaningful assessment of any potential association between operative duration and outcomes. Reports describing early institutional experiences similarly highlight the importance of careful preparation and stepwise case progression when introducing robotic surgery into pediatric practice. ( 3 , 4 ) Choledochal cyst excision Choledochal cyst excision requires careful dissection in proximity to major vascular, biliary and pancreatic structures and precise biliary reconstruction. These technical demands make minimally invasive reconstruction challenging, particularly in smaller patients. In our series, all cyst excisions were completed robotically without conversion or major complication. Comparative analyses have reported perioperative outcomes similar to laparoscopy, with acceptable morbidity profiles in both approaches. Although robotic procedures are associated with increased cost in many settings, reported complication rates and length of stay are comparable between platforms. ( 5 , 9 ) A progressive reduction in docking time—from 45 minutes in the first case to 10 minutes in the fourth—reflects early team familiarization and workflow refinement. This trend suggests that efficiency improves with structured repetition and standardized port configuration during the initial phase of the program. Colorectal and pelvic procedures Pelvic reconstruction for anorectal malformation requires careful identification of the fistula and controlled dissection within a narrow operative field. Minimally invasive approaches have been increasingly applied to these procedures, with published series reporting low conversion rates and acceptable early morbidity. ( 6 , 10 ) In our cohort, all pelvic dissections were completed robotically without conversion or major complication. The platform provided stable instrument control during fistula division and reconstruction. These characteristics may be particularly relevant in our setting, where delayed referral is common and patients often present with chronic colonic dilation, fecal loading, inflammation, or prior diversion procedures. Such factors can distort pelvic anatomy and increase operative complexity compared with classic textbook cases. Although long-term functional outcomes require further follow-up, short-term perioperative results in this series were comparable to those described in other pediatric robotic colorectal reports. ( 6 , 10 ) Limitations and Context of Implementation in LMIC Setting This report represents the early experience of a newly established pediatric robotic program at a single institution and reflects the practice of one primary console surgeon. The limited number of cases and short follow-up restrict conclusions regarding long-term functional outcomes, particularly for reconstructive colorectal procedures. Additionally, the absence of a laparoscopic or open comparison group precludes direct assessment of relative operative efficiency or postoperative recovery. A formal cost analysis was not performed. The economic impact of robotic surgery remains an important consideration in resource-constrained settings, where capital expenditure and consumable costs may influence program sustainability. Comparative analyses in pediatric choledochal cyst surgery have reported similar short-term outcomes between robotic and laparoscopic approaches, though at higher overall procedural cost. ( 9 ) In our institution, careful case selection and institutional support were essential to start the program. Despite these limitations, this series provides early experience from a public tertiary referral center operating in a resource-constrained healthcare setting. Experience from other institutions suggests that careful preparation, team training, and gradual expansion of case complexity can support safe program development. Ongoing follow-up, broader experience, and future cost-effectiveness analyses will be important to better define the role of pediatric robotic surgery in similar LMIC environments. CONCLUSION This study presents the first reported pediatric robotic surgery case series from the Philippines and describes the initial experience of a newly established program in a public tertiary referral center. All procedures were completed robotically without major complications, and short-term outcomes were consistent with those reported in other early pediatric series. These findings indicate that pediatric robotic surgery can be introduced in a resource-constrained healthcare setting with careful preparation and appropriate case selection. Ongoing case accrual, longer follow-up, and future cost evaluation will be important to better define its role in pediatric surgical practice within LMIC settings. Declarations Ethics approval This study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2025-0806-01). The requirement for individual informed consent was waived due to the retrospective design and use of anonymized data. Conflict of interest The author declares that there are declare no competing interests. No financial or non-financial conflicts of interest exist with respect to the conduct, authorship, and publication of this study. Use of artificial intelligence Generative artificial intelligence (ChatGPT, OpenAI) was used to assist in language refinement and structural editing of the manuscript. All clinical content, interpretation of data, and final editorial decisions were made solely by the author. The author takes full responsibility for the accuracy and integrity of the content. Funding This research received no external funding. Author Contribution Jan Miguel C. Deogracias: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing – original draft, Writing – review & editing. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. References Denning NL, Kallis MP, Prince JM (2020) Pediatric Robotic Surgery. Surg Clin North Am 100(2):431–443. 10.1016/j.suc.2019.12.004 O’Brien LP, Hannan E, Antao B, Peirce C (2023) Paediatric robotic surgery: a narrative review. J Robot Surg 17(4):1171–1179. 10.1007/s11701-023-01523-z Soto Beauregard C, De Rodríguez J, Domínguez Amillo E, Gómez Cervantes M (2022) Ávila Ramírez L. Implementing a pediatric robotic surgery program: future perspectives. Cir Pediátrica 35(4):187–195. 10.54847/cp.2022.04.19 Wallace MW, Ram C, Mina A, Lovvorn HN, Patel A, Hopkins MB et al (2024) Collaborative Implementation of Robotic Surgery Into an Academic Pediatric Surgery Practice. J Surg Res 302:883–890. 10.1016/j.jss.2024.07.057 Zhang Mxin, Chi S, qing, Cao G, qing, Tang J feng, Tang S (2023) tao. Comparison of efficacy and safety of robotic surgery and laparoscopic surgery for choledochal cyst in children: a systematic review and proportional meta-analysis. Surg Endosc. ;37(1):31–47. 10.1007/s00464-022-09442-0 Sharma S, Geetha V (2024) Robotic-assisted pull-through procedures for anorectal malformation: a systematic review. Pediatr Surg Int 40(1):194. 10.1007/s00383-024-05782-1 Georgeson KE, Inge TH, Albanese CT (2000) Laparoscopically assisted anorectal pull-through for high imperforate anus—A new technique. J Pediatr Surg 35(6):927–931. 10.1053/jpsu.2000.6925 PubMed PMID: 10873037 Pham HD, Okata Y, Vu HM, Tran NX, Nguyen QT, Nguyen LT (2019) Robotic-assisted surgery for choledochal cyst in children: early experience at Vietnam National Children’s Hospital. Pediatr Surg Int 35(11):1211–1216. 10.1007/s00383-019-04518-w Yin T, Chen S, Li Q, Huang T, Li L, Diao M (2022) Comparison of outcomes and safety of laparoscopic and robotic-assisted cyst excision and hepaticojejunostomy for choledochal cysts: A systematic review and meta-analysis. Ann Med Surg 75. 10.1016/j.amsu.2022.103412 Gazzaneo M, Bosisio M, Mandarano G, Bulotta AL, Alberti D, Riccipetitoni G (2025) Robotic surgery in anorectal malformations: Where are we? A systematic review. Pediatr Surg Int 41(1):184. 10.1007/s00383-025-06098-4 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-9154292","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612858262,"identity":"a638f134-a22f-4305-9359-d2adb83503dd","order_by":0,"name":"Jan Miguel Deogracias","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACxgYGAwiLGYg/gFkJYGHitDDOIEYLEBjAWcw8xGhhbj+88cGHX/fk+duZH3+2bbvDwM+eY8BcuAOPw3rSig1n9hUbzjjMZiad2/aMQbLnjQHzzDN4tMzgMZPm7Ulg3MDMYMac23aYweAG0BbeNrxazH8DtdhvYGb//NkSqMWeCC1mzDw/EhI3MPMYSDOCbJEgpAXoF8mZDQnJMw7zlEn2nHvGI3HmWcHhmXi0GAJD7MOHPwm2/f3HN3/4UXZHjr89eePjQnxaGkBWIRQcAEfNYdwaGBjkweQfhBYwyYxPyygYBaNgFIw4AAAW+lHJ8vPV6QAAAABJRU5ErkJggg==","orcid":"","institution":"Philippine General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jan","middleName":"Miguel","lastName":"Deogracias","suffix":""}],"badges":[],"createdAt":"2026-03-18 04:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9154292/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9154292/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105904325,"identity":"13c3ad10-d0b4-4ce5-aa22-8aaa6ccef357","added_by":"auto","created_at":"2026-04-01 10:07:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":670950,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9154292/v1/a17b1d83-0bb6-464b-9799-fc90f75e24dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePediatric Robotic Surgery in the Philippines: Initial Experience and Early Outcomes\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMinimally invasive techniques are now routinely used in many areas of pediatric surgery. In selected conditions, laparoscopic approaches are associated with faster recovery, less postoperative pain, and improved perioperative outcomes compared with open procedures. Despite these benefits, complex operations in children remain demanding. Small patient size, limited intra-abdominal working space, and reliance on straight laparoscopic instruments may complicate delicate reconstruction, particularly during deep pelvic or complex abdominal surgery. Robotic systems were developed to overcome some of these limitations by increasing instrument mobility and improving visual control during minimally invasive procedures.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEarly adoption of robotic technology in pediatric surgery occurred primarily within urologic procedures, with gradual expansion into general pediatric surgical applications. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Establishing a pediatric robotic program requires institutional investment, operating room workflow adaptation, team training, and structured case selection. Published implementation experiences emphasize that safe integration depends not only on technology acquisition but also on multidisciplinary coordination and progressive escalation of case complexity. In resource-limited healthcare systems, financial constraints and competing service priorities may delay adoption despite potential technical benefits. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eClinical experience with pediatric robotic surgery has expanded beyond urology to include selected hepatobiliary and colorectal procedures. In choledochal cyst excision, comparative analyses have demonstrated perioperative outcomes similar to laparoscopy, with safe reconstruction and acceptable morbidity profiles. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Robotic-assisted pull-through procedures for anorectal malformation have likewise been reported as technically feasible, particularly during deep pelvic dissection.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Despite these encouraging findings, most published data originate from high-resource settings, and experience from low- and middle-income countries remains limited.\u003c/p\u003e \u003cp\u003ePublished data on pediatric robotic surgery from Southeast Asia are limited, and to date, no published pediatric robotic series has been reported from the Philippines. In 2024, University of the Philippines\u0026ndash;Philippine General Hospital performed the country\u0026rsquo;s first general pediatric robotic operation\u0026mdash;a robotic-assisted choledochal cyst excision in a 10-year-old child. This case series represents the first documented pediatric robotic surgery experience in the Philippines, focusing on feasibility, safety, and short-term outcomes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study is a retrospective descriptive case series of pediatric patients who underwent robotic-assisted surgery at a public tertiary referral center in the Philippines following the introduction of a pediatric robotic surgery program. All consecutive patients aged\u0026thinsp;\u0026lt;\u0026thinsp;19 years who underwent robotic-assisted surgery between September 2024 and October 2025 were included. There were no exclusion criteria. Demographic, clinical, and perioperative data were extracted from electronic medical records and operative logs by the primary investigator and cross-checked for accuracy prior to analysis. All patients were followed for a minimum of 30 days postoperatively and outpatient clinic records were reviewed.\u003c/p\u003e \u003cp\u003eOperative and perioperative variables collected included the type of robotic procedure performed, robotic platform used, docking time, console time, and total operative time, estimated intraoperative blood loss, conversion to laparoscopic or open surgery, intraoperative and postoperative complications, time to full oral intake, duration of postoperative pain control, and postoperative length of hospital stay. Postoperative complications were classified according to the Clavien-Dindo classification and recorded within 30 days of surgery. All data were anonymized prior to analysis. Data were analyzed descriptively, with continuous variables reported as medians with ranges and categorical variables summarized as frequencies and percentages. No comparative statistical analyses were performed due to the descriptive nature of the study.\u003c/p\u003e \u003cp\u003e This study was conducted in accordance with the STROCSS 2021 guidelines for reporting surgical case series. Ethical approval was obtained from the University of the Philippines Manila Research Ethics Board.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eOverall Cohort Characteristics\u003c/h2\u003e \u003cp\u003eA total of nine pediatric patients underwent robotic-assisted surgical procedures during the study period. The cohort included 5 males and 4 females, with a median age of 6 years (range 2\u0026ndash;16) and median weight of 19.5 kg (range 12.7\u0026ndash;58.0). All procedures were performed electively at a public tertiary referral center using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA), the 8 cases in the da Vinci Si and one in the da Vinci Xi (total proctocolectomy). All procedures were performed by a single pediatric surgeon as the primary console operator.\u003c/p\u003e \u003cp\u003eSurgical procedures included choledochal cyst excision (n\u0026thinsp;=\u0026thinsp;4), robot-assisted anorectal pullthrough (RAARP) for anorectal malformation (n\u0026thinsp;=\u0026thinsp;2), robotic total proctocolectomy for infantile inflammatory bowel disease and familial polyposis syndrome (n\u0026thinsp;=\u0026thinsp;2), and robotic unilateral oophorocystectomy for ovarian teratoma (n\u0026thinsp;=\u0026thinsp;1). All cases were completed robotically, with no unplanned conversions to laparoscopic or open surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en: 9\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian: 6 (range: 2\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male : female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 : 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian: 19.5 (range: 12.7\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of surgical procedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003echoledochal cyst excision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en: 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eanorectal pullthrough for anorectal malformation (RAARP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en: 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal proctocolectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en: 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eunilateral oophorocystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en: 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRobotic choledochal cyst excision\u003c/h3\u003e\n\u003cp\u003eFour patients underwent robotic-assisted excision of choledochal cysts. All cases involved Todani type I cysts, with widest cyst diameters ranging from 14 to 53 mm. Patient ages ranged from 3 to 10 years, with weights between 14.2 and 38.0 kg. Three patients were female and one was male.\u003c/p\u003e \u003cp\u003eHepaticoduodenostomy was the biliary\u0026ndash;enteric reconstruction performed in all four cases. All cases were performed robotically in the da Vinci Si system using three 8-mm ports, one 12-mm optical port and one 5-mm assist port.\u003c/p\u003e \u003cp\u003eDocking time ranged from 10 to 45 minutes, console time from 210 to 480 minutes, and total operative time from 240 to 545 minutes. A reduction in docking time, console time, and total operative time was observed across sequential cases.\u003c/p\u003e \u003cp\u003eEstimated intraoperative blood loss ranged from 25 to 150 mL, and no patient required intraoperative or postoperative blood transfusion. There were no recorded intraoperative complications and no conversions to laparoscopic or open surgery.\u003c/p\u003e \u003cp\u003ePostoperative length of stay ranged from 5 to 8 days. Duration of intravenous analgesia ranged from 2 to 6 days. Only one patient required postoperative parenteral opioid administration. Time to full enteral feeding ranged from 3 to 6 days.\u003c/p\u003e \u003cp\u003eNo postoperative complications or reinterventions were recorded. All patients were reviewed at 30-day follow-up and were clinically well.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative and Postoperative Outcomes of Robotic Choledochal Cyst Excision (Individual Patient Data)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCase 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCase 4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years) / Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 / F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 / F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 / F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 / M\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidest cyst diameter (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDocking time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative parenteral opioid use (# of doses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to full enteral diet (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNo intraoperative complications, conversions, or postoperative complications occurred.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNo intraoperative or postoperative blood transfusions were required.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAll patients were reviewed at 30-day postoperative follow-up without complications.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eRobot-assisted Anorectal pullthrough for Anorectal Malformation\u003c/h3\u003e\n\u003cp\u003eTwo patients underwent RAARP for anorectal malformation with recto\u0026ndash;bladder neck fistula, following prior diverting colostomies during infancy. Both patients were male, aged 2 and 8 years, with weights of 12.7 kg and 20.4 kg, respectively.\u003c/p\u003e \u003cp\u003eThe procedures were performed following the technique of laparoscopy-assisted anorectal pullthrough (LAARP) described by Georgeson et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Both procedures were done in the da Vinci Si system. Console times were 195 and 190 minutes, while total operative times were 272 and 240 minutes, respectively. There were no intraoperative complications and no conversions to laparoscopic or open surgery.\u003c/p\u003e \u003cp\u003ePostoperative length of hospital stay was 7 and 8 days. Duration of postoperative parenteral analgesia was 3 days in both patients, with 1 and 2 doses of parenteral opioid administered, respectively. Time to full enteral feeding was 4 and 5 days.\u003c/p\u003e \u003cp\u003eNo postoperative complications or reinterventions were recorded. Both patients were reviewed at 30-day postoperative follow-up without complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative and Postoperative Outcomes of RAARP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years) / Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 / M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 / M\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKrickenbeck classification of ARM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto\u0026ndash;bladder neck fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecto\u0026ndash;bladder neck fistula\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of stoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescending colostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransverse colostomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDocking time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative parenteral opioid use (# of doses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to full diet (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNo intraoperative complications, conversions, or postoperative complications occurred.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNo blood transfusions were required.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eBoth patients were reviewed at 30-day postoperative follow-up without complications.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eRobot-assisted total proctocolectomy\u003c/h3\u003e\n\u003cp\u003eTwo male patients underwent robotic-assisted total proctocolectomy with straight ileoanal anastomosis (SIAA) and diverting ileostomy for infantile ulcerative colitis and familial adenomatous polyposis (FAP), respectively. Patients were aged 6 and 13 years, with weights of 18.5 kg and 24.4 kg, respectively. The first case of infantile ulcerative colitis was done in the da Vinci Si while the case of FAP was performed in the da Vinci Xi.\u003c/p\u003e \u003cp\u003eDocking times were 30 and 16 minutes, console times were 145 and 429 minutes, and total operative times were 609 and 610 minutes, respectively. Estimated intraoperative blood loss was 60 mL and 80 mL, respectively. The patient with infantile ulcerative colitis underwent a combined robotic and laparoscopic approach in the da Vinci Si. The robotic portion was performed for the pelvic and left-sided colonic mobilization and laparoscopy was used in the right-sided colonic dissection. The patient with FAP underwent a pure robotic-assisted procedure in the newer da Vinci Xi system, which allowed multi-quadrant surgery with single docking.\u003c/p\u003e \u003cp\u003ePostoperative length of hospital stay was 8 and 10 days, respectively. The patient with FAP developed a chylous leak noted in the peritoneal drain, which was managed conservatively and classified as Clavien\u0026ndash;Dindo grade II. No reoperations were required.\u003c/p\u003e \u003cp\u003eDuration of postoperative intravenous analgesia was 8 and 7 days. Only one patient received a single dose of parenteral opioid. Time to full enteral feeding was 4 and 5 days. Both patients were reviewed at 30-day postoperative follow-up without further complications.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRobot-assisted unilateral oophorocystectomy\u003c/h2\u003e \u003cp\u003eOne 16-year-old female patient underwent robotic unilateral oophorocystectomy for a right ovarian teratoma. The patient weighed 58 kg.\u003c/p\u003e \u003cp\u003eDocking time was 26 minutes, console time was 70 minutes, and total operative time was 145 minutes. Estimated intraoperative blood loss was 10 mL. The procedure was completed robotically without complication or conversion. Postoperative length of hospital stay was 2 days. The patient was reviewed at 30-day postoperative follow-up without complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative and Postoperative Outcomes of Robotic Total Proctocolectomy and Oophorocystectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCase 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)/ Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/ M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13/ M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16/ F\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfantile ulcerative colitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamilial adenomatous polyposis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight ovarian teratoma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal proctocolectomy, SIAA, ileostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal proctocolectomy, SIAA, ileostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight oophorocystectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDocking time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative parenteral opioid use (# of doses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to full diet (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChylous leak (Clavien-Dindo grade II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAcross the entire cohort of nine patients, there were no intraoperative complications and no unplanned conversions to laparoscopic or open surgery. One patient (11%) developed a postoperative complication classified as Clavien-Dindo grade II, which was managed conservatively without reoperation. There were no major postoperative complications (Clavien-Dindo grade III or higher) and no mortality. All patients were reviewed at 30-day postoperative follow-up without additional complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary Operative and Postoperative Outcomes for the Entire Cohort (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDocking time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian: 26 (range: 10\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian: 195 (range: 70\u0026ndash;480)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian: 272 (range: 145\u0026ndash;610)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian: 60 (range: 10\u0026ndash;150)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian: 7 (range: 2\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversions to lap/open\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications (overall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day follow-up completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis report describes the first pediatric robotic surgery case series from the Philippines and presents the early clinical experience of a newly established program in a public tertiary referral center. Although robotic surgery is well integrated into pediatric practice in many high-income settings, published data from LMICs remain limited.\u003c/p\u003e \u003cp\u003eIn this initial cohort, all procedures were completed robotically without unplanned conversion, and no major perioperative complications occurred. Operative duration reflected the early phase of program implementation, yet perioperative outcomes were comparable to those reported in previously published pediatric series of robotic hepatobiliary and colorectal surgery. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) These findings suggest that pediatric robotic surgery can be introduced safely in a resource-constrained setting with careful case selection and coordinated implementation.\u003c/p\u003e\n\u003ch3\u003eFeasibility and Safety\u003c/h3\u003e\n\u003cp\u003eThe introduction of robotic-assisted surgery into pediatrics requires deliberate planning, team preparation, and careful case selection. In our program, the initial cases were intentionally chosen based on procedural familiarity. All index operations were procedures that the primary surgeon had previously performed laparoscopically with established experience. This approach was adopted to prioritize patient safety during the early phase of robotic integration and to limit technical variability unrelated to the platform itself.\u003c/p\u003e \u003cp\u003eAdult robotic surgeons with established console experience were also present during the initial cases and served as proctors. Their involvement provided technical oversight and team support, particularly during docking, troubleshooting, and optimization of operative workflow. This structured introduction\u0026mdash;built upon prior laparoscopic expertise and multidisciplinary mentorship\u0026mdash;likely contributed to the absence of major intraoperative complications and the successful completion of all procedures without conversion.\u003c/p\u003e \u003cp\u003eSimilar experiences have been described during early program development in other centers. Pham et al. reported safe initial outcomes in a 39-case series of robotic choledochal cyst excisions in Vietnam, with no conversions or intraoperative complications.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Systematic reviews of RAARP have likewise demonstrated feasibility with low perioperative morbidity in selected pediatric patients. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLonger operative times are expected during the early phase of adopting a new platform, particularly while the operating teams become accustomed to docking, port configuration, and console coordination. In our series, operative duration likely reflects this initial adjustment period. No major perioperative complications were observed. However, the small number of cases does not allow meaningful assessment of any potential association between operative duration and outcomes. Reports describing early institutional experiences similarly highlight the importance of careful preparation and stepwise case progression when introducing robotic surgery into pediatric practice. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCholedochal cyst excision\u003c/h2\u003e \u003cp\u003eCholedochal cyst excision requires careful dissection in proximity to major vascular, biliary and pancreatic structures and precise biliary reconstruction. These technical demands make minimally invasive reconstruction challenging, particularly in smaller patients.\u003c/p\u003e \u003cp\u003eIn our series, all cyst excisions were completed robotically without conversion or major complication. Comparative analyses have reported perioperative outcomes similar to laparoscopy, with acceptable morbidity profiles in both approaches. Although robotic procedures are associated with increased cost in many settings, reported complication rates and length of stay are comparable between platforms. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA progressive reduction in docking time\u0026mdash;from 45 minutes in the first case to 10 minutes in the fourth\u0026mdash;reflects early team familiarization and workflow refinement. This trend suggests that efficiency improves with structured repetition and standardized port configuration during the initial phase of the program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eColorectal and pelvic procedures\u003c/h2\u003e \u003cp\u003ePelvic reconstruction for anorectal malformation requires careful identification of the fistula and controlled dissection within a narrow operative field. Minimally invasive approaches have been increasingly applied to these procedures, with published series reporting low conversion rates and acceptable early morbidity. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn our cohort, all pelvic dissections were completed robotically without conversion or major complication. The platform provided stable instrument control during fistula division and reconstruction. These characteristics may be particularly relevant in our setting, where delayed referral is common and patients often present with chronic colonic dilation, fecal loading, inflammation, or prior diversion procedures. Such factors can distort pelvic anatomy and increase operative complexity compared with classic textbook cases.\u003c/p\u003e \u003cp\u003eAlthough long-term functional outcomes require further follow-up, short-term perioperative results in this series were comparable to those described in other pediatric robotic colorectal reports. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Context of Implementation in LMIC Setting\u003c/h2\u003e \u003cp\u003eThis report represents the early experience of a newly established pediatric robotic program at a single institution and reflects the practice of one primary console surgeon. The limited number of cases and short follow-up restrict conclusions regarding long-term functional outcomes, particularly for reconstructive colorectal procedures. Additionally, the absence of a laparoscopic or open comparison group precludes direct assessment of relative operative efficiency or postoperative recovery.\u003c/p\u003e \u003cp\u003eA formal cost analysis was not performed. The economic impact of robotic surgery remains an important consideration in resource-constrained settings, where capital expenditure and consumable costs may influence program sustainability. Comparative analyses in pediatric choledochal cyst surgery have reported similar short-term outcomes between robotic and laparoscopic approaches, though at higher overall procedural cost. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) In our institution, careful case selection and institutional support were essential to start the program.\u003c/p\u003e \u003cp\u003eDespite these limitations, this series provides early experience from a public tertiary referral center operating in a resource-constrained healthcare setting. Experience from other institutions suggests that careful preparation, team training, and gradual expansion of case complexity can support safe program development. Ongoing follow-up, broader experience, and future cost-effectiveness analyses will be important to better define the role of pediatric robotic surgery in similar LMIC environments.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study presents the first reported pediatric robotic surgery case series from the Philippines and describes the initial experience of a newly established program in a public tertiary referral center. All procedures were completed robotically without major complications, and short-term outcomes were consistent with those reported in other early pediatric series. These findings indicate that pediatric robotic surgery can be introduced in a resource-constrained healthcare setting with careful preparation and appropriate case selection. Ongoing case accrual, longer follow-up, and future cost evaluation will be important to better define its role in pediatric surgical practice within LMIC settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e This study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2025-0806-01). The requirement for individual informed consent was waived due to the retrospective design and use of anonymized data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eThe author declares that there are declare no competing interests. No financial or non-financial conflicts of interest exist with respect to the conduct, authorship, and publication of this study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eUse of artificial intelligence\u003c/h2\u003e \u003cp\u003eGenerative artificial intelligence (ChatGPT, OpenAI) was used to assist in language refinement and structural editing of the manuscript. All clinical content, interpretation of data, and final editorial decisions were made solely by the author. The author takes full responsibility for the accuracy and integrity of the content.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJan Miguel C. Deogracias: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDenning NL, Kallis MP, Prince JM (2020) Pediatric Robotic Surgery. Surg Clin North Am 100(2):431\u0026ndash;443. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.suc.2019.12.004\u003c/span\u003e\u003cspan address=\"10.1016/j.suc.2019.12.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Brien LP, Hannan E, Antao B, Peirce C (2023) Paediatric robotic surgery: a narrative review. J Robot Surg 17(4):1171\u0026ndash;1179. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-023-01523-z\u003c/span\u003e\u003cspan address=\"10.1007/s11701-023-01523-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoto Beauregard C, De Rodr\u0026iacute;guez J, Dom\u0026iacute;nguez Amillo E, G\u0026oacute;mez Cervantes M (2022) \u0026Aacute;vila Ram\u0026iacute;rez L. Implementing a pediatric robotic surgery program: future perspectives. Cir Pedi\u0026aacute;trica 35(4):187\u0026ndash;195. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.54847/cp.2022.04.19\u003c/span\u003e\u003cspan address=\"10.54847/cp.2022.04.19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallace MW, Ram C, Mina A, Lovvorn HN, Patel A, Hopkins MB et al (2024) Collaborative Implementation of Robotic Surgery Into an Academic Pediatric Surgery Practice. J Surg Res 302:883\u0026ndash;890. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jss.2024.07.057\u003c/span\u003e\u003cspan address=\"10.1016/j.jss.2024.07.057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Mxin, Chi S, qing, Cao G, qing, Tang J feng, Tang S (2023) tao. Comparison of efficacy and safety of robotic surgery and laparoscopic surgery for choledochal cyst in children: a systematic review and proportional meta-analysis. Surg Endosc. ;37(1):31\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-022-09442-0\u003c/span\u003e\u003cspan address=\"10.1007/s00464-022-09442-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma S, Geetha V (2024) Robotic-assisted pull-through procedures for anorectal malformation: a systematic review. Pediatr Surg Int 40(1):194. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00383-024-05782-1\u003c/span\u003e\u003cspan address=\"10.1007/s00383-024-05782-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgeson KE, Inge TH, Albanese CT (2000) Laparoscopically assisted anorectal pull-through for high imperforate anus\u0026mdash;A new technique. J Pediatr Surg 35(6):927\u0026ndash;931. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/jpsu.2000.6925\u003c/span\u003e\u003cspan address=\"10.1053/jpsu.2000.6925\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePubMed PMID: 10873037\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePham HD, Okata Y, Vu HM, Tran NX, Nguyen QT, Nguyen LT (2019) Robotic-assisted surgery for choledochal cyst in children: early experience at Vietnam National Children\u0026rsquo;s Hospital. Pediatr Surg Int 35(11):1211\u0026ndash;1216. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00383-019-04518-w\u003c/span\u003e\u003cspan address=\"10.1007/s00383-019-04518-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYin T, Chen S, Li Q, Huang T, Li L, Diao M (2022) Comparison of outcomes and safety of laparoscopic and robotic-assisted cyst excision and hepaticojejunostomy for choledochal cysts: A systematic review and meta-analysis. Ann Med Surg 75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amsu.2022.103412\u003c/span\u003e\u003cspan address=\"10.1016/j.amsu.2022.103412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGazzaneo M, Bosisio M, Mandarano G, Bulotta AL, Alberti D, Riccipetitoni G (2025) Robotic surgery in anorectal malformations: Where are we? A systematic review. Pediatr Surg Int 41(1):184. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00383-025-06098-4\u003c/span\u003e\u003cspan address=\"10.1007/s00383-025-06098-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pediatric robotic surgery, pediatric minimally-invasive surgery, choledochal cyst, pediatric colorectal surgery, anorectal malformation, low-middle income country","lastPublishedDoi":"10.21203/rs.3.rs-9154292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9154292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003ePediatric robotic surgery has expanded globally but remains under-reported in low- and middle-income countries. We report the first Philippine series of pediatric robotic-assisted general surgery, describing early program implementation and 30-day outcomes in a public tertiary referral center.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA retrospective descriptive case series was conducted of pediatric patients (less than 19 years-old) who underwent robotic-assisted surgery between September 2024 and October 2025. Demographic characteristics, operative metrics (docking time, console time, total operative time, and estimated blood loss), as well as short-term postoperative outcomes, were summarized descriptively.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eNine pediatric robotic procedures were performed using the da Vinci platform: four choledochal cyst excisions with hepaticoduodenostomy, two robotic-assisted anorectal pull-throughs for anorectal malformation, two total proctocolectomies (ulcerative colitis; familial adenomatous polyposis), and one ovarian oophorocystectomy. Age ranged from 2\u0026ndash;16 years; the lowest weight was 12.7 kg. Median docking, console, and total operative times were 26 (10\u0026ndash;45), 195 (70\u0026ndash;480), and 272 (145\u0026ndash;610) minutes, respectively. Median estimated blood loss was 60 (10\u0026ndash;150) mL. There were no unplanned conversions or intraoperative complications. One postoperative complication occurred (chylous leak, Clavien\u0026ndash;Dindo II) managed conservatively. No Clavien\u0026ndash;Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III complications, mortality, or unplanned ICU admissions occurred; all patients completed 30-day follow-up.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003ePediatric robotic surgery was feasible with acceptable 30-day outcomes during early implementation in a resource-constrained public healthcare setting. Operative metrics and morbidity were within ranges reported in published pediatric robotic series. Continued case accrual and longer follow-up are required to evaluate functional outcomes, cost implications, and long-term program sustainability.\u003c/p\u003e","manuscriptTitle":"Pediatric Robotic Surgery in the Philippines: Initial Experience and Early Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-31 09:52:44","doi":"10.21203/rs.3.rs-9154292/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"65c2cdaf-8c92-4f4a-abc2-78fc1ae79ee9","owner":[],"postedDate":"March 31st, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T21:34:50+00:00","index":18,"fulltext":""},{"type":"reviewerAgreed","content":"82288034455594152291552628003466504543","date":"2026-05-11T05:58:06+00:00","index":17,"fulltext":""},{"type":"reviewerAgreed","content":"288270941411688281774206393484003919097","date":"2026-05-09T21:50:59+00:00","index":16,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T09:52:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-31 09:52:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9154292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9154292","identity":"rs-9154292","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}