ROBOT-ASSISTED SURGERY IN PEDIATRIC
PATIENTS: RESULTS OF A FRENCH
MULTICENTER STUDY ON 1401 PATIENTS

Quentin Ballouhey, Ciro Esposito, Kiarash Taghavi, Hubert Lardy, Nicolas Berte, Olivier Abbo, Marc-David Leclair, Sarah Garnier, Matthieu Peycelon, Geraldine Hery, et al.

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► To cite this version:

Quentin Ballouhey, Ciro Esposito, Kiarash Taghavi, Hubert Lardy, Nicolas Berte, et al. ROBOT-ASSISTED SURGERY IN PEDIATRIC PATIENTS: RESULTS OF A FRENCH MULTICENTER STUDY ON 1401 PATIENTS. Journal of Pediatric Surgery, 2025, 60 (8), pp.162397. 10.1016/j.jpedsurg.2025.162397. hal-05163166

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# Robot-Assisted Surgery in Pediatric Patients: Results of a French Multicenter Study on 1401 Patients

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Quentin Ballouhey<sup>a</sup>, Ciro Esposito<sup>b, *</sup>, Kiarash Taghavi<sup>c, 1</sup>, Hubert Lardy<sup>d</sup>, Nicolas Berte<sup>e</sup>, Olivier Abbo<sup>f</sup>, Marc David Leclair<sup>g</sup>, Sarah Garnier<sup>h</sup>, Matthieu Peycelon<sup>1</sup>, Géraldine Hery<sup>j</sup>, Aurélien Scalabre<sup>k</sup>, Pierre Meignan<sup>l</sup>, Carmen Capito<sup>c</sup>, Pauline Lopez<sup>c</sup>, Sabine Sarnacki<sup>l</sup>, Laurent Fourcade<sup>a</sup>, Alexis P. Arnaud<sup>m</sup>, Thomas Blanc<sup>l</sup>

## ARTICLE INFO

**Article history:**

Received 30 November 2024

Received in revised form

25 April 2025

Accepted 29 May 2025

**Keywords:**

Robot-assisted surgery

Robotics

Pediatrics

Training

Neonates

Complexity

## ABSTRACT

**Introduction:** Establishing a robotic program in pediatric surgery remains challenging, with evidence-based practices still evolving. Over the last five years, robot-assisted surgery (RAS) has become the standard approach for several pediatric indications. This study presents the first national analysis of pediatric RAS in France, aiming to evaluate indications, procedural trends, and technical considerations.

**Methods:** A retrospective, multi-institutional study was conducted across 11 French centers with active pediatric robotic programs over the period 2007–2020. Clinical and organizational data were collected through standardized questionnaires and centralized database analysis. A Surgical Complexity Score (SCS) was developed to classify procedures.

**Results:** A total of 1401 RAS procedures were performed, including 301 children <15 kg and 93 < 10 kg. Centers handled a median of 1.4 cases/month, with 91 types of procedures performed. The 5 most frequent procedures were pyeloplasty (34 %), nephrectomy (12.7 %), antireflux surgery (9.2 %), ureteral reimplantation (5.7 %), and biliary procedures (5.6 %). Over time, procedural complexity increased, with 204 cases classified as high complexity (SCS 3). A strong correlation was observed between center experience and inclusion of patients <15 kg (r = 0.873; p = 0.0004), while conversion rates (3 %) were not influenced by experience. Twenty-four fellows were trained using standardized curricula and dual-console platforms.

**Conclusions:** Pediatric RAS has significantly grown in France, proving to be safe and feasible even in infants under 10 kg. Urology remains the main indication, followed by gastrointestinal and biliary surgery. Despite current limitations—especially instrument size—RAS offers advantages in precision, ergonomics, and surgical education. Future innovation may enhance its broader adoption in pediatric surgery.

© 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license

(http://creativecommons.org/licenses/by/4.0/).

<footnote><sup>a</sup> Pediatric Surgery Unit, Hôpital des Enfants, Limoges Cedex, France</footnote>

<footnote><sup>b</sup> Pediatric Surgery Unit, Federico II University, Naples, Italy</footnote>

<footnote><sup>c</sup> Department of Pediatrics, Monash University, Melbourne, Australia</footnote>

<footnote><sup>d</sup> Pediatric Surgery Unit, Hôpital de Clocheville, Tours Cedex, France</footnote>

<footnote><sup>e</sup> Pediatric Surgery Unit, CHU de Nancy, Nancy, France</footnote>

<footnote><sup>f</sup> Pediatric Surgery Unit, CHU de Toulouse, Toulouse, France</footnote>

<footnote><sup>g</sup> Pediatric Surgery Unit, CHU de Nantes, Nantes, France</footnote>

<footnote><sup>h</sup> Pediatric Surgery Unit, CHU de Montpellier, Montpellier, France</footnote>

<footnote><sup>i</sup> Department of Pediatric Surgery and Urology, CHU Robert-Debré, Paris, France</footnote>

<footnote><sup>j</sup> Pediatric Surgery Unit, Hôpital du Kremlin-Bicêtre, APHP, Paris, France</footnote>

<footnote><sup>k</sup> Pediatric Surgery Unit, CHU de Saint Etienne, Saint. Etienne, France</footnote>

<footnote><sup>l</sup> Department of Pediatric Surgery and Pediatric Urology, Hôpital Necker-Enfants Malades, France</footnote>

<footnote><sup>m</sup> Pediatric Surgery Unit, CHU Rennes, Institut NuMeCan, INRAe, INSERM, Univ Rennes, Rennes, France</footnote>

<footnote>* Corresponding author. Pediatric Surgery Unit Federico II, Federico II University of Naples, Italy. E-mail address: ciroespo@unina.it (C. Esposito).</footnote>
# 1. Introduction

Robot-assisted surgery (RAS) has become widely utilized for various adult surgical procedures [1] and has progressively expanded its application to pediatric surgery since its introduction in 2001 [2–6]. Robotic platforms facilitate minimally invasive surgeries, often with greater safety and efficiency thanks to enhanced optics, precise movements, better ergonomics, and increased degrees of freedom. The improved ergonomics provides a great benefit since the surgeon can operate seated at the robotic console, with improved alignment of vision and hand movement eliminating tremor. Furthermore, RAS demonstrated a shorter learning curve compared to traditional laparoscopy, especially for complex reconstructive procedures [4,5].

Despite all these advantages the large-scale adoption of RAS in children still faces significant challenges. The largest barrier is represented by the significant cost of acquiring and maintaining the da Vinci robot [6,7]. Additionally, adapting adult-oriented robotic systems to the smaller anatomy of pediatric patients, especially neonates, poses technical difficulties due to the relatively large size of robotic instruments and the limited intra-abdominal working space available in smaller children and neonates [6,7]. To date, pediatric RAS has been performed in children as young as newborns, with the smallest patients weighing less than 15 kg, although neonatal cases remain rare due to technical limitations and platform availability [8]. The rarity and diversity of pediatric surgical procedures further complicate the development of expertise in robotic techniques.

While most studies focus on single-center experience in pediatric RAS [9–13], broader analyses that provide a multicenter perspective remain scarce [14]. Over time technical challenges, such as instrument size [15], feasibility in small infants [7,16], costs and accessibility, have been documented [17]. Despite these hurdles, robotic surgery has gained an established role in pediatric urology and oncology fields [18,19]. Several centers have described their institutional journey in implementing a pediatric robotic program [20,21]. In such centers, RAS has replaced open and/or laparoscopic surgery in certain settings, although the clinical advantages of the robotic approach have not always been easy to define or substantiate with traditional study parameters [22]. Since the implementation of pediatric robotic surgery in Europe, few multi-institutional studies have been performed [22–24].

This study aimed to evaluate the status of pediatric RAS on a national level, 15 years after its implementation in Europe. The primary objective of this study was to quantify the national pediatric robotic surgical activity in France by assessing the total number of procedures performed and their distribution by type. The secondary objectives were to analyze the development, organizational characteristics, and evolution of pediatric robotic programs at a national level, including patient demographics, surgeon training, platform accessibility, and procedural trends.

# 2. Materials and methods

## 2.1. Study design

This observational study (ClinicalTrials.gov identifier NCT03274050) received approval from the appropriate Institute Review Boards (IRBs) and from an independent ethics committee (Comité de Protection des Personnes Ile de France VII). A questionnaire was distributed to all French pediatric centers with a robotic program to collect organizational and clinical data (Supplementary Material 1). The medical records of children who underwent RAS at all pediatric robotic centers in France since the inception of the French pediatric robotic program (2007–2020)

were reviewed. For each center, patients aged over 18 years were excluded, even if treated by pediatric surgeons.

## 2.2. Parameters assessed

Data from each center were collected in a protected national database and subsequently analyzed. Organizational data included: the start date of the pediatric robotic program, the type of robotic platform used at each center, and whether the platform was in a dedicated pediatric hospital or shared with adult services. Additional information included the number of surgeons involved at the program's inception, and the number of surgeons or fellows trained during the study period. The questionnaire was completed by the surgical lead of the robotic program at each center and verified by other surgeons within the institution.

Relevant clinical data included patients' age and weight at the time of surgery, surgical indication, and type of procedure performed. Postoperative morbidity was not evaluated in this study. The analysis focused exclusively on intraoperative events and safety outcomes, including conversion rates to open or laparoscopic surgery and intraoperative complications associated with technical issues related to the robotic system.

Case selection for RAS was determined independently at each center based on patient characteristics, procedural feasibility, and surgeon experience. Centers initially favored standardized urological procedures in children >15 kg. As experience increased, indications broadened to include younger patients and more complex cases.

A Surgical Complexity Score (SCS) was developed by experienced pediatric robotic surgeons from the participating centers, through a consensus-based approach. Although not externally validated, this score served as an internal tool for procedure stratification based on the standardized version of each procedure rather than case-specific variables. Each procedure was retrospectively assigned a score of 1 (simple), 2 (intermediate) or 3 (complex), according to its standard technical difficulty, including intracorporeal suturing demand, anatomical access, operative duration, and literature-based assessments of difficulty. The classification into 3 levels was aimed at stratifying the general complexity of the procedure types, rather than the difficulty of individual cases.

Set-up time was defined as the interval from skin incision to the start of console-based robotic surgery and included trocar positioning and docking of the robotic system. Total operative time included both the set-up time and console time.

## 2.3. Statistical analysis

Statistical analysis was performed with Prism 5® Mac® software (GraphPad software; San Diego, California, USA). Continuous variables were expressed as medians with interquartile range (IQR: 25th-75th percentiles) while categorical variables were reported as absolute numbers and percentages.

Student's t-test was used for parametric continuous data [mean and standard deviation (SD) are presented], whereas the Mann-Whitney test for non-parametric continuous data (medians are presented). Inter-center concordance was assessed using the intra-class correlation coefficient (ICC) with 95 % confidence intervals. A p-value <0.05 was considered statistically significant.

# 3. Results

All contacted pediatric centers returned a completed questionnaire; all were university hospital centers. Each center utilized the
<table><caption>**Table 1**
Data from the 11 participating pediatric robotic surgical centers.</caption><thead><tr><th>Center #</th><th>Start date</th><th>Activity duration years</th><th>Dedicated pediatric robotic platform</th><th>Fellows trained in robotic surgery n=</th><th>Number of procedures</th><th>Cases/month</th><th>Mean SCS</th><th>Median patient age years (IQR)</th><th>Median patient weight kg (IQR)</th><th>Emergent cases n=</th></tr></thead><tbody><tr><td>1</td><td>04/2007</td><td>13.7</td><td>0</td><td>3</td><td>291</td><td>1.7</td><td>1.96</td><td>5.9 (2.8; 10.5)</td><td>20.0 (13.0; 33.1)</td><td>4</td></tr><tr><td>2</td><td>04/2008</td><td>12.8</td><td>0</td><td>3</td><td>195</td><td>1.3</td><td>1.94</td><td>4.7 (2.3; 10.4)</td><td>17.3 (12.1; 30.8)</td><td>7</td></tr><tr><td>3</td><td>11/2013</td><td>7.2</td><td>0</td><td>2</td><td>130</td><td>1.5</td><td>1.71</td><td>9.4 (4.9; 13.9)</td><td>29.0 (17.0; 47.0)</td><td>0</td></tr><tr><td>6</td><td>10/2014</td><td>6.3</td><td>0</td><td>2</td><td>101</td><td>1.3</td><td>2.13</td><td>8.9 (6.2; 11.1)</td><td>29.0 (23.2; 41.6)</td><td>0</td></tr><tr><td>4</td><td>03/2015</td><td>5.8</td><td>0</td><td>1</td><td>84</td><td>1.2</td><td>1.89</td><td>9.1 (6.5; 13.9)</td><td>30.0 (21.0; 49.0)</td><td>0</td></tr><tr><td>5</td><td>08/2015</td><td>5.4</td><td>0</td><td>2</td><td>77</td><td>1.2</td><td>1.99</td><td>7.1 (5.5; 12.7)</td><td>24.5 (20.8; 33.8)</td><td>1</td></tr><tr><td>7</td><td>10/2016</td><td>4.3</td><td>1 da Vinci Xi (Intuitive surgical)</td><td>3</td><td>350</td><td>7.0</td><td>2.24</td><td>8.1 (4.5; 10.1)</td><td>23.6 (17.0; 29.8)</td><td>2</td></tr><tr><td>8</td><td>10/2016</td><td>4.3</td><td>0</td><td>2</td><td>72</td><td>1.4</td><td>2.05</td><td>10.3 (6.3; 13.1)</td><td>29.0 (22.0; 42.0)</td><td>0</td></tr><tr><td>9</td><td>04/2019</td><td>1.7</td><td>1 da Vinci Si (Intuitive surgical)</td><td>2</td><td>67</td><td>3.3</td><td>2.11</td><td>12.6 (7.6; 14.2)</td><td>40 (22.0; 57.5)</td><td>0</td></tr><tr><td>10</td><td>09/2019</td><td>1.5</td><td>0</td><td>2</td><td>13</td><td>0.7</td><td>1.55</td><td>12.6 (9.8; 14.4)</td><td>50 (43.0; 55.0)</td><td>0</td></tr><tr><td>11</td><td>01/2020</td><td>1</td><td>0</td><td>2</td><td>21</td><td>1.7</td><td>1.71</td><td>11.9 (9.9; 15.6)</td><td>25.0 (19.2; 33.7)</td><td>0</td></tr><tr><td><strong>Total</strong></td><td></td><td><strong>63.9</strong></td><td><strong>2</strong></td><td><strong>24</strong></td><td><strong>1401</strong></td><td></td><td></td><td></td><td></td><td><strong>14</strong></td></tr><tr><td><strong>Mean ± SD</strong></td><td></td><td><strong>5.1 ± 4.2</strong></td><td></td><td></td><td><strong>127 ± 108</strong></td><td><strong>2 ± 1.7</strong></td><td><strong>1.9 ± 0.2</strong></td><td><strong>8.6 ± 2.6</strong></td><td><strong>29.3 ± 19.5</strong></td><td><strong>1.2 ± 2.2</strong></td></tr><tr><td><strong>Median (IQR)</strong></td><td></td><td><strong>5.4 (3–6.7)</strong></td><td></td><td></td><td><strong>84 (69.5–162.5)</strong></td><td><strong>1.4 (1.2–1.8)</strong></td><td></td><td><strong>7.8 (3.7–11.8)</strong></td><td><strong>24 (15–40)</strong></td><td></td></tr></tbody></table>

IQR, interquartile range; SCS, surgical complexity score; SD, standard deviation.

da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), including models S, Si, X, or Xi.

A total of 1401 children (689 boys and 712 girls) underwent RAS during the study period. The median patients' age was 7.8 years (IQR 3.7–11.8), with a median weight of 24 kg (IQR 15–40), and a median height of 123 cm (IQR 98–145). Overall, 301 (21.4 %) children weighed less than 15 kg and 93 (6.6 %) weighed less than 10 kg.

The annual number of robotic procedures increased progressively, reaching 299 in 2020. At the time of the study, more than 30 pediatric surgeons were involved in the French robotic program and most performed both urology and general pediatric surgery. All pediatric surgeons performing console surgery during the study period were officially certified as “console-surgeons” for the da Vinci Surgical System, according to the requirements of the Intuitive Surgical training pathway. This included simulator sessions, wet/dry lab training, and proctored clinical cases. Certification was a prerequisite for independent console use at all participating centers, ensuring a standardized training level across institutions. Additionally, 24 fellows were trained for independent robotic platform use during the study period. One center discontinued its pediatric robotic program after two years due to limited access to the robotic platform shared with adult services. The data from this center were excluded.

The median duration of robotic program activity was 5.4 years (IQR 3–6.7), with a median throughput of 1.4 patients per center per month (IQR 1.2–1.8). In seven centers, access to the robotic platform required transport from the pediatric service. Two centers had a dedicated robotic platform for pediatric surgery, and both used da Vinci Si and Xi models. These centers recorded significantly higher procedural volumes per month (7.0 and 3.3 cases/month, respectively; $p = 0.01$).

Data from the 11 participating pediatric robotic surgical centers are summarized in Table 1.

Across all centers, 91 different surgical procedures were performed. Urological indications were the most common (871/1,401, 62 %), followed by abdominal (337/1,401, 24 %) and oncological (137/1,401, 9.7 %) procedures. The 5 most frequent procedures were pyeloplasty (34 %), nephrectomy (12.7 %), antireflux procedures for gastro-esophageal reflux disease (GERD) (9.2 %), ureteral extra-vesical reimplantation (5.7 %), and biliary procedures such as cholecystectomy and choledocal cyst excision (5.6 %).

Neonatal robotic procedures were rare (0.6 %) but included diaphragmatic hernia repair, esophageal atresia repair, and

duodenal atresia repair. Emergent procedures were reported in 14 cases (1 %) and defined as surgery required within 24 h of diagnosis due to the risk of rapid clinical deterioration. These included volvulus (n = 3), esophageal atresia with tracheoesophageal fistula (n = 4), acute small bowel obstruction from a bezoar (n = 2), duodenal atresia (n = 1), perforated appendicitis with generalized peritonitis (n = 3), and intestinal perforation (n = 1). All emergent procedures were performed in high-volume centers with strong robotic experience and rapid platform access.

A total of 204 procedures were classified as level 3 on the Surgical Complexity Score (SCS). Data analysis showed a trend toward increased procedural complexity over time, consistent with growing surgical confidence and experience with robotic techniques (Fig. 1).

Table 2 provides an overview of robotic procedures performed in 1401 pediatric cases.

Same-day discharge was reported in 9 cases (0.6 %) from one center, including seven cholecystectomies, one nephrectomy, and one upper pole nephrectomy. No intraoperative deaths occurred. Emergency undocking was needed in three cases (two due to venous bleeding). Undocking and redocking were performed in 24 cases (1.7 %) in non-emergency settings, mostly during the initial learning curve.

The overall procedural completion rate was 97 %. Conversion to open surgery was necessary in 36 cases (2.5 %) and to laparoscopy in six (0.5 %). The median weight in converted cases was 23 kg (range 3–84). Causes for conversion included limited workspace, technical issues, or bleeding. In the five centers with >100 cases, level 3 SCS procedures reported the highest conversion rates.

Regarding the broadening of indications, children <15 kg were progressively considered for RAS after approximately 30 procedures had been completed at a center. A strong positive correlation was observed between surgical experience and median patient weight ($r = 0.873$; $p = 0.0004$). The center with the lowest median weight (17.3 kg) was considered pioneering in neonatal robotic surgery. A correlation was also found between experience and the number of cases involving children <10 kg ($r = 0.756$; $p = 0.02$). However, no correlation was found between conversion rates and center experience or patient weight, nor between workspace-related conversions and center experience. No significant differences were observed between centers in total operative time or procedural completion rate. Operative duration varied according to procedure complexity, although no statistically significant positive
<figure><img src="image_4.png" /><figcaption>Fig. 1. Trend of Surgical Complexity Score (SCS) over time across the centers.</figcaption></figure>

correlations were found. The center with the largest caseload had the highest median SCS (2.24; IQR 1.9–2.5), though no similar correlation was found for the other centers.

## 4. Discussion

This study represents the first comprehensive national analysis of pediatric robot-assisted surgery (RAS) in France, encompassing over 1400 procedures performed across 11 tertiary centers over the period 2007–2020. It provides a broad overview of indications, practice patterns and trends in utilization of RAS over time. The findings confirm a significant and progressive increase in RAS utilization in pediatric patients, particularly in the past 5 years, highlighting its growing acceptance as a standard approach in selected pediatric procedures.

One of the important findings of our study is the effective integration of surgical training within robotic programs. A total of 24 fellows were trained during the study period, aided by the dual-console system and a standardized certification process. These results stand in contrast to the common criticism that robotic platforms are incompatible with surgical education and instead highlights their value in skill acquisition. It has been demonstrated that junior and senior surgeons can achieve comparable levels of expertise in pediatric robotic surgery, meaning that competence is influenced by both individual surgical experience and by the experience of the pediatric robotic team [25]. Over time, two sustainable models of robotic implementation emerged: (1) centers that regularly perform high-volume, standardized robotic procedures (particularly urological) and (2) innovative centers that gradually expand indications to include younger or more complex patients.

Our results indicate that pediatric urology remains the main field of application for pediatric RAS, with pyeloplasty as the most commonly procedure performed [26]. While more complex surgeries—such as bilateral Lich-Gregoir procedure [27] and cholecystectomy [28]—have been performed since the early stages of the RAS program, their broader adoption remains limited. Institutional access to robotic platforms and patient selection criteria continue to influence case mix and innovation. Scheduling emergent, neonatal, or day-cases is difficult without a dedicated robotic platform for pediatric surgery. Although no brand-new techniques were identified, the inclusion of rarely performed robotic

procedures—such as neonatal esophageal atresia and diaphragmatic hernia repairs—demonstrates the expanding boundaries of pediatric RAS. Our results emphasize that robotic surgery may be feasible in selected emergent situations, but remains limited by accessibility, set-up time, and institutional protocols.

Neonatal robotic surgery may be considered the “final frontier” of experienced pediatric robotic centers [29]. In our study, the lowest patient weight recorded was 3 kg, although most procedures in children under 10 kg were highly selective and performed in expert centers. Currently, robotic procedures in neonates remain technically feasible but are still rare due to limitations in working space and instrument size. Based on current literature and our national experience, a realistic lower weight threshold for standard implementation is approximately 8–10 kg. Neonatal robotic surgery (<5 kg) should be considered only in referral centers with dedicated robotic platforms and trained multidisciplinary teams.

We identified new findings from the study data. First, a strong positive correlation was observed between center experience and the inclusion of patients <15 kg, suggesting that experience promotes broader indications over time and enables the safe extension of RAS to smaller and more challenging patients. Second, we also noted a lack of correlation between conversion rate and center experience, which contrasts with trends in adult robotic surgery and suggests that pediatric RAS may have distinct learning dynamics. Previous reports have confirmed that conversion rates in pediatric robotic surgery are low, particularly when compared with laparoscopic procedures [30]. In the present study, two distinct peaks in conversion rates were observed: the first occurred in the early phase of the robotic program and the second emerged after the completion of approximately 100 procedures. As surgical programs matured, conversions became more frequent in lower-weight infants, primarily due to limited operative workspace. The initial peak of conversions likely reflects the early learning curve of the surgical team, while the later peak may be attributed to the growing complexity of cases as indications expanded. Previous large-scale studies have demonstrated that major intraoperative events remain uncommon in pediatric robotic surgery, provided that a consistent and well-informed anesthetic strategy is applied [31]. Occasional conversions are to be expected and should not be interpreted as failures of the robotic platform or surgical technique, but rather as prudent responses to intraoperative challenges — particularly when operating in confined space or performing
<table><caption>**Table 2**
Overview of robotic procedures performed in 1401 pediatric cases.</caption><thead><tr><th>Procedure</th><th>Details of approach</th><th>SCS</th><th>Median patient weight, kg (IQR)</th><th>Median operative time, min (IQR)</th><th>Total n=</th></tr></thead><tbody><tr><td><strong>Urology</strong></td><td></td><td></td><td></td><td></td><td><strong>871</strong></td></tr><tr><td>Pyeloplasty</td><td>Transperitoneal</td><td>2</td><td>26.8 (9–62)</td><td>117 (97–156)</td><td>379</td></tr><tr><td>Pyeloplasty</td><td>Retroperitoneal</td><td>2</td><td>27 (18–46)</td><td>164 (143–225)</td><td>80</td></tr><tr><td>Redo pyeloplasty</td><td></td><td>3</td><td>32.5 (25–54)</td><td>233 (185–298)</td><td>15</td></tr><tr><td>Ureterocalycostomy</td><td></td><td>3</td><td>41.1 (15–70)</td><td>177.6 (90–240)</td><td>6</td></tr><tr><td>Nephrectomy</td><td>Transperitoneal</td><td>1</td><td>45.8 (33–65)</td><td>115 (93–158.5)</td><td>142</td></tr><tr><td>Nephrectomy</td><td>Retroperitoneal</td><td>1</td><td>33.6 (28–55)</td><td>131.6 (104–170)</td><td>37</td></tr><tr><td>Upper or lower nephrectomy</td><td>Transperitoneal</td><td>2</td><td>39.8 (25–63.5)</td><td>158.5 (134–202)</td><td>51</td></tr><tr><td>Upper or lower nephrectomy</td><td>Retroperitoneal</td><td>2</td><td>36.5 (28–57.8)</td><td>199.5 (168–219)</td><td>3</td></tr><tr><td>Partial nephrectomy</td><td>Transperitoneal</td><td>2</td><td>22.4 (16–38)</td><td>175.4 (118–225)</td><td>5</td></tr><tr><td>Partial nephrectomy</td><td>Retroperitoneal</td><td>2</td><td>17.9 (8.2–22.9)</td><td>201 (130–245)</td><td>3</td></tr><tr><td>Mitrofanoff procedure</td><td></td><td>2</td><td>16.6 (14–17.3)</td><td>346 (296–478)</td><td>7</td></tr><tr><td>Detrusorotomy</td><td></td><td>1</td><td>27.5 (24–48.5)</td><td>125 (108–152)</td><td>2</td></tr><tr><td>Ileocystoplasty</td><td></td><td>3</td><td>32.9 (27.8–38)</td><td>523 (432–659)</td><td>2</td></tr><tr><td>Ureterocystoplasty</td><td></td><td>3</td><td>22.5</td><td>290</td><td>1</td></tr><tr><td>Bladder neck reconstruction</td><td></td><td>3</td><td>28.9</td><td>400</td><td>1</td></tr><tr><td>Retrovesical Mullerian remnants excision</td><td></td><td>2</td><td>48.5 (45–68)</td><td>155 (105–205)</td><td>11</td></tr><tr><td>Uretero-ureteral anastomosis</td><td>Transperitoneal</td><td>1</td><td>15.8 (8.5–62)</td><td>139.5 (108–275)</td><td>8</td></tr><tr><td>Uretero-ureteral anastomosis</td><td>Retroperitoneal</td><td>1</td><td>17.9 (15.3–22.5)</td><td>166 (130–294)</td><td>4</td></tr><tr><td>Lich Gregoir procedure</td><td>Unilateral</td><td>2</td><td>19 (13–25)</td><td>126 (108–140)</td><td>46</td></tr><tr><td>Lich Gregoir procedure</td><td>Bilateral</td><td>2</td><td>20.5 (15–29.6)</td><td>162 (135–198)</td><td>24</td></tr><tr><td>Ureteral reimplantation</td><td>Without tapering</td><td>2</td><td>19.8 (15.6–26.3)</td><td>158 (124–190)</td><td>5</td></tr><tr><td>Ureteral reimplantation</td><td>With tapering</td><td>2</td><td>22.6 (16.9–25.8)</td><td>220 (155–290)</td><td>6</td></tr><tr><td>Bladder cyst excision</td><td></td><td>2</td><td>15.9 (13.2–25)</td><td>105 (90–149.5)</td><td>17</td></tr><tr><td>Renal cyst removal</td><td>Transperitoneal</td><td>1</td><td>38.5 (28–65)</td><td>85 (65–120)</td><td>6</td></tr><tr><td>Renal cyst removal</td><td>Retroperitoneal</td><td>1</td><td>42.8</td><td>95</td><td>1</td></tr><tr><td>Urachal remnant excision</td><td></td><td>1</td><td>28.5 (22–68.5)</td><td>90 (72–135)</td><td>4</td></tr><tr><td>Dysgenetic gonadal excision</td><td></td><td>1</td><td>18.6 (15–22.2)</td><td>91.5 (58–125)</td><td>2</td></tr><tr><td>Parapelvic cyst excision</td><td></td><td>2</td><td>35.5 (29–42)</td><td>112 (89–135)</td><td>2</td></tr><tr><td>Urogenital sinus mobilization</td><td></td><td>2</td><td>12.5</td><td>155</td><td>1</td></tr><tr><td><strong>Gynecology</strong></td><td></td><td></td><td></td><td></td><td><strong>11</strong></td></tr><tr><td>Salpingectomy</td><td></td><td>1</td><td>45.6 (38–55)</td><td>96 (69–121)</td><td>6</td></tr><tr><td>Ileal vaginoplasty</td><td></td><td>2</td><td>32.6 (28.5–46.3)</td><td>330 (285–430)</td><td>3</td></tr><tr><td>Gartner cyst excision</td><td></td><td>1</td><td>56.5</td><td>200</td><td>1</td></tr><tr><td>Partial hysterectomy</td><td></td><td>1</td><td>60</td><td>156.6</td><td>1</td></tr><tr><td><strong>Biliary and spleen</strong></td><td></td><td></td><td></td><td></td><td><strong>141</strong></td></tr><tr><td>Cholecystectomy</td><td></td><td>1</td><td>48 (23–70)</td><td>80 (51–115)</td><td>67</td></tr><tr><td>Splenectomy</td><td></td><td>2</td><td>20 (13–67)</td><td>134.5 (77–165)</td><td>26</td></tr><tr><td>Partial splenectomy</td><td></td><td>2</td><td>35 (10.5–80)</td><td>162.5 (110–245)</td><td>36</td></tr><tr><td>Choledochal cyst excision</td><td></td><td>3</td><td>12.8 (10.5–15)</td><td>203 (125–280)</td><td>12</td></tr><tr><td><strong>Gastrointestinal surgery</strong></td><td></td><td></td><td></td><td></td><td><strong>196</strong></td></tr><tr><td>Nissen fundoplication</td><td></td><td>2</td><td>30.3 (9.6–68)</td><td>142 (104–190)</td><td>65</td></tr><tr><td>Nissen fundoplication + gastrostomy</td><td></td><td>2</td><td>33.6 (28–55)</td><td>186.8 (140–270)</td><td>59</td></tr><tr><td>Redo Nissen fundoplication</td><td></td><td>3</td><td>29.5 (10.5–59)</td><td>155 (116–195)</td><td>4</td></tr><tr><td>Toupet procedure</td><td></td><td>2</td><td>26.3</td><td>168</td><td>1</td></tr><tr><td>Heller procedure</td><td></td><td>2</td><td>48.9 (35–70)</td><td>199.5 (178–300)</td><td>5</td></tr><tr><td>Colectomy</td><td></td><td>2</td><td>54.6 (24–80)</td><td>220.5 (115–545)</td><td>6</td></tr><tr><td>Coloprotectomy</td><td></td><td>3</td><td>48.5 (17–78)</td><td>215 (165–350)</td><td>4</td></tr><tr><td>Rectosigmoidectomy with anal anastomosis</td><td></td><td>3</td><td>45 (23–67)</td><td>240 (200–280)</td><td>2</td></tr><tr><td>Appendectomy</td><td></td><td>1</td><td>26.8 (20–65)</td><td>66 (52–125)</td><td>3</td></tr><tr><td>Anorectal malformation repair</td><td></td><td>2</td><td>12.1 (10.9–12.3)</td><td>228.7 (86–275)</td><td>12</td></tr><tr><td>Ladd procedure</td><td></td><td>2</td><td>13.2 (12.9–13.5)</td><td>105 (74.5–135.5)</td><td>2</td></tr><tr><td>Gastric banding</td><td></td><td>2</td><td>118.5 (107–130)</td><td>82.5 (79–86)</td><td>2</td></tr><tr><td>Cystic abdominal lymphangioma resection</td><td></td><td>2</td><td>62 (38.5–70)</td><td>145 (133–195)</td><td>3</td></tr><tr><td>Extra lobar sequestration resection</td><td></td><td>3</td><td>15.8</td><td>120</td><td>1</td></tr><tr><td>Larrey hernia</td><td></td><td>3</td><td>26.5 (18.9–35)</td><td>185 (155–230)</td><td>3</td></tr><tr><td>Duodenal obstruction repair</td><td></td><td>2</td><td>18.9 (13.5–30.8)</td><td>118 (86–140)</td><td>4</td></tr><tr><td>Sigmoidopexy</td><td></td><td>2</td><td>26.8</td><td>205</td><td>1</td></tr><tr><td>Esophageal replacement</td><td></td><td>3</td><td>22.2 (16–28.4)</td><td>363.5 (310–417)</td><td>2</td></tr><tr><td>Bezoar extraction</td><td></td><td>2</td><td>43.6 (29.5–68.3)</td><td>115 (90–152)</td><td>5</td></tr><tr><td>Thoracoabdominal enteric cyst resection</td><td></td><td>3</td><td>20.5 (16–35)</td><td>106 (73–139.5)</td><td>3</td></tr><tr><td>Gastropexy for volvulus</td><td></td><td>2</td><td>15.6</td><td>146</td><td>1</td></tr><tr><td>Bowel duplication resection</td><td></td><td>2</td><td>12.5 (9.9–17.5)</td><td>90 (78–125)</td><td>5</td></tr><tr><td>Sigmoid excision (volvulus)</td><td></td><td>2</td><td>35.5 (29–42)</td><td>165 (129–201)</td><td>2</td></tr><tr><td>Anterior meningocele excision</td><td></td><td>3</td><td>15.6</td><td>268.5</td><td>1</td></tr><tr><td><strong>Neonatal surgery</strong></td><td></td><td></td><td></td><td></td><td><strong>6</strong></td></tr><tr><td>Diaphragmatic hernia repair</td><td></td><td>2</td><td>3.6</td><td>165</td><td>1</td></tr><tr><td>Esophageal atresia repair</td><td></td><td>3</td><td>3.1 (3.0–3.4)</td><td>230 (180–285)</td><td>4</td></tr><tr><td>Duodenal atresia repair</td><td></td><td>2</td><td>3.5</td><td>175.5</td><td>1</td></tr><tr><td><strong>Thoracic surgery</strong></td><td></td><td></td><td></td><td></td><td><strong>32</strong></td></tr><tr><td>Pulmonary sequestration resection</td><td></td><td>2</td><td>13.5</td><td>89.5</td><td>1</td></tr><tr><td>Segmentectomy</td><td></td><td>3</td><td>16.8</td><td>125</td><td>1</td></tr><tr><td>Lobectomy</td><td></td><td>2</td><td>9.5 (8.5–13.1)</td><td>140 (99–205)</td><td>14</td></tr></tbody></table>

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<table><caption>**Table 2 (continued)**</caption><thead><tr><th>Procedure</th><th>Details of approach</th><th>SCS</th><th>Median patient weight, kg (IQR)</th><th>Median operative time, min (IQR)</th><th>Total n=</th></tr></thead><tbody><tr><td>Diaphragmatic Morgagni hernia repair</td><td></td><td>3</td><td>10.5 (8.8–23)</td><td>98.6 (75–146)</td><td>8</td></tr><tr><td>Bronchogenic cyst/Esophageal duplication removal</td><td></td><td>2</td><td>40.3 (21.7–51.5)</td><td>172.5 (140–215)</td><td>7</td></tr><tr><td>Costal exostosis excision</td><td></td><td>1</td><td>45.8</td><td>126.5</td><td>1</td></tr><tr><td><strong>Oncology</strong></td><td></td><td></td><td></td><td></td><td><strong>137</strong></td></tr><tr><td>Neuroblastic tumor resection</td><td></td><td>3</td><td>14 (10–18)</td><td>130 (83–178)</td><td>23</td></tr><tr><td>Retroperitoneal lymph node excision</td><td></td><td>3</td><td>52.8 (48.7–56.9)</td><td>195.5 (154–237)</td><td>2</td></tr><tr><td>Total nephrectomy</td><td></td><td>3</td><td>31.5 (20–47.8)</td><td>263 (185–306)</td><td>7</td></tr><tr><td>Partial nephrectomy</td><td>Transperitoneal</td><td>3</td><td>23.7 (16.4–56)</td><td>135 (108–169)</td><td>4</td></tr><tr><td>Partial nephrectomy</td><td>Retroperitoneal</td><td>3</td><td>25.8</td><td>148.5</td><td>1</td></tr><tr><td>Adrenal tumor resection (pheochromocytoma included)</td><td>Unilateral</td><td>3</td><td>28.4 (8.6–62)</td><td>192 (158–246)</td><td>45</td></tr><tr><td>Adrenal tumor resection (pheochromocytoma included)</td><td>Bilateral</td><td>3</td><td>33 (29–39)</td><td>249 (207–341)</td><td>3</td></tr><tr><td>Pancreatectomy</td><td></td><td>3</td><td>38.5 (16.6–65.8)</td><td>248 (200–355)</td><td>3</td></tr><tr><td>Gastrectomy</td><td></td><td>3</td><td>37.9 (27.8–48)</td><td>230 (190–270)</td><td>2</td></tr><tr><td>Mediastinal and pelvic teratoma excision</td><td></td><td>3</td><td>23.6 (8–39.2)</td><td>106.7 (93.4–120)</td><td>2</td></tr><tr><td>Myofibroblastic tumor excision</td><td></td><td>3</td><td>18.9</td><td>198</td><td>1</td></tr><tr><td>Multiple pulmonary metastasis excision</td><td></td><td>3</td><td>68</td><td>180</td><td>1</td></tr><tr><td>Thymectomy</td><td></td><td>3</td><td>25.2</td><td>168</td><td>1</td></tr><tr><td>Ovariectomy</td><td></td><td>3</td><td>33.6 (25.2–42)</td><td>78.4 (69.3–87.5)</td><td>2</td></tr><tr><td>Sacral neurofibroma excision</td><td></td><td>3</td><td>33.8</td><td>175</td><td>1</td></tr><tr><td>Thyroidectomy</td><td>Transaxillary</td><td>3</td><td>26.2 (18.9–65)</td><td>171.2 (69–635)</td><td>26</td></tr><tr><td>Thyroidectomy</td><td>Retroauricular</td><td>3</td><td>27.5 (19.5–59)</td><td>142 (128–250)</td><td>12</td></tr><tr><td>Parathyroidectomy</td><td>Transaxillary</td><td>3</td><td>29.5</td><td>125</td><td>1</td></tr><tr><td><strong>Transoral surgery</strong></td><td></td><td></td><td></td><td></td><td><strong>7</strong></td></tr><tr><td>Cervical cystic excision</td><td></td><td>3</td><td>22</td><td>95</td><td>1</td></tr><tr><td>Congenital cystic excision</td><td></td><td>3</td><td>19.5 (15–55)</td><td>115.6 (85–140)</td><td>6</td></tr></tbody></table>

IQR, interquartile range; SCS, surgical complexity score.

complex procedures where patient safety must take precedence [32].

Despite the progress made, current robotic platforms still present limitations for pediatric use. While the introduction of 3-mm robotic instruments by major manufacturers remains uncertain due to mechanical limitations affecting dexterity and force transmission, recent developments suggest alternative pathways for pediatric adaptation. These include the potential for flexible robotic systems, single-port platforms with smaller trocars, and increased availability of scaled-down systems from new market entrants [33,34]. Furthermore, software-driven improvements in tremor filtration and force feedback may enhance safety in small spaces even with current 5–8 mm instruments. The future of pediatric robotic surgery may therefore evolve more through miniaturized access platforms and improved ergonomics than purely by reducing instrument diameter.

This study has some limitations, including its descriptive and observational nature, the retrospective design, the multicenter participation, and heterogeneity in surgical techniques and perioperative practices among centers. The lack of a control group of open or laparoscopic procedures was due to the retrospective design and lack of standardized data across centers. However, the primary aim of the study was to provide a comprehensive national overview of pediatric RAS implementation and evolution in France over the period 2007–2020, rather than a comparative analysis across surgical techniques or outcomes. Future prospective studies should aim to compare RAS to conventional techniques in terms of indications, outcomes, and cost-effectiveness. As robotic platforms become more accessible, institutional strategies should focus on surgeon training, case selection, and the development of dedicated pediatric pathways to maximize safety, efficacy, and educational value.

In conclusion, this national study documents the significant growth of pediatric robot-assisted surgery (RAS) in France, particularly over the past five years. The findings confirm its safety and effectiveness, including children under 15 kg. Urological procedures remain the leading indication, followed by gastrointestinal and biliary surgeries. Robotic surgery offers key advantages, including enhanced precision, superior ergonomics, and valuable training

opportunities, as demonstrated by the successful education of 24 fellows using dual-console systems. The main limitation remains the 8-mm instrument size of the da Vinci system, which contrasts with the 3-mm tools used in conventional pediatric laparoscopy. Future innovations—such as single-port platforms or smaller instruments—may overcome this barrier and expand the role of RAS in pediatric surgery.

## Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## Conflicts of interest

The authors have no conflicts of interest to disclose.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpedsurg.2025.162397.

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