Minimally Invasive Pediatric Surgery

Patricio Gargollo, M.D.
Mayo Clinic, Rochester, MN USA
THP Editor, Minimally Invasive Surgery in Pediatrics


Overview of Minimally Invasive Webinar Series

The Hendren Project (THP) has created an online platform for health care provider collaboration, education and research. It has advanced and expanded the access of pediatric sub-specialists throughout the world to recognized experts in subsets of pediatric surgical fields thus creating a truly unique international surgical collaborative. Through the creation of online repositories, social media outreach and educational webinars, THP represents true medical education innovation in the digital age. Currently, the pediatric urology subset of THP retains a group of world renowned surgical experts in various fields within this specialty covering most of the major surgical issues encountered by practitioners. This proposal aims to broaden the scope of THP to include minimally invasive and robotic-assisted surgery (MIS) both in pediatric surgery and pediatric urology.

Current Status

During the last three decades there have been remarkable and unprecedented advances in the implementation and development of minimally invasive surgery (MIS). In pediatric surgical subspecialties the rate of progress in MIS has been slower but there has been a recent resurgence given the advent or robotic assisted surgery.   In fact, recent publications suggest that the rate of robotic assisted procedures in pediatric urology for various common conditions has risen incrementally. MIS in pediatric surgery and urology therefore represents a fertile area for global education and research appropriately coinciding with the mission of the Hendren Project.


There are several limitations in the use of traditional laparoscopic surgery including a two-dimensional view of the surgical field, counterintuitive “fulcrum” movements and rigid, non-articulating instruments. This can result in loss of hand-eye coordination and a lack of an ergonomic position for the surgeon.

Perhaps the greatest innovation in MIS has been the advent of robotic assisted surgery. This new technology offers three-dimensional visualization, articulating instruments, tremor reduction, motion scaling, 10X magnification, and ergonomic position for the surgeon. This method was initially developed for adult surgery, but its use has been progressively extended to the field of pediatric urology and pediatric surgery. Currently there are close to 1900 operational surgical robots installed throughout the world and this number continues to grow. Further innovation will include smaller instrumentation and ideally more affordable robotic platforms. The role of THP in MIS surgical innovation will be to serve as a public platform to disseminate current advances in this field as well as to discuss the benefits and limitations of new technology.


Like with many new techniques in surgery there are various areas of controversy in MIS and robotic assisted surgery. Currently there are multiple purported advantages of MIS including reduced postoperative discomfort, reduced need for narcotic pain medication, decreased morbidity, decreased incision size, decreased hospital stay, faster recovery, improved cosmetic results, and decreased job loss time for caretakers. Some of these, however, are anecdotal or based on incomplete data. This provides an opportunity for education and research and yet another area of exploration by THP.


Perhaps one of the greatest areas of controversy centers on when should MIS or robotic technology be utilized in children? Which procedures are ideal or suboptimal for MIS? Some of these issues have already been raised an again create a potentially fruitful area for The Hendren Project collaboration and discussion.

A second major challenge currently facing robotic assisted surgery specifically is cost. The startup investment for a Da Vinci surgical system is close to 2 million dollars. Subsequent significant costs can be incurred through acquisition of the disposable instrumentation necessary for robotic assisted procedures. Furthermore, consideration needs to be taken for the longer operative times which are associated with most robotic procedures as compared to their open counterparts. This leads to higher operating room costs. One of the challenges facing this technology is how do we minimize cost? This is particularly important in developing countries where the cost makes robotic platforms unattainable. Again all of these subject areas require further exploration for which the international platform of THP would be ideal

Future Directions

As for all new technologies, an objective evaluation is essential with the need to respond to several questions: Is the technology feasible? Is the technology safe? Is the technology efficient? Does it bring about benefits compared with current technology? What are the procedures derived from most benefits of robotic assistance? Where can we expand and innovate in pediatric surgery to incorporate this technology for the benefit of our patients? How can we create opportunity and access to this technology in patients living in developing countries?  I envision that THP collaboration among surgeons and institutions is an important future avenue to continue innovation of this technology.

The Hendren Project and MIS

As someone who personally trained under Dr. Hardy Hendren I know firsthand what an innovative surgeon and thinker he is. His mentorship and leadership have inspired generations of physicians including myself.  I firmly believe that few areas of pediatric surgery provide as much opportunity for growth, innovation, education, research and collaboration as minimally invasive and robotic surgery.  Through the addition of this section to THP we will create a collaborative of both pediatric urologists and pediatric surgeons with international expertise in MIS.

The MIS Editorial Board will provide guidance for identifying topics that will be discussed here. All of the physicians on the board are proven experts in MIS and cover the majority of the international physician base that would benefit from THP and the education efforts therein.

A series of informative webinars of will be conducted that will provide for the discussion of various topics in MIS including:

  • Starting a minimally invasive surgery program
  • The role and feasibility of MIS in pediatric patients
  • Procedure specific topics
  • Avoiding complications in MIS
  • MIS in the new-born
  • Future directions in MIS and robotic surgery in pediatrics
  • Difficult case discussions / Video footage review
  • Increasing THP visibility on social media including twitter and facebook with patient case-oriented posts, video abstracts, and case discussions

I believe The Hendren Project represents the type of innovative education and surgical advancement embodied by Dr. Hardy Hendren, and I am honored to lead the new minimally invasive and robotic assisted surgery section.