Advancements and Outcomes of Robotic-Assisted Surgery in Pediatric Patients: A Multicenter Analysis

Girolamo Mattioli^1,2Giulia Rotondi^1,2Stefano Avanzini¹Michele Torre^1,2Gaia Brenco^1,2Carmelo Romeo³Francesco Molinaro⁴Marco Prestipino⁵Maurizio Cheli⁶Francesco Lacanna⁶Gabriella Paoli⁷Silvano Cincotti⁸Chiara Tombetti⁸Barbara Razore¹Laura Oddera⁹Maria Beatrice Damasio¹⁰Andrea Michele Gino Maria Wolfler¹¹Giuseppe Spiga¹²Federico Palo^1*

• ¹Department of Pediatric Surgery, Giannina Gaslini Institute (IRCCS), Genoa, Italy
• ²Universita degli Studi di Genova Dipartimento di Neuroscienze Riabilitazione Oftalmologia Genetica e Scienze Materno-Infantili, Genoa, Italy
• ³Universita degli Studi di Messina Dipartimento di Patologia Umana dell'Adulto e dell'Eta Evolutiva Gaetano Barresi, Messina, Italy
• ⁴Universita degli Studi di Siena Dipartimento di Scienze Mediche Chirurgiche e Neuroscienze Sezione di Medicina e Chirurgia, Siena, Italy
• ⁵Division of Pediatric Surgery, Azienda Ospedaliera di Perugia, Perugia, Italy
• ⁶Division of Pediatric Surgery, Aziende Socio Sanitarie Territoriale Papa Giovanni XXIII, Bergamo, Italy
• ⁷ALiSa Sistema Sanitario Regione Liguria, Genoa, Italy
• ⁸Universita degli Studi di Genova Dipartimento di Ingegneria Meccanica Energetica Gestionale e dei Trasporti, Genoa, Italy
• ⁹Department of Clinical Engineering, Istituto Giannina Gaslini, Genoa, Italy
• ¹⁰Department of Radiology, Giannina Gaslini Institute (IRCCS), Genoa, Italy
• ¹¹Department of Emergency, Division of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
• ¹²Department of Planning, Control and Quality Management, Giannina Gaslini Institute (IRCCS), Genoa, Italy

Background: Robotic surgery (RS) has gained widespread adoption in adult surgical specialties but faces unique challenges in pediatric applications due to anatomical, technical, and economic factors. This multicenter study evaluates the feasibility, clinical outcomes, and organizational implications of implementing robotic-assisted surgery in pediatric patients across various surgical disciplines. Methods: Data were retrospectively collected from 569 pediatric patients undergoing RS between 2015–2016 and 2020–2025 at five Italian pediatric surgery centers. Procedures included urological, gastrointestinal, oncological, and thoracic surgeries. Patient demographics, operative details, complications, and conversion rates were analyzed. Standardized operating room setups and trocar placements were developed to optimize surgical ergonomics. Results: The median patient age was 73.8 months (range 4–575.3 months), with 9.3% weighing less than 10 kg. Urological procedures comprised 47.2% of cases, with a 0.7% conversion rate to open surgery. Gastrointestinal, oncological, and thoracic procedures had conversion rates of 3.9%, 27.2%, and 13.5%, respectively. Postoperative major complications occurred in 8% of cases. The study confirmed the safety and feasibility of RS even in patients with significant clinical complexity (20.5% ASA ≥3). Robotic technology provided enhanced precision, dexterity, and visualization, enabling complex reconstructions in confined anatomical spaces. Centralized care in dedicated pediatric centers was critical for successful implementation. Conclusions: Robotic surgery represents a significant advancement in pediatric minimally invasive surgery, offering clinical benefits across multiple specialties. Despite economic and logistical challenges, centralization and dedicated multidisciplinary teams are essential to optimize outcomes and ensure safe, sustainable adoption of robotic techniques in pediatric surgery.