Robot-assisted surgery, at the beginning, was conceived as a military tool for remote surgical care of the injured soldier, and later, in the 1990s, was introduced in the clinical practice . Despite the fact that robotic surgery has reached high levels of expertise in adults with some procedures done as a gold standard yet the size and variety of available robotic instrumentation represent a limit for pediatric patients and the overall size of the robotic system can restrict the surgical indications . The first report describing the use of robotic surgical systems for abdominal procedures in children
were published was published by Heller and colleagues in 2002 . They reported a series of 11 children who underwent Thal or Nissen fundoplication for treatment of gastroesophageal reflux disease using a Da Vinci system. Mean patient age was 12 years and no complications were reported. From that time the applicability of robotic surgery in pediatric fields has made important progress and the indications for the intervention have been extended to other pathologies and to patients of lower age and weight. A retrospective study in 2019  demonstrated that weight cannot be considered an absolute limit for robotic surgery. The improvement of instruments permits to perform complex surgical procedures in low-weight children without additional difficulties. Also, other studies [10, 11] reported case series that demonstrated the safety and feasibility of robot in pediatric surgery. Our results confirm this process of growth in Italy: there is an evident and progressive increase in the number of interventions every year. This finding not only certified the rise of pediatric surgical indications, but also an improvement in the learning curve. A systematic review in 2013 showed an increase, through the years, both in case volumes of robotic surgical procedures in children and in the published literature on this subject. The Authors describe fundoplication, pyeloplasty and pulmonary resection as main procedures performed with robot . These data are in agreement with our results that confirm a shared consent in considering robot-assisted surgery a gold standard for the treatment of gastroesophageal reflux and for ureteropelvic junction obstruction.
Several studies demonstrated no significant differences in outcomes and complications between laparoscopy and robot in the approach of these diseases [13,14,15]. In our case series, we observed a high prevalence of cholecystectomy and nephrectomy. There is a wide consensus in considering robotic unappropriated for these interventions, since both can be safely performed laparoscopically with a low risk of complications, lower cost, and same cosmetic result [16,17,18,19,20,21].
We could explain this application of robotic in Italy according to the availability of device. In many centers, pediatric surgeons share the robotic system with general surgeons and urologists, and this made possible to lower costs, widen surgical indications and increase the learning curve for robotic surgery. Thoracic surgery presents a different situation, with a few number of interventions performed both in our series and literature. In pediatric population majority of thoracic diseases are congenital (CPAM, lobar emphysema, lung sequestration) and they need an intervention in the first months of life, which is impossible due to lack of suitable instrument size, until now, the use of robot according to unavailability of small size instruments. Even in toddlers, the thoracic cavity is small and trocar positioning with triangulation and are difficult. There is also a need for single lung ventilation that makes it a challenge also for the anesthesiologists . In the Italian experience, the pulmonary partial resection for the treatment of pleural blebs is the most common indication for thoracic robotic surgery. This is a common disease in teenagers and young adults, who present dimensions of thorax more suitable for robotic approach.