How to Jumpstart a Robotic Practice in Pediatrics with Dr. Juan Gurria

The learning curve from laparoscopy to robotics is dramatically flatter than from open to laparoscopy, with proficiency in cholecystectomy now requiring 17 cases versus 35 historically, and colon cases requiring 15 cases versus 75.

In 2025, robotic pediatric surgery cases increased 18% nationally compared to 2024, with pediatric surgeons using robotics increasing 1.3% per quarter and new pediatric surgeons adopting the technology increasing 7.5%.

Cincinnati Children's Hospital performs 200-250 robotic cases annually across multiple specialties including general surgery, urology, gynecology, and some transplant cases.

At Cincinnati Children's, credentialing requires 7 proctored cases by a pediatric surgeon after completing online and hands-on training.

There are currently 8-9 new robotic systems available globally beyond the da Vinci, including systems with 5mm instruments available in Asia and single-tower designs.

Attending surgeons must be credentialed before residents for safety reasons—the attending must be expert enough to immediately take control if the trainee's instruments move in the wrong direction or approach a vessel incorrectly.

Pediatric patients under pneumoperitoneum have cardiac output intimately related to stroke volume mediated by heart rate; they compensate for decreased stroke volume by increasing heart rate rather than increasing contractility like adults.

Pediatric patients have greater CO2 absorption during pneumoperitoneum and require tolerance of some respiratory acidosis; renal perfusion is more sensitive to pressure changes, causing faster metabolic derangements than in adults.

For small pediatric patients (5 kg), port spacing can be reduced to 2-2.5 fingers distance instead of the standard 5 fingers, and pulling ports back increases external working distance between port heads dramatically.

Gurria has successfully performed robotic surgery on patients as small as 4.8-5 kg, including a choledochal cyst in a 5 kg baby who went home on day 3.

Robotic choledochal cyst cases at Cincinnati Children's decreased to 2.5 hours compared to historical laparoscopic controls.

Opening unnecessary robotic instruments can add $3000 to case costs; standardizing preference cards and opening only required instruments significantly reduces variable costs.

Fixed costs for robotic programs (capital depreciation, service contracts) are diluted by volume; at 50 cases annually cost per case is $8000, but at 200 cases it drops to $2000.

In academic institutions, robotic case turnover time targets 30 minutes, comparable to laparoscopic cases, with docking time for cholecystectomy between 8-12 minutes from first incision to console.

Gurria's robotic cholecystectomy times are two-thirds of his laparoscopic colleagues' average times at Cincinnati Children's.

Gurria does not perform appendectomies robotically, considering them simple, fast cases better suited to laparoscopy.

For adolescent inguinal hernias, Gurria performs transabdominal preperitoneal (TAP) repair robotically, but converts to laparoscopic indirect repair if the defect is indirect rather than direct.

Robotic graspers are more aggressive than laparoscopic instruments; surgeons must develop optical feedback skills to judge appropriate tissue tension, particularly when running bowel.

When tying knots robotically, the suture shows a small amount of fluid extrusion just before breaking, providing visual feedback for appropriate tension.

The newest da Vinci system enables telementoring with live viewing and will soon allow remote instrument control for proctoring from distant locations.