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Back to Journal »Robotic Surgery: Research and Review» Volume 8

The anesthesia significance of robot-assisted surgery for pediatric patients

Authors Wakimoto M, Michalsky M, Nafiu O, Tobias J 

Published on May 25, 2021, Volume 2021: 8 pages 9-19

DOI https://doi.org/10.2147/RSRR.S308185

Single anonymous peer review

Editor approved for publication: Dr. Masoud Azodi

Mayuko Wakimoto,1 Marc Michalsky,2 Olubukola Nafiu,3 Joseph Tobias3 1 Department of Anesthesiology, Osaka Police Hospital, Osaka, Japan; 2Pediatric Surgery, National Children's Hospital and Ohio State University School of Medicine, Columbus, Ohio, USA; 3 Columbus, Ohio, Nationwide Children’s Hospital and Ohio State University School of Medicine, Department of Anesthesiology and Pain. Corresponding author: Mayuko Wakimoto, Department of Anesthesiology, Osaka Police Hospital, Osaka, Japan. It is used in children and has a variety of potential clinical benefits, including reducing postoperative pain, shortening the length of hospital stay, and improving cosmetic results. Although the associated costs and device limitations for smaller pediatric patients are still related issues, the combination of surgeon comfort associated with ergonomic design and enhanced 3D high-fidelity imaging and tissue processing is possible compared to traditional minimally invasive methods. Will improve surgery and postoperative results. Given that the demand for this innovative technology in the field of pediatric surgery may continue to expand, pediatric anesthesiologists will be required to provide anesthesia care for patients exposed to this new surgical technique with unique functions, intraoperative requirements and potential complications. The current manuscript provides a narrative review of robot-assisted surgery and discusses important anesthesia considerations and potential complications of these techniques. [Keywords]: Robot-assisted surgery, pediatric anesthesia, minimally invasive surgery

We are always looking for innovative surgical techniques that are less invasive, limit physiological stress, and provide better clinical results after surgery. Robot-assisted surgery (RAS) has become a common practice in many professions and many institutions in the adult population in response to the increasing demand for improved surgical accuracy and visualization, rapid postoperative recovery, and improved cosmetic results. The potential benefits of RAS in adults include smaller surgical incisions, shorter time to get out of bed after surgery, shorter hospital stays, improved cosmetic results, and reduced postoperative pain. 1-4 Despite these advantages, RAS is generally still more costly than traditional minimally invasive surgical techniques, including laparoscopy and/or thoracoscopy as well as conventional or "open" surgical procedures. 5,6 After the first report of RAS in a pediatric patient in 2002, its application in children has been expanded to include multiple surgeries and multiple surgeries. Specialties such as urology, general pediatric surgery, and cardiothoracic surgery for infants to adolescents (Table 1). 7 The dramatic increase in manuscripts published in the past 18-20 years indicates a rapid increase in its use in children (Figure 1). The number of published manuscripts increased from 3 in 2002 to more than 40 in 2019. The most common surgical procedure in these publications is urology, followed by pediatric surgery. 8 Table 1 Application of Robot-assisted Surgery in Pediatrics Figure 1 A number of manuscripts related to pediatric robot-assisted surgery published in the past 18 years. Each column represents the number of papers published that year, which has increased from 3 in 2002 to more than 40 in 2019. Use "robot assisted surgery", "pediatrics", "anaesthesia", "anaesthesia", "complications from 2002 to 2019". Filter abstracts to exclude animal or adult studies and publications written in languages ​​other than English. If applicable, also checked and added a reference list of published articles. "Multiple" includes various procedures such as urology and general surgery. Others include articles focusing on the learning curve of robotic surgery for instruments or surgeons. Unknown includes articles that do not have a specific program name in the abstract.

Table 1 The application of robot-assisted surgery in the pediatric population

Figure 1 The number of published manuscripts related to pediatric robotic-assisted surgery in the past 18 years. Each column represents the number of papers published that year, which has increased from 3 in 2002 to more than 40 in 2019. Use "robot assisted surgery", "pediatrics", "anaesthesia", "anaesthesia", "complications from 2002 to 2019". Filter abstracts to exclude animal or adult studies and publications written in languages ​​other than English. If applicable, also checked and added a reference list of published articles. "Multiple" includes various procedures such as urology and general surgery. Others include articles focusing on the learning curve of robotic surgery for instruments or surgeons. Unknown includes articles that do not have a specific program name in the abstract.

The use of robotic surgical systems in pediatric patients may present a variety of unique and challenging features, including patient positioning, limited patient access, and physiological changes caused by the necessary CO2 injection to improve surgical visualization. It may be necessary to understand these unique challenges and adjust the anesthesia technique during RAS. The current manuscript addresses the anesthesia considerations and potential complications of RAS, with a focus on pediatric patients. This review also briefly discusses the physiological significance of carbon dioxide injection, which is still a prerequisite for laparoscopic surgery and RAS. The author used PubMed/Medline to review the relevant literature from 2002 to 2020, and combined the following terms: "robot assisted surgery", "pediatrics", "anaesthesia", "anaesthesia" and "complications". Screen abstracts to exclude animal or adult studies and publications written in languages ​​other than English. In addition, other manuscripts in the reference list of published articles that were not identified from the literature search were also checked.

The U.S. Food and Drug Administration (FDA) currently only approved two “universal” robotic systems for adults, namely the Da Vinci Surgical System (Intuitive Surgical Inc, Mountain View, California, USA) and the Senhance Surgical System (TransEnterix, Inc, Research Triangle Park, North Carolina). As of December 31, 2020, there are 5989 active systems in operation worldwide, of which 3720 are in the United States alone. Since it was approved by the FDA in 2000, the Da Vinci Surgical System has been dominating the general clinical market space in the United States and the world. . Despite the recent launch of the Senhance system in 2018 and several other competing platforms currently being used outside the United States that are under development or awaiting regulatory approval, the Da Vinci system is still the only robot approved by the FDA for pediatric indications.

The Da Vinci system consists of three separate components: 1) the surgeon's console, 2) the patient cart and 3) the vision cart (Figure 2). The surgical surgeon sits in front of the surgeon's console, which is equipped with various surgical instrument array control devices. These surgical instruments are connected to the patient's cart and then controlled while viewing the patient's anatomy through a high-fidelity 3D display. The vision cart acts as a digital communication hub between all components and supports 3-dimensional (3D) vision systems. Figure 2 The components of the Da Vinci robotic surgery system, including vision carts, patient carts and surgeon consoles.

Figure 2 The components of the Da Vinci robotic surgery system, including vision carts, patient carts and surgeon consoles.

The da Vinci Surgical robotic system was originally designed for adult patients undergoing cardiac surgery, so its technology is not universally applicable to smaller pediatric patients. For example, compared with traditional laparoscopic instruments, endoscopes tend to be larger in size, especially for infants. Currently available robotic instruments include two endoscope 3D camera sizes (12 mm and 8.5 mm) and two instrument sizes (5 mm and 8 mm). The latter includes needle holders, scissors, graspers, cautery instruments, ultrasonic energy instruments and various other disposable and reusable accessories. 7 These instruments (5 mm and 8 mm sizes) are relatively larger than the conventionally available 3 mm instruments and are used for laparoscopic surgery in infants and newborns. Because of these differences, the length of the surgical incision for RAS is larger and relatively longer than that of laparoscopic or thoracoscopic techniques. In addition, 8mm instruments are usually better than 5mm instruments because there is no bipolar electrocautery for the 5mm size, only unipolar electrocautery. In addition, the wrist movement of the 5mm device is limited compared to the 8mm device, especially when the patient is small and has limited space. 10,11

Another consideration is the recommended distance between surgical access ports. The manufacturer of the Da Vinci surgical system recommends that the distance between the robot ports be 4-8 cm, depending on the specific platform, in order to provide enough space for the movement of surgical instruments inside and outside the body cavity. Due to the smaller body size and more limited surgical range, achieving sufficient distance between ports can be challenging for pediatric patients. Therefore, a well-thought-out plan is essential to ensure the optimal distance between ports. 7-9 In addition, it is also recommended to make minor modifications to the surgical technique, such as allowing the distance between the trocar insertion sites to be 5-6 cm as the distance between the ports increases. insufflation. 9 In view of the limitations imposed by the device and the potential size limitations of the patient, the adaptation of RAS is still challenging except for adolescents and larger pediatric populations. This applies to pediatric patients less than 1 year old and weighing less than 10 kg. Table 2 summarizes the general benefits and limitations of robotic surgery systems. Table 2 Benefits and limitations of robot-assisted surgery for pediatric patients

Table 2 Benefits and limitations of robot-assisted surgery for pediatric patients

In recent years, robotic surgery has been widely used in various operations such as urology, gynecology, gastrointestinal, thoracic, endocrine and cardiac surgery. Perioperative care may be affected by anticipated surgical procedures, patient-related comorbidities, and RAS techniques. The latter includes not only the use of robotic systems, but also the inflation of the target body cavity (ie, abdomen or chest) and its potential impact on physiological functions. Some of the effects of RAS are not specific to the use of the robot itself, but are the result of the use of minimally invasive techniques, including the use of CO2 insufflation in the chest or abdomen to facilitate visualization of the surgery.

Like minimally invasive techniques (laparoscopy or thoracoscopy), preoperative laboratory examinations and examinations are usually guided by the surgical procedure and the patient’s comorbidities. Taking into account the possibility of blood loss and the proximity of major blood vessels, the preoperative hemoglobin value and type and crossover are usually suitable for intrathoracic surgery and those that require a large number of intra-abdominal operations or resections. Similarly, placement of additional peripheral venous cannulas or intraoperative monitoring, including placement of invasive cannulas to monitor intra-arterial and central venous pressure (CVP), is more guided by the patient’s status and expected surgical procedures than by RAS Unique meaning. Specific anesthesia considerations for RAS include limited direct contact with the patient by robotic surgical equipment, patient positioning, and space issues caused by the physiological effects of inflating a closed cavity (Figure 3). With the newer Da Vinci system (Xi and Si), some of these problems have been significantly improved. Figure 3 Intraoperative photo of the robotic surgery system. The robotic surgery system is docked on the operating table with the operating table in the reverse Trendelenburg position to facilitate surgical visualization of abdominal contents. The patient's head is on the right side.

Figure 3 Intraoperative photo of the robotic surgery system. The robotic surgery system is docked on the operating table with the operating table in the reverse Trendelenburg position to facilitate surgical visualization of abdominal contents. The patient's head is on the right side.

The RAS of the abdomen and pelvis requires carbon dioxide (CO2) to be blown into a closed cavity (abdominal cavity) to form a pneumoperitoneum and achieve effective visualization. In addition, during lower or upper abdominal surgery, a steep Trendelenburg position or head-up (reverse Trendelenburg position) positioning may be required to further improve visualization. Increased intra-abdominal pressure (IAP) and CO2 absorption during insufflation may affect respiratory and hemodynamic functions. The impact of laparoscopy on the physiology of end-organs has been reviewed elsewhere. 10-13 The increase in IAP during insufflation will move the cephalic diaphragm, which may lead to the main intubation. Therefore, it may be necessary to continuously evaluate bilateral breath sounds, especially in smaller patients. limited. Increased IAP also affects respiratory and cardiovascular function. Respiratory changes include decreased functional residual capacity, decreased lung compliance, and increased airway resistance. These effects can change the ventilation/perfusion (V/Q) match and increase dead space ventilation, leading to hypoxemia and hypercapnia.

The absorption of gas used for insufflation and patient positioning may further affect respiratory function. Due to its high solubility and limited physiological effects during unintentional systemic embolism, carbon dioxide (CO2) is commonly used for insufflation. Its absorption can cause hypercapnia during surgery, the extent of which is affected by the duration of surgery and IAP. The patient’s posture may also affect respiratory function. Trendelenburg position can cause head-to-head displacement of the diaphragm, which usually worsens respiratory function. Reverse Trendelenburg position usually unloads the diaphragm and partially mitigates the effects of increased IAP.

Physiological changes can usually be controlled by appropriately changing ventilation settings, including an increase of 20-25% in ventilation per minute to compensate for CO2 absorption and adjustment of average airway pressure (positive end expiratory pressure [PEEP], peak inflation pressure [PIP] and inhalation). Air time) to increase the average airway pressure and compensate for the reduced FRC, reduced compliance, and increased resistance. Most importantly, IAP must be noted and restricted. The effect of blowing on respiratory function is related to IAP, because blowing pressure below 10 mmHg has little effect on respiratory function. 10-13 The use of new mechanical ventilation techniques, such as volume assurance and pressure-regulated ventilation, may better maintain tidal volume during changes in respiratory resistance and compliance, thereby maintaining minute ventilation more effectively than pressure or volume control techniques. 14 In addition to affecting respiratory function, increased IAP and changes in dead space and ventilation-perfusion matching may affect end-tidal carbon dioxide monitoring. Although it is still the standard of care for intraoperative monitoring during general anesthesia, end-tidal carbon dioxide (ETCO2) monitoring during insufflation may be inaccurate, and alternative continuous techniques (such as percutaneous CO2 monitoring) may provide specific measures for continuous CO2 monitoring. Advantage. 15

The effect of inflation on hemodynamic function usually includes a decrease in preload and an increase in afterload. In the adult population, these manifestations are an increase in mean arterial pressure, systemic vascular resistance, and left ventricular afterload, accompanied by a reduction in the area of ​​the heart index, stroke volume index, and IAP set to 15 mmHg. 16-20 In the pediatric population, hemodynamic changes vary with IAP. Low-pressure carbon dioxide pneumoperitoneum (IAP 5-6 mmHg) in other healthy children does not affect hemodynamic function. 21,22 However, when the IAP was 10 mmHg, Gueugniaud et al. reported that the aortic blood flow measured by esophageal Doppler decreased to 67 ± 9% of baseline, and stroke volume decreased to 68 ± 10% of baseline. Systemic vascular resistance increased to 162 ± 34% of baseline. 23 IAP is greater than 12 mmHg. Other researchers have used transesophageal echocardiography to confirm that the left ventricular systolic function is weakened, and the cardiac index is significantly decreased compared with baseline (about 10-13%). 22,24 Like respiratory changes, hemodynamic changes will be affected by the patient's position and hypercapnia caused by CO2 absorption. The hemodynamic effects of hypercapnia include pulmonary vasoconstriction, increased systemic vascular resistance, and arrhythmia. Although these hemodynamic changes can usually be well tolerated within a limited time in otherwise healthy pediatric patients, the impact on patients with existing myocardial function may be magnified. Despite these concerns, a retrospective database study confirmed the safety of laparoscopic surgery for CHD infants, including the benefits of shortening the length of hospital stay. 25 It is generally recommended that the inflation pressure be ≤10-12 mmHg to limit its impact on cardiac output and tissue oxygenation.

Technical challenges, size limitations, and limited equipment suitable for pediatrics have resulted in limited reports on robotic-assisted thoracic surgery for infants and children. So far, these reports are limited to small series or isolated case reports for the treatment of congenital diaphragmatic hernia, esophageal atresia, mediastinal cyst, diaphragmatic hernia, lobectomy, esophageal cyst, and patent ductus arteriosus. 26-30 Due to size limitations and limited surgical access, one-lung ventilation (OLV) technology may be required to achieve surgical visualization. 31-33 Depending on the age and weight of the patient, there are multiple options, including dual-chamber ETT, bronchial blockers, and main tracheal intubation. Intraoperative anesthesia care techniques during OLV have been reviewed elsewhere. 31-33 Given the technical challenges of OLV in neonates and infants, using standard two-lung ventilation to blow CO2 into the pleural cavity is an additional option, although this may lead to systemic hypercapnia and systemic absorption of CO2 ( See above) and the influence of structural movement in the chest cavity on hemodynamics. 34-37 Surgery usually uses two instrument arms, a camera arm, and occasionally an additional 5 mm non-robotic accessory port. Carbon dioxide (CO2) is used to blow at a low flow rate and kept as low as possible throughout the procedure Under pressure. The physiological significance of CO2 insufflation includes the possibility of inadvertent gas embolism, systemic CO2 absorption across the pleura or peritoneum, and an increase in intrathoracic or intra-abdominal pressure.

For older versions of the Da Vinci system, patient access during intraoperative care is limited. These issues have been improved through updated platforms, which improve access to the patient’s airway and limbs even when the system is docked and in use. Improved access is considered a relative security advantage of the new system. The patient should be safely positioned and filled to prevent skin and soft tissue damage during the operation when the patient needs to be immobile for a long time. During the operation, the robot arm may touch the patient's head, body or limbs (Figure 4). The endotracheal tube and all intravenous catheters must be secured. Make sure to place all non-intrusive monitoring and make sure it is working properly before docking the robot. Enough venous access is usually ensured before the operation, because the patient's access during the operation is limited due to the presence of the robot and the patient's arm by their side. For long-term surgery, place a urinary catheter. The use of catheters with indwelling temperature probes facilitates intraoperative temperature monitoring. For intravenous infusions, free drip devices are often used for liquid administration because they can detect venous infiltration earlier. When the infusion pump is used for liquids or drugs, the pressure limit should be checked regularly. Recently, new devices have appeared on the market, and it is recommended to detect venous infiltration earlier when the direct observation site is limited. 38 Figure 4 shows an intraoperative photograph of the bedside. The patient’s head is covered with a foam pillow (white arrow) to prevent pressure from any surgical instruments or operators. The anesthesia circuit (red arrow); orogastric tube (yellow arrow); Bair Hugger tube (green arrow); and peripheral intravenous infusion (black arrow) are marked. The patient's head is covered with plastic, and the upper body Bair Hugger™ is placed to maintain a normal body temperature.

Figure 4 The intraoperative photograph shows the head of the bed. The patient’s head is covered with a foam pillow (white arrow) to prevent pressure from any surgical instruments or operators. The anesthesia circuit (red arrow); orogastric tube (yellow arrow); Bair Hugger tube (green arrow); and peripheral intravenous infusion (black arrow) are marked. The patient's head is covered with plastic, and the upper body Bair Hugger™ is placed to maintain a normal body temperature.

Data in the adult literature proves the importance of patient position and padding, as information from adults indicates that the most common complications include peripheral neuropathy, corneal abrasions, vascular complications (including compartment syndrome), and edema The impact of (brain, eyes, and airway).39 The authors conclude that the Trendelenburg position combined with insufflation and longer operation time is highly associated with the risk of complications; therefore, the positioning must be suitable for patient safety. Pre-existing neurological diseases, obesity, and surgery time of more than 240 minutes are identified risk factors for complications.

In addition, for various reasons, it may always be necessary to switch to open surgery. In a retrospective study of 39 pediatric patients, 3 (7.5%) needed to be converted to open surgery due to insufficient operating space. 40 This was related to the obvious flatulence and insufficient ability to contract in the liver in 2 patients. A patient. These 3 patients were significantly younger (average age of 2.97 years and 9.83 years), and weight (average weight of 11.83 kg and 35.47 kg) was lighter than the others in the surgical cohort. Other factors leading to the need to switch to open surgery have not yet been determined, including the duration of ventilation with the mask before the tracheal intubation, the dose of neuromuscular blockers, age, and the type of bowel preparation used. The authors concluded that the incidence of switching to open surgery is acceptable, mainly related to insufficient work space for smaller patients, and not affected by measurable anesthesia factors or different bowel preparation options.

During the operation, it is recommended to perform standard American Society of Anesthesiologists monitoring on otherwise healthy patients. Two peripheral venous catheters are usually placed because access to the patient during the operation is limited. Depending on the patient's comorbidities, more invasive monitoring may be required. Arterial catheters may be beneficial for patients with frequent blood monitoring, cardiovascular or respiratory complications, or surgeries that may cause hemodynamic instability due to bleeding or mutual interference of large blood vessels. In our practice, the depth of anesthesia monitor may help titrate the anesthetic and prevent the patient from moving. There are several methods of induction and maintenance of anesthesia, including inhalation or intravenous injection techniques. So far, there is no evidence to prove the superiority of any technology.

As with traditional minimally invasive techniques, robotic surgery avoids the use of nitrous oxide because it may cause intestinal distension. In addition, this technique was chosen to limit the possibility of postoperative nausea and vomiting, because one of the goals of minimally invasive surgery is to get out of bed and discharge early. It is recommended to use a cuffed endotracheal tube for endotracheal intubation to minimize air leakage during mechanical ventilation, especially when IAP increases during CO2 injection. RAS requires neuromuscular blockers (NMBA) to avoid injury from accidental movement of the patient, promote mechanical ventilation, and improve the visualization of the surgical field. If the depth of anesthesia is insufficient and the patient moves, the fixed nature of the instrument when the robot is docked and inserted into the instrument may cause serious organ or blood vessel damage. With these issues in mind, neuromuscular blockade is continued throughout the operation, and appropriate monitoring is performed to maintain the required level of blockade.

Enhanced postoperative recovery (ERAS) technology is widely used in robotic-assisted colorectal and gastrointestinal surgery. 41,42 ERAS is a multimodal, multidisciplinary approach designed to enable patients to recover faster from surgery. These guidelines include administering carbohydrate beverages within 2 hours before surgery, minimally invasive surgery, details about intraoperative intravenous fluid management, avoiding or removing drainage tubes and catheters as soon as possible, getting to the ground as soon as possible, and starting oral intake on the day of surgery. These technologies have successfully achieved improved recovery, shortened hospital stays, reduced postoperative complications, reduced readmission rates and reduced costs. Although initially introduced in the adult population, similar success has been reported in patients of pediatric age. 41 The experience of a single institution implementing ERAS in pediatric colorectal surgery shows that the median length of hospital stay has been significantly reduced, and the rate of complications or readmissions has not increased. 42 Table 3 summarizes our institution’s ERAS protocol. Table 3 Modified ERAS protocol for robot-assisted colorectal surgery

Table 3 The modified ERAS protocol for robot-assisted colorectal surgery

Like traditional minimally invasive methods, compared with open surgical techniques, RAS reduces the need for postoperative analgesics. It is reported that compared with non-robotic minimally invasive techniques, it has more favorable pain characteristics under guidance. 43-45 This less invasive method, combined with the ERAS program that emphasizes adjuvant analgesics, can minimize postoperative opioid use and promote early getting out of bed and discharge. The use of regional anesthesia techniques and parenteral administration of non-opioids (such as acetaminophen and non-steroidal anti-inflammatory drugs) can also help limit the demand for parenteral opioids. 46 Regional anesthesia techniques may involve blocking or infiltrating the entry site with an amide local anesthetic (bupivacaine, levobupivacaine, or ropivacaine) at the transverse abdominis plane (TAP). The total dose of these drugs should be limited to 2-2.5 mg/kg, and the concentration should be adjusted from 0.2-0.5% according to the volume required to achieve satisfactory fascia diffusion and dermatome coverage. Depending on the need for sudden pain, opioids can be injected intravenously (morphine, hydromorphone) or oral (oxycodone).

Following success in the adult population and proving its advantages, the application of RAS will continue to expand in pediatric patients. 47 Innovations in equipment will make these technologies more suitable for smaller patients. Despite the reported advantages of this technique, robotic surgery poses special challenges for anesthesia providers, especially in pediatric patients. In addition to our comments, readers can refer to Reference 46 to learn more about these issues. 48 Although recent innovations have improved patient access, even modern robotic surgical systems may limit anesthesia provider access to patients requiring careful preoperative evaluation and planning. Intraoperative anesthesia problems include the physiological effects of CO2 injection and increased IAP. These problems are similar to minimally invasive (laparoscopy and thoracoscopy) and robotics. In view of the fixed nature of the instruments and operating table, a deep neuromuscular block is maintained during the operation to avoid the possibility of organ and blood vessel damage when the patient moves unintentionally. With the development of these technologies, evidence-based medicine is needed to evaluate the cost-effectiveness of robotic surgery, its impact on postoperative results (pain, length of stay), and determine the best technology for perioperative care, including anesthesia plan, ERAS technology , And intraoperative monitoring.

Dr. Michalsky received an honoraria from Intuitive Surgical, Inc (Sunnyvale, California) for providing professional education services. Intuitive Surgical, Inc does not participate in or access the original content reported in the work. All authors have no competing financial interests and report no other conflicts of interest in this work.

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