Pediatric anesthesia for minimally invasive surgery in pediatric urology

Minimally invasive surgery in the operating rooms near you

PURPOSE OF REVIEW

This review delineates the benefits of minimally invasive surgery (MIS) and its utilization at surgical centers and our institution. It further explores the literature for comparative outcomes of performing MIS to traditional open surgery for a variety of surgical subspecialties.

RECENT FINDINGS

In addition to its proven safety when compared to the open surgical technique, MIS has broad applications in many surgical subspecialties to enhance perioperative outcomes in both pediatric and adult patients.

SUMMARY

Although there are certain disadvantages with regard to cost of implementation in nascent communities and total operating time when the surgical complexity increases (such as utilizing a robotic approach), the added benefit of improved patient outcomes due to smaller incision sites is repeatedly proven in the literature making this technique globally essential.

Perioperative and Operative Considerations for Minimally Invasive Surgery in Pediatric and Adolescent Gynecology

Minimally invasive surgery (MIS) techniques, including vaginoscopy, laparoscopy, and robotic-assisted surgery, have revolutionized the field of gynecology, offering numerous benefits, such as reduced postoperative pain, shorter hospital stays, and faster recovery. Although these techniques are widely employed in adult gynecologic surgery, their application in pediatric and adolescent patients requires careful consideration due to anatomic differences, patient size, and specific surgical requirements in children. Various aspects of MIS in pediatric and adolescent gynecology, including patient positioning, laparoscopic and robotic instrument choices, trocar placement, surgical techniques, and perioperative pediatric adaptations to MIS, are discussed. The findings highlight the unique challenges and opportunities in performing MIS for pediatric and adolescent patients undergoing gynecologic surgery, emphasizing the need for specialized training and multidisciplinary collaboration.

European Association of Urology/European Society for Paediatric Urology Guidelines on Paediatric Urology: Summary of the 2024 Updates

BACKGROUND AND OBJECTIVE

We present an overview of the 2024 updates for the European Association of Urology (EAU)/European Society for Paediatric Urology (ESPU) guidelines on paediatric urology to offer evidence-based standards for perioperative management, minimally invasive surgery (MIS), hydrocele, congenital lower urinary tract obstruction (CLUTO), trauma/emergencies, and fertility preservation.

METHODS

A broad literature search was performed for each condition. Recommendations were developed and rated as strong or weak on the basis of the quality of the evidence, the benefit/harm ratio, and potential patient preferences.

KEY FINDINGS AND LIMITATIONS

Recommendations for perioperative management include points related to fasting, premedication, antibiotic prophylaxis, pain control, and thromboprophylaxis in patients requiring general anaesthesia. MIS use is increasing in paediatric urology, with no major differences observed among different MIS approaches. For hydrocele, observation is the initial approach recommended. For persistent cases, treatment varies according to the type of hydrocele. CLUTO cases should be managed in tertiary centres with multidisciplinary expertise in prenatal and postnatal management. Neonatal valve ablation remains the mainstay of treatment, but associated bladder dysfunction requires continuous treatment. Among urological traumas and emergencies, renal trauma is still an important cause of morbidity and mortality. Conservative management has become the standard approach in haemodynamically stable children. Ischaemic priapism is a medical emergency and requires stepwise management. Initial management of nonischaemic priapism is conservative. Fertility preservation in prepubertal children and adolescents has become an increasingly relevant issue owing to the ever-increasing number of cancer survivors receiving gonadotoxic therapies. A major limitation is the scarcity of relevant literature.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This summary of the 2024 EAU/ESPU guidelines provides updated guidance for evidence-based management of some paediatric urological conditions.

PATIENT SUMMARY

We provide a summary of the updated European Association of Urology/European Society for Paediatric Urology guidelines on paediatric urology. There are recommendations on steps to take before and immediately after surgery, management of hydrocele, congenital lower urinary tract obstruction, and urological trauma/emergencies, as well as preservation of fertility. Recommendations are based on a comprehensive review of recent studies.

Transcutaneous Hitching Sutures in Paediatric Minimally Invasive Surgery: A Novel Technique of "Assistant Without Port"

BACKGROUND

Transcutaneous hitching sutures in paediatric minimally invasive surgery (MIS) is a unique and rare technique. This technique has been used previously in adult patients undergoing gastric resections and laparoscopic cholecystectomy; however, its use in paediatric population has never been reported in the world literature. The primary objective of this study was to bring out the advantages and feasibility of this technique in minimally invasive gastrointestinal, hepatobiliary, urological and thoracoscopic surgeries on paediatric patients.

MATERIALS AND METHODS

This retrospective observational study was conducted on 167 paediatric patients who underwent MIS surgery for different indications between April 2016 and March 2020 at two paediatric surgery tertiary care centres.

RESULTS

A total of 167 patients, including 91 boys and 76 girl patients between the age group of new-born period to 12 years were operated. The mean hospital stay was 4 days. Five out of 167 cases (3%) had post-operative surgical emphysema, which resolved spontaneously. At 6-month follow-up, parental satisfaction was 100%, and in 99% of patients, scars were imperceptible.

CONCLUSION

This versatile technique is of exemplary utility, especially in paediatric patients where there is a paucity of working space at low intra-abdominal pressure, and eases the dissection even in narrow and closed spaces with a better functional and cosmetic outcome.

Noninvasive carbon dioxide monitoring in pediatric patients undergoing laparoscopic surgery: transcutaneous vs. end-tidal techniques

PURPOSE

The present study aimed to investigate the correlation between transcutaneous carbon dioxide partial pressure (PtcCO₂) and arterial carbon dioxide pressure (PaCO₂) and the accuracy of PtcCO₂ in predicting PaCO₂ during laparoscopic surgery in pediatric patients.

METHODS

Children aged 2-8 years with American Society of Anesthesiologists (ASA) class I or II who underwent laparoscopic surgery under general anesthesia were selected. After anesthesia induction and tracheal intubation, PtcCO₂ was monitored, and radial arterial catheterization was performed for continuous pressure measurement. PaCO₂, PtcCO₂, and end-tidal carbon dioxide partial pressure (PetCO₂) were measured before pneumoperitoneum, and 30, 60, and 90 min after pneumoperitoneum, respectively. The correlation and agreement between PtcCO₂ and PaCO₂, PetCO₂, and PaCO₂ were evaluated.

RESULTS

A total of 32 patients were eventually enrolled in this study, resulting in 128 datasets. The linear regression equations were: PtcCO₂ = 7.89 + 0.82 × PaCO₂ (r² = 0.70, P < 0.01); PetCO₂ = 9.87 + 0.64 × PaCO₂ (r² = 0.69, P < 0.01). The 95% limits of agreement (LOA) of PtcCO₂ - PaCO₂ average was 0.66 ± 4.92 mmHg, and the 95% LOA of PetCO₂ - PaCO₂ average was -4.4 ± 4.86 mmHg. A difference of ≤ 5 mmHg was noted between PtcCO₂ and PaCO₂ in 122/128 samples and between PetCO₂ and PaCO₂ in 81/128 samples (P < 0.01).

CONCLUSION

In pediatric laparoscopic surgery, a close correlation was established between PtcCO₂ and PaCO₂. Compared to PetCO₂, PtcCO₂ can estimate PaCO₂ accurately and could be used as an auxiliary monitoring indicator to optimize anesthesia management for laparoscopic surgery in children; however, it is not a substitute for PetCO₂.

REGISTRATION NUMBER OF CHINESE CLINICAL TRIAL REGISTRY

ChiCTR2100043636.

Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP)

BACKGROUND

Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally.

METHODS

A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place.

RESULTS

During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management.

CONCLUSION

Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Anesthetic Implications of Robotic-Assisted Surgery in Pediatric Patients

The novel technology of robotic-assisted surgery (RAS) has been utilized in children for the past two decades with several potential clinical benefits including reduction of postoperative pain, shortened hospital length of stay, and improved cosmetic outcomes. While associated costs and the limitations regarding instruments for smaller pediatric patients remain relevant issues, surgeon comfort related to ergonomic design in combination with enhanced three-dimensional high-fidelity imaging and tissue handling compared to traditional minimally invasive approached may offer improved surgical and postoperative outcomes. Given that the demand for this innovative technology will likely continue to expand in the field of pediatric surgery, pediatric anesthesiologists will be called upon to provide anesthetic care to patients exposed to this novel surgical technology with its unique features, intraoperative requirements, and potential complications. The current manuscript provides a narrative review of robotic-assisted surgery and discusses important anesthetic considerations and potential complications of these techniques.

Robotic-Assisted Urologic Surgery in Infants: Positioning, Trocar Placement, and Physiological Considerations

Pediatric robotic-assisted laparoscopic procedures are becoming increasingly common. They have been shown to be safe in younger patients, including infants. Successful adoption of robotic-assisted surgery in infants requires an understanding of the technical factors unique to this patient population. This review will delineate the specific considerations to safely perform robotic-assisted laparoscopic procedures in infants, including physiological changes associated with pneumoperitoneum in infants, positioning, trocar placement, and docking.