Anesthetic Implications of Robotic-Assisted Surgery in Pediatric Patients

Anesthetic challenges in pediatric robot-assisted surgeries

With the advent of minimally invasive surgeries, robot-assisted techniques have gained popularity because they overcome various shortcomings of standard laparoscopic surgeries. Despite the associated costs and limitations among the pediatric population, surgeon comfort due to the ergonomic design, in combination with enhanced three-dimensional high-fidelity imaging and tissue handling, may offer better surgical and postoperative outcomes. However, robotic surgeries require innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel. Anesthesiologists should become well versed with these changes by learning the basic features of robotic surgical systems to offer appropriate anesthetic care and promote patient safety. In this original case report, we present a 3-year-old child posted for robot-assisted left heminephrectomy and excision of the lower megaureter. It provides instructive significance for anesthesia management, especially taking into account the age of the patient and associated concerns.

Pharmacological Insights of Ropivacaine and Clinical Applications: A Narrative Review

This review focuses on ropivacaine, a long-acting amide local anaesthetic, detailing its pharmacology and clinical applications. The article highlights its applications in providing analgesia, prolonging pain relief, and improving recovery outcomes in surgical settings. Ropivacaine is particularly effective for epidural labor analgesia in obstetrics, promoting stable hemodynamics and rapid onset when used with adjuvants. Its prolonged anesthetic effects reduce the need for postoperative opioids in peripheral nerve blocks. Intrathecal administration may enhance functional recovery and postoperative analgesia in various surgical procedures. While effective in treating acute pain, its role in chronic pain management remains unclear, indicating a need for further research. The review underscores the versatility and efficacy of ropivacaine in acute pain management and the importance of exploring its potential in chronic pain treatment.

Robotic surgeries in pediatric patients: an early experience in a single center

Purpose

Robotic surgery (RS) has the advantages of 3-dimensional view, optical magnification, motional scaling, and improved ergonomics and degree of freedom. Although RS has widely been performed on pediatric patients lately, there are still numerous restrictions and ambiguous indications. The purpose of this study was to report our early experience with RS on pediatric patients at a single center.

Methods

Electronic medical records of patients who underwent RS with the da Vinci Xi surgical platform (Intuitive Surgical, Inc.) in Seoul National University Children Hospital from November 2019 to August 2021 were reviewed retrospectively. The median follow-up was 21.0 months (range, 12.3-31.8 months). An online survey was conducted to investigate satisfaction with robotic surgical scars.

Results

Fifty-four patients underwent robotic surgeries (median age at operation, 11.1 years [range, 0.1-17.8 years]). In our hospital, patients had 20 different kinds of robotic surgeries, including choledochal cyst excision with hepaticojejunostomy, ovarian mass excision, and others. Median operation time and console time were 157.5 minutes (range, 45-505 minutes) and 40 minutes (range, 11-360 minutes), respectively. All cases were done without conversion into open or laparoscopic methods. Postoperative complications were found in 5 patients. According to an online survey, over half of patients (60.9%) answered that they felt satisfied with scars.

Conclusion

Our early experience demonstrated the safety and feasibility of RS in children with a range of diagnoses and complicated procedures. With more experience, RS could be an alternative to traditional open or laparoscopic operations in pediatric patients. Further studies are needed to clarify indications of pediatric RS.

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.

The Role of the Versius Surgical Robotic System in the Paediatric Population

The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, dexterity, and ergonomics, could make it a superior choice over the traditional laparoscopic approach. However, its implementation in the paediatric surgery arena has been limited primarily due to the unavailability of appropriately sized instruments as per paediatric body habitus, therefore, requiring more technologically advanced systems. The Versius surgical robotic system is a new modular platform that offers several benefits such as articulated instruments which pass through conventional 5 mm ports, compact arms for easier manoeuvrability and patient access, the ability to mimic conventional port placements, and adaptive machine learning concepts. Prior to its introduction to paediatric surgery, it needs to go through a careful pre-clinical and clinical research program.