Pediatric Anesthesia: Case Report
Neonates with biliary atresia typically present with obstructive jaundice. The treatment of choice is the Kasai portoenterostomy (1,2), which can be performed via laparotomy or laparoscopy. The laparoscopic Kasai procedure has the potential advantages of minimally invasive surgery, fewer adhesions, and rapid postoperative recovery (3). However, challenges inherent to traditional laparoscopy include limited instrument mobility, two-dimensional vision, and amplification of natural tremor (4,5). Laparoscopy is particularly difficult in infants because of the smaller operative field (6). The robotic surgical system is designed to improve the surgeon’s ability to perform complex procedures, but its use presents unique challenges to the pediatric anesthesiologist. We report the first case of an infant undergoing laparoscopic Kasai with robot-assistance and discuss the anesthetic considerations.
A 2-mo-old, 4.1 kg, male infant with biliary atresia was scheduled for laparoscopic Kasai using the da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA). The robotic system consisted of a remote operating console and a wide-based surgical cart (Fig. 1). A practice run ensured that we could maneuver the cart away from the operating room (OR) table and gain access to the patient in <1 min. After inhaled anesthesia induction with sevoflurane, peripheral IV access, tracheal intubation, and radial arterial line insertion followed without difficulty. Endotracheal tube position was confirmed by auscultation, and a precordial stethoscope was placed over the patient’s left chest. An orogastric tube decompressed the stomach, and an esophageal probe was inserted to monitor temperature. The patient was elevated 4 in. off the OR table on blankets and egg crate to allow the greatest range of motion for the robotic arms (Fig. 2). The OR table was positioned in 30 degrees of reverse Trendelenburg to facilitate surgical exposure. The robotic cart was positioned over the head of the table (Fig. 3). Preparation, port placement, and docking took 53 min. The laparoscopic procedure was performed with an insufflation pressure of 10–15 mm Hg over 8 h 50 min. Anesthetic maintenance consisted of isoflurane at 1 minimum alveolar anesthetic concentration in oxygen/air, fentanyl, and rocuronium with pressure control ventilation. The patient remained hemodynamically stable during surgery without significant acidosis. Minimal urine output was measured secondary to leakage around the Foley catheter. After skin closure and drape removal, the patient was found to have lower extremity pitting edema presumably because of the reverse Trendelenburg and the pneumoperitoneum. The patient was admitted to the intensive care unit for recovery, and the edema resolved within 24 h. He was extubated the next day, had his first stool on postoperative day (POD) 2, and was discharged on POD 5 after an uneventful postoperative course.
Patient safety during robot-assisted laparoscopy requires advance planning. Although robotic technology offers distinct advantages to the pediatric laparoscopic surgeon, pediatric anesthesiologists need to familiarize themselves with issues related to robot-assisted surgery. First, access to the patient is severely limited, making preparation and open communication between the anesthesiologist and surgeon essential. The OR team must practice the crisis scenario of removing the robotic equipment and gaining access to the patient rapidly should the need arise. If room size allows, alternative placement of the robotic cart over the left side of the OR table may improve access to infants. Confirming proper endotracheal tube depth with fluoroscopy after patient positioning may help prevent an airway emergency.
Minimal patient access during robot-assisted surgery requires special monitoring. A left-sided precordial stethoscope monitors for inadvertent right mainstem intubation. Before positioning the robotic cart, pressure points must be carefully padded. Core temperature should be maintained with warm IV fluids and forced air warming. Placement of an intraarterial catheter allows continuous monitoring of arterial blood pressure and interval blood gas sampling. Extension tubing may be required for IV and arterial lines. Urine output should be measured to aid in fluid management during long procedures. A central venous catheter is a reasonable consideration as a monitor of central venous pressure.
Finally, until surgeons become accustomed to robotic technology, prolonged operative time with CO2 peritoneal insufflation will exaggerate negative physiologic effects. These include decreased lung volumes, impaired ventilation, and increased CO2 absorption, making arterial blood gas monitoring crucial (7). In addition, the pneumoperitoneum decreases venous return, which may result in lower extremity edema and a 50% reduction in cardiac index, especially in the reverse Trendelenburg position (8).
As the use of robotic surgical systems increases, setup and operative times will most likely decrease. Anesthesiologists need to be aware that robotic equipment can interfere with patient access and prepare accordingly. In the case of an airway emergency or cardiac arrest, resuscitating the patient requires disengaging the robotic instruments before backing the cart away from the OR table (9). The introduction of this new technology into the OR emphasizes the need for teamwork among the anesthesiologists, surgeons, and nurses to maximize safety and minimize risk to our patients.
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