Secondary Logo

Journal Logo

Anesthetic Concerns for Robot-Assisted Laparoscopy in an Infant

Mariano, Edward R. MD*; Furukawa, Louise MD*; Woo, Russell K. MD; Albanese, Craig T. MD; Brock-Utne, John G. MD, PhD*

doi: 10.1213/01.ANE.0000137394.99683.66
Pediatric Anesthesia: Case Report
Free
SDC

A 2-mo-old infant with biliary atresia was scheduled for laparoscopic Kasai with robot assistance. Before surgery, a practice trial maneuvering the cumbersome robotic equipment was performed to ensure rapid access to the patient in case of emergency. IV access, tracheal intubation, and arterial line placement followed inhaled anesthesia induction with sevoflurane. Robotic setup took 53 min and severely limited patient access. No adverse events occurred during the procedure requiring the removal of the robotic equipment, and the patient was discharged after a stable postoperative recovery. Advance preparation is required to maximize patient safety during robotic surgery.

IMPLICATIONS: The robotic surgical system for pediatric laparoscopy severely limits the anesthesiologist’s access to the patient and requires advance preparation to ensure patient safety. We present the anesthetic management of the first successful robot-assisted laparoscopic Kasai procedure in an infant.

Department of *Anesthesia and †Surgery, Division of Pediatric Anesthesia, Stanford University Medical Center, California

Accepted for publication June 15, 2004.

Address correspondence and reprint requests Edward R. Mariano, MD, Department of Anesthesia, Stanford University Medical Center, 300 Pasteur Dr. H3580, Stanford, CA 94305. Address e-mail to ermariano@hotmail.com.

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.

Back to Top | Article Outline

Case Report

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.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Back to Top | Article Outline

Discussion

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.

Back to Top | Article Outline

References

1. Grosfeld J. Is there a place for the Kasai procedure in biliary atresia? Curr Opin Gen Surg 1994:168–72.
2. Lau JT, Ong GB. Biliary atresia before and after the introduction of the Kasai-type procedure. Aust N Z J Surg 1983;53:129–31.
3. Esteves E, Clemente Neto E, Ottaiano Neto M, et al. Laparoscopic Kasai portoenterostomy for biliary atresia. Pediatr Surg Int 2002;18:737–40.
4. Hubens G, Coveliers H, Balliu L, et al. A performance study comparing manual and robotically assisted laparoscopic surgery using the da Vinci system. Surg Endosc 2003;17:1595–9.
5. Lorincz A, Langenburg S, Klein MD. Robotics and the pediatric surgeon. Curr Opin Pediatr 2003;15:262–6.
6. Hollands CM, Dixey LN. Applications of robotic surgery in pediatric patients. Surg Laparosc Endosc Percutan Tech 2002;12:71–6.
7. Cunningham AJ, Brull SJ. Laparoscopic cholecystectomy: anesthetic implications. Anesth Analg 1993;76:1120–33.
8. Joris JL, Noirot DP, Legrand MJ, et al. Hemodynamic changes during laparoscopic cholecystectomy. Anesth Analg 1993;76:1067–71.
9. Parr KG, Talamini MA. Anesthetic implications of the addition of an operative robot for endoscopic surgery: a case report. J Clin Anesth 2002;14:228–33.
© 2004 International Anesthesia Research Society