Anesthetic Implications of Robotic-Assisted Surgery in Pediatric Patients

Abstract

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.

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)

“…Given the constraints imposed by the robotic instruments and potential anatomical space limitations of the patient, the use of RAS in patients less than 1 year old or weighing less than 10 kg remains especially challenging, although there are reports of RAS being performed on patients weighing less than 7 kg [6,8,12,15,16]. There is currently no consensus on pediatric patient selection for RAS and there are no established parameters to guide this decision [8].…”

“…Due to the high cost of RAS, it has been applied mainly in complex pediatric reconstructive procedures such as pyeloplasty, fundoplication, ureteral reimplantation and choledochus cyst removal, and less frequently in simpler procedures such as varicocelectomy or appendicectomy [6][7][8][9][10]16]. Robotic operating rooms (ORs) are often shared by several specialties, including adult surgery, and therefore may be located outside of pediatric hospitals or departments [6].…”

“…• The limited number or size of studies • Important flaws in study design or methods • Inconsistency of findings across individual studies • Gaps in the chain of evidence • Findings not generalizable to routine primary care practice • Lack of information on important health outcomes More information may allow estimation of effects on health outcomes 2. Robotic surgery can be considered mainly in patients weighing more than 10 kg and older than one year [8,9,12,15,16,18,[20][21][22][23] (Grade A-Level High) 3. Based on the experience at individual centers, robotic surgery can also be performed in selected patients of lower weight or age [8,9,12,15,18,[20][21][22][23] (Grade C-Level High) 4.…”

“…The adoption of a suitable ERAS (Enhanced Recovery After Surgery) program reduces the direct costs of robotic surgery and promotes its economic sustainability [48] (Grade A-Level High) 2. Every center conducting robotic surgery should implement an enhanced recovery program based on the most recent evidence for each type of pediatric robotic surgery [16,[49][50][51] (Grade B-Level Moderate)…”

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

“…Robot-assisted surgery has also been utilized in the paediatric population for the past two decades, with numerous reported clinical benefits including less postoperative pain, shorter hospital length of stay, reduced operative trauma, minimal scarring, less postoperative pain, reduced opioid use, reduced risk of infection, and improved cosmetic outcomes [ 6 , 8 ]. Following the first described use of robot-assisted surgery in children in 2001 [ 9 ], its applications in the paediatric population have expanded to include multiple procedures across specialties such as urology, cardiothoracic surgery, and general paediatric surgery for patients ranging in age from infants to adolescents [ 10 ], with studies indicating its safety and efficacy in children [ 11 , 12 ].…”