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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 155-157  

Robotic pyeloplasty in an infant: Minimal access surgery with minimal ‘access’ to the patient


Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Mridul Dhar
Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_671_18

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How to cite this article:
Dhar M, Mageshwaran T, Payal YS, Agarwal A. Robotic pyeloplasty in an infant: Minimal access surgery with minimal ‘access’ to the patient. Indian J Anaesth 2019;63:155-7

How to cite this URL:
Dhar M, Mageshwaran T, Payal YS, Agarwal A. Robotic pyeloplasty in an infant: Minimal access surgery with minimal ‘access’ to the patient. Indian J Anaesth [serial online] 2019 [cited 2019 Jun 25];63:155-7. Available from: http://www.ijaweb.org/text.asp?2019/63/2/155/251980



Sir,

Robotic surgery has revolutionised minimal access surgery by enhancing surgical technique and at the same time minimising or negating human errors.[1],[2] Paediatric robotic surgery (PRS) can be performed for a wide range of indications ranging from urological surgery such as pyeloplasty to congenital cardiac defect repairs.[3] Anaesthetic management of such cases offers unique challenges with respect to paediatric physiology and its interaction with iatrogenic pneumoperitoneum. The following case highlights nuances of management of such a case presenting to our institute.

A 1-month 23-day-old male infant weighing 3.7 kg, suffering from left pelvi-ureteric junction obstruction with hydronephrosis, was posted for robotic pyeloplasty. Pre-anaesthetic evaluation revealed no significant history or findings in examination and laboratory results. On the day of surgery after appropriate age-specific preparation of the theatre, general anaesthesia was induced and the trachea was intubated with a 3-mm Microcuff® polyurethane endotracheal tube (ETT). A precordial stethoscope was secured. Warmed 2% dextrose in a lactated ringer solution was given for intraoperative fluid requirements. Volume-controlled mechanical ventilation with appropriate pressure limitation (20–22 cmH2O) was used. Anaesthesia was maintained with sevoflurane, intermittent atracurium and fentanyl IV. Nitrous oxide was avoided.

A slight right lateral position was achieved by elevating the loin with a soft bolster and secured to the table with padded straps. Extra padding was applied at all pressure points. The face and ETT were covered with cotton padding to prevent inadvertent injury from the moving arms of the robot [[Video 1] (online)]. Pneumoperitoneum was created slowly with an initial intra-abdominal pressure (IAP) of 8 mmHg after insertion of the umbilical port (8 mm robotic). Urinary bladder and stomach were decompressed prior to port insertion. Rest of the three ports were inserted under vision, two operative (8 mm) and one assistant port (5 mm) [Figure 1]. Docking of ports was initiated with the daVinci® robotic system. After docking, IAP was reduced to 6 mmHg maintenance pressure [Figure 2]. The ETT position was rechecked after establishing pneumoperitoneum and after position changes. Intra-operative ventilation was managed by titrating minute ventilation to obtain an ETCO2 of 35–40 mmHg.
Figure 1: Insertion of robotic ports

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Figure 2: Docked arms of daVinci® robotic system on the patient

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Haemodynamic parameters remained stable during the course of the surgery. Sympathetic response to pneumoperitoneum was managed with aliquots of IV fentanyl and increasing depth of inhalational agent. Airway pressures and IAP were noted periodically. Urine catheter was clamped during most part of the surgery to provide good surgical conditions over the ureter and output was estimated by visual inspection of urine dribbling in the surgical field. The patient was checked intermittently under the drapes to make sure the robotic arms were away from the body. Postoperatively, feeding was resumed after 2 h.

Pelvic robotic surgeries including urological procedures offer an added advantage and better surgical access compared to conventional laparoscopic surgery.[2],[4] PRS is less frequently being performed in younger infants less than 6 months, mostly because of equipment-related issues.[4] But due to newer paediatric-specific instruments and formalisation of PRS systems in hospitals, anaesthesiologists will encounter much younger patients coming for such surgeries.[5]

Basic principles of PRS management essentially remain the same as for conventional paediatric laparoscopic surgery. These broadly include fluid management, countering systemic and endocrine effects of pneumoperitoneum, ventilation management, and avoiding and managing complications related to carbon dioxide absorption.[1] A high index of suspicion should be kept for detection of complications such as pnuemothorax and venous air embolism. PRS offers other challenges such as restricted access to the patient once docking of robotic arms has taken place. Thus, all airway, IV and monitoring tubes and lines should be properly secured prior to draping and docking. Sometimes, steep extreme surgical positions for prolonged periods may be required, especially in urinary bladder surgery.[2] General measures to prevent hypothermia, hypercarbia, hypoxemia and fluid overload should also be taken.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors thank Dr. Intezar Ahmed and Dr. Manish Gupta, Department of Paediatric Surgery, All India Institute of Medical Sciences, Rishikesh.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Muñoz CJ, Nguyen HT, Houck CS. Robotic surgery and anaesthesia for paediatric urologic procedures. Curr Opin Anaesthesiol 2016;29:337-44.  Back to cited text no. 1
    
2.
Howe A, Kozel Z, Palmer L. Robotic surgery in paediatric urology. Asian J Urol 2017;4:55-67.  Back to cited text no. 2
    
3.
Suematsu Y, Pedro J. Robotic paediatric cardiac surgery: Present and future perspectives. Am J Surg 2004;188:98-103.  Back to cited text no. 3
    
4.
Mattioli G, Pini Prato A, Razore B, Leonelli L, Pio L, Avanzini S, et al. Da Vinci robotic surgery in a paediatric hospital. J Laparoendosc Adv Surg Tech A 2017;27:539-45.  Back to cited text no. 4
    
5.
Bütter A, Merritt N, Dave S. Establishing a paediatric robotic surgery program in Canada. J Robot Surg 2017;11:207-10.  Back to cited text no. 5
    


    Figures

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