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H. Y. Zhao and C. Zhan
3.3 Endoscope Management
1. The distal end of the endoscope may reach a
high temperature of 50–55 °C during use.
When the endoscope controller is turned on,
avoid contact with skin, tissues, cloth dressings, etc., to prevent skin burns.
2. When the endoscope lens is connected to the
system and emits light, avoid looking directly
at it.
3. When the endoscope is fogging, immerse the
lens end in 50 °C warm water for 10 s (the
temperature does not exceed 55°C, and the
time does not exceed 15s).
4. Lay a sterile table to place the 3D endoscope
camera separately, connect it to the endoscope
controller 30 min in advance to preheat it,
place it between the image processing platform and the end of the operating table, cover
it with sterile towels, and leave the surroundings empty to avoid pollution [4].
3.4 Endo Wrist Device
Management
1. According to the needs of specialist surgery
and the usage habits of surgeons, the special
equipment is congured as a package of specialist surgery equipment. Instruments that
are not commonly used or of variable frequency are sterilized separately for easy turnover. EndoWrist instruments are programmed
to be used a predetermined number of times.
At the same time, attention should be given
to the limitation of the maximum number of
sterilizations of the instruments to avoid the
possibility of not being used after sterilization
[4].
2. Establish equipment use les to record equipment name, use date, use status, repair application, and other information for easy
traceability.
3. Disposal after use: When cleaning the instrument during the operation, the scrub nurse
uses moist gauze to wipe off the blood on the
tip and surface of the instrument. During the
operation, the tip of the instrument was kept
free of blood scabs and tissue attachment.
After the operation, the instrument should be
pre- treated in time and placed properly for
transportation. The scrub nurse and the nurse
in the supply room handed over face-to-face
and handed over detailed information on the
instrument such as the name, quantity, use status, and completeness. After sterilization is
completed, the instruments are placed in a
dedicated rack for storage [5].
3.5 Intraoperative Control
andInstrument Arm
Management
According to the age of the child, the pneumoperitoneum pressure is maintained at
6–10mmHg, the ow rate is 2–4L/min, and the
single-bipolar coagulation is maintained at
15–20. Children’s abdomen operation space is
limited, and the distance between the holes is
closer than that of adults [6]. To ensure the maximum reach and minimum arm interference, the
instrument arms should be arranged in parallel to
maintain a punch distance of the mechanical
arms, and attention should be given to the operating conditions to avoid equipment collisions.
When replacing the operating forceps, ensure
that the front joints remain straight to prevent
shifting of the tip of the operating forceps and
damaging the tissue when the operating forceps
enter for the second time. At the same time, attention should be given to the gap between the child
and the distance between the robotic arm and the
child’s body to avoid squeezing. After the operation, remove the robotic arm, remove the sterile
protective cover, and retract the robotic arm to
the smallest extent [7].
3.6 Personnel Management
andTraining
3.6.1 Da Vinci Operating Room
Personnel Management
Strictly controlling the entry and exit of personnel, except for the surgeon, anesthesiologist, and
nurse of this surgery, the rest of the staff are not
3 Robotic Operating Room Conguration
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19
allowed to enter the robot operating room to visit.
The instrument is hung with eye-catching signs
to avoid accidental damage or collisions caused
by unqualied personnel [1].
3.6.2 Establish da Vinci Surgical
Medical Team
The da Vinci robotic surgery medical team was
established before the operation, and nurses who
had rich experience in specialist open surgery
and procient in cooperation with laparoscopic
surgery were selected to participate in the professional training of the da Vinci robotic surgery
system [8]. Before the operation, the team conducts preoperative simulation training, sets up
various simulation scenes of robotic surgery, and
repeats the practice, so that the nurses can achieve
the team skills required for the work, and obtain
professional certicates after the assessment [9].
3.6.3 Nurse Training
The da Vinci Surgical Nursing Specialist Group,
which is jointly trained by nurses with professional certicates and equipment engineers, was
established to provide standardized and staged
training for new nurses in the specialist group.
Establish a training package including theoretical
training, operational training, and simulation
training, and modularize the training content
according to the training period [10]. The training content includes the knowledge of the robotic
surgery system, which includes the performance
of robotic surgery equipment, use procedures,
operating methods, equipment names, uses, disassembly and cleaning, installation methods,
daily maintenance, fault identication and preliminary. After completing all the content of the
training package, the theory and operation assessment will be carried out, and then the next stage
of simulation training can be entered after passing the assessment. Simulation training is mainly
to simulate the operation site, use similar equipment to increase its realism, and simulate many
special situations that may occur during the
operation, which helps to improve the learning
effect. Its practice content includes preoperative
preparation, space layout, placement of the surgical position, layout of the surgical hole, and
placement of the bedside arm system. Only after
completing all training content and passing the
assessment can the nurse serve as a robotic surgery nurse. Finish the special operation cooperation manual used as daily training, including
pathophysiology, article preparation, anesthesia
methods, surgical positions, surgical platform
paths, surgical procedures, precautions, and personnel station maps [11].
3.7 Position Placement
ofPediatric Robotic Surgery
1. Supine position: When the newborn is placed
in the posture, the overall body of the child
should be raised by 10–15cm to increase the
operating space of the robotic arm and avoid
collisions between the robotic arm and the
operating table.
(a) The child is placed in the supine position
with the head high, and the restraint belt
is used to properly x the child, paste a
lm sticker on the bone carina position
bone of the child, place a silicone head
ring under the head with cloth glue, and
place a home-made water bag on the body
with gloves on the limbs to prevent pressure ulcers. Properly arrange venous
access, urinary catheters, zinc wire, etc.,
to prevent skin damage. It is suitable for
the radical treatment of choledochal
cysts, malrotation of the intestine, circular pancreas, etc.
(b) The child is placed in the supine position
with the head low, the chest is lined with
cotton pads and xed with cloth tape,
shoulder pads are placed under the shoulders on both sides to prevent the patient
from sliding down when the head is low
and the feet are high or the patient’s position changes or accidents, placed under
the head circle, the limbs are put into the
water bag, and the lower limbs are xed
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H. Y. Zhao and C. Zhan
with restraint straps. For urology patients,
the hips are raised, the head is lowered in
the supine position, and the knees are
xed with cloth glue lined with cotton
pads. It is suitable for anal atresia, megacolon, ovarian cysts, vesicoureteral
replantation, prostate cysts, etc.
2. Lateral position:
(a) General thoracic surgery: The child is
lying on the contralateral side at 90°, with
a head circle under the head, and a semicircular soft cushion under the armpit to
ensure that the gap between the side ribs
of the patient is enlarged. The surgical
site is exposed and the patient’s blood
vessels and nerves are not compressed. In
addition, place two U-shaped silicone
pads was placed on the abdomen and
back to x the child. The upper limb of
the contralateral side is stretched out 90°,
and the restraint belt is xed stably. The
iliac area is reinforced with cloth glue. A
soft pillow was placed between the lower
limbs, straightening the lower limbs of
the contralateral side, and exing the
lower limbs of the affected side 90°.
Water bags were placed between the feet.
Suitability for lobectomy, mediastinal
tumor, PDA ligation, etc [12].
(b) Urology: The child is lying on the contra-
lateral side at 60°, close to the bedside of
the contralateral side, expanding the
operating space of the robotic arm. The
head ring is placed under the head, and a
U-shaped silicone was placed on the back
for xation with wide tape. A soft pillow
was placed between the lower limbs, the
lower limb of the contralateral side was
straightened, the lower limb of the
affected side was extended, and water
bags were placed on the feet. Attentions
should be given to the use of soft pads to
protect the skin of the patient’s vulnerable
parts and keep the joints in a functional
position. Suitability for renal pelvic ureteral anastomosis, nephrectomy, adrenal
tumors, and etc.
References
1. Zeng J. Design of the compound operating room
with da Vinic robotic surgical system. China Medical
Devices. 2016;31:121–3. in Chinese)
2. Giedelman C, Covas Moschovas M, Bhat S, et al.
Establishing a successful robotic surgery program
and improving operating room efciency: literature
review and our experience report. J Robot Surg.
2021;15:435–42.
3. Lenihan JP Jr. How to set up a robotic-assisted laparoscopic surgery center and training of staff. Best Pract
Res Clin Obstet Gynaecol. 2017;45:19–31.
4. Larkins K, Mohamed JE, Mohan H, et al. How I Do
It: Structured Narration for Cognitive Simulationbased Training in Robotic Surgery. J Surg Educ.
2023;80:624–8.
5. Jin Y, Zhang Y, Cai D, et al. Robot-Assisted Resection
of Intestinal Duplication in Children. J Laparoendosc
Adv Surg Tech A Part. 2022;32:1288–92.
6. Suo J, Hua R, Li N, et al. Cleaning and sterilization
management of Da Vinci robot surgical instruments.
Chinese J Disinfect. 2017;34:97–9.
7. Zhang H, Zeng Z, Cheng G, et al. Scientic management of the introduction of Da Vinci surgical robot
into the use process. Beijing Biomedical Engineering.
2021;40:101–4.
8. Wu K, Zhang X. Application value of specialist group
management in Da Vinci robot surgical instrument
management. Medical Equipment. 2019;32:61–2.
9. Wei A, Li S, Pei H, et al. Application of ne management in Da Vinci robot surgical instrument management. J Modern Med Health. 2021;37:345–7.
10. Yu X, He M. Application of modular training model
in coordination training for robotic surgery. Chinese J
Robot Surg. 2022;3:217–23.
11. Shen X, Shi Z, Zhou Y, Yang J. Training of operating room nurses over Da Vinci robot surgery based on
checklist management. J Nurses Sci. 2022,37:34–6.
12. Tan B, Guo D, Tang L, et al. A comparative study
of two kinds of posture placement by robot-assisted
laparscopic radical prostatectomy. J Nurses Train.
2019;34:1043–5.
Pediatric Anesthesia forRobotic
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Surgery inChildren
JinjinHuang andYaoqinHu
4
Along with the rapid development of minimally
invasive techniques, laparoscopy and thoracoscopy have become increasingly mature and are
widely used in pediatric surgeries. Robotic surgery is the result of transformation in the minimally invasive surgical evolution [1]. Currently,
the use of robotic platforms is widely accepted
in many adult surgeries, especially urologic and
gynecologic operations. The use of robotic surgery in pediatric patients is almost a decade later
than in adults. Due to the limitations of equipment and technology, the application of robotic
surgery in pediatrics lags behind that in adults.
The advantages of robotic-assisted surgery
(RAS) include smaller surgical incisions,
improved precision, improved accuracy of the
movements, less pain, and shorter hospital stays.
The limitations of RAS may be the size of robot,
the size of the patients, the cost, and so on.
Therefore, all these factors may result in more
complicated anesthetic management, particularly in younger children, such as neonates and
infants. It is necessary to acquire prociency in
the pathological and physiological changes asso-
ciated with pneumoperitoneum/pneumothorax,
and be aware of the potential complications, so
that we can provide safer and more effective
anesthesia for pediatric patients undergoing
robotic surgery. In addition, we should pay more
attention to the inuence of patients’ position,
lengths of operating time, loss of water, and so
on (Fig. 4.1).
Fig. 4.1 Robot arm
J. Huang (*) · Y. Hu
Department of Anaesthesiology, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: 6196008@zju.edu.cn; huyaoqin@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_4
21
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J. Huang and Y. Hu
4.1 Robotic-Assisted
Thoracoscopic Surgery
Robotic approaches have been used in many
chest surgeries, including surgeries for congenital diaphragmatic hernia, esophageal atresia,
mediastinal cysts, diaphragmatic hernia, pulmonary lobectomy, esophageal cysts, and patent
ductus arteriosus [2–6], with outstanding shortterm outcomes. The concerns and key points of
anesthesia were have changed equally since the
development of technology. Compared with minimally invasive surgery performed in other
regions of the body, robotic-assisted thoracoscopic surgery (RATS) is full of different challenges. Specic anesthetic considerations for
RATS includes the size of the robotic surgery
device, which may limit the ability of anesthesiologist to access the patients, the patient positions, and the absorption of CO2, which insufates
in the thorax [7].
RATS may require the anesthetist to use the
one- lung ventilation (OLV) technique to provide
satisfactory visualization for surgeon. The lungs
of infants are softer and easier to compress than
those of adults. Moreover, the residual volume is
larger and nearly equal to the functional residual
capacity (FRC) in young children. Therefore, if
the healthy lung is only ventilated, even in tidal
breathing, lung compliance will decrease, and airway closure will increase. For the pediatric population, the intercostal space and thoracic cavity
are much smaller than those in adults, and lung
isolation techniques are also not as mature as
those in adults. Before the robot is docked, bronchoberscope should be used to conrm the optimal position of the endotracheal tube. During the
period of one- lung ventilation, pressure-controlled ventilation may provide superior serum
oxygen tension and reduced peak airway pressures compared rather than volume-controlled
ventilation [8].
Patient positioning plays an important role in
the surgery. The position of RATS is lateral, similar to the position of VATS, which limits the ability of anesthetist to access to the patient’s arms
and face. Therefore, the anesthesiology team
should ensure that patients are visible and accessible. Additionally, robotic surgery has the risk
that robotic arms may injure the patients, with
additional potential for facial injuries [9], and we
should check patients’ facial frequently. Infant
has small thoracic size. During RATS, the hydrostatic pressure gradient between dependent and
nondependent lungs will decrease, which will
inhibit hypoxic pulmonary vasoconstriction.
Therefore, infants in the lateral position during
one-lung ventilation(OLV) will be more susceptible to hypoxia [10].
The surgeon insufates CO2 into the thorax to
obtain a wider visualization. However, systemic
absorption of carbon dioxide(CO2), which insufates into the intrapleural cavity, may lead to
hypercarbia [11]. The shift of intrathoracic structures will lead to hemodynamic effects. Therefore,
maintain the ow rates and pressure as low as
possible when infusing carbon dioxide into the
chest (Fig. 4.2) [12].
d
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23
a
Fig. 4.2 The child patient needs to undergo single-lung
ventilation. (a) ber bronchoscopy view of the tracheal
bifurcation and carina; (b) ber bronchoscopy left main
b
4.2 Robotic-Assisted Urologic
Surgery
Pediatric urological surgery is one of the most
common surgeries that employs robotic assistance in children. Pyeloplasty, surgery for treating vesicouretric reux, nephrectomy, and
heminephrectomy are the most commonly performed operations. The concerns about anesthesia in robotic-assisted urologic surgery are
patient positioning, pathophysiological changes
in the pneumoperitoneum, and absorption of
CO2. In general, patients with congenital malformation of the urogenital system often
undergo minimally invasive surgery. Those
patients are always associated with heart mal-
c
bronchus occlusion procedure; (c) image of trachea bifurcation under beroptic bronchoscope; (d) ventilator
parameters during sing
formations [13]. Therefore urological conditions are always a signal to rule out congenital
heart disease. Those patients concerns about
renal insufciency, anemia, electrolyte imbalance, metabolic problems, and hypertension. In
pediatric patients, a pneumoperitoneum pressure of 4–12mmHg is usually enough to explore
the surgical area and provide an adequate surgical eld of vision, because prepubertal children
have softer abdominal walls and smaller peritoneal cavities than adults [14]. In addition,
because of the increasing intraperitoneal pressure, the diaphragm will be elevated. Therefore,
the functional residual capacity and lung compliance will decline, airway resistance and
physiological dead space will increase, and V/Q
will mismatch [13].
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J. Huang and Y. Hu
Position has different effects on the circulatory system, including cardiac output and blood
pressure. The head-up position will reduce
venous return of the heart blood volume and cardiac lling pressure. Additionally, some urological surgeries require lithotomy, in the lateral or
prone position, which will result in potential
nerve injuries. In addition, the steep Trendelenburg
position will reduce lung compliance and induce
inspiratory pressure increases, which increase the
risk of barotrauma in patients.
In several cystoscopy and prostate surgeries
that require the use of irrigation solution, it may
be difcult to estimate blood loss and increase
the risk of a reduction in body temperature.
Children have a larger body surface area to mass
ratio and thinner subcutaneous fat, which will
make them more prone to lose heat. We can use
warming blanket, infusion warming, and forced
air warmers to avoid hypothermia. The insufng
uid should be warmed, and the ow velocity
should be less than 2L/min [15].
4.3 Robotic-Assisted General
Surgery
The applications of robotic-assisted general surgery include colectomy [16], fundoplication, and
so on. RAS(robotic-assisted surgery) requires
carbon dioxide insufation into the abdomen to
provide effective visualization. Meanwhile some
patients may need a reverse or steep Trendelenburg
position.
The pneumoperitoneum will increase intraabdominal pressure (IAP). Increased IAP may
affect the circulatory and respiratory systems.
When carbon dioxide is insufated in the abdominal cavity, the diaphragm is shifted to the
cephalic side. This will potentially inuence the
position of tracheal intubation, so anesthetists
should assess the bilateral breath sounds frequently, especially in young children who have
lower mainstem bronchi length. All these factors
may lead to several inuences on the respiratory
system, including decreased functional residual
capacity, lower lung compliance, and high airway
resistance. Therefore, it will change the ventilation/ perfusion (V/Q) ratio and increase dead
space ventilation, which can result in hypoxemia
and hypercarbia. Position and CO2 absorption
may inuence the circulatory system, including
the increased systemic vascular resistance, higher
pulmonary vascular resistance, and decreased
cardiac index [7]. The pneumoperitoneum and
reverse-Trendelenburg position may lead to an
increase in stroke volume variation (SVV),
MSFP and central venous pressure (CVP) and a
decrease in the microcirculatory perfusion index
[17]. In addition, with the increase in IAP levels,
the inferior vena cava may be compressed, resulting in a reduction in venous return ,which can
lead to decreased cardiac output and hypotension. In healthy pediatric patients, these changes
can be compensated for a limited time and can
easily offset by changes in ventilator parameters
[18, 19]. However, in patients with pre- existing
myocardial function injury, the impact may be
magnied. Anesthetists should pay more attention to patients with congenital heart disease
(CHD ).
4.4 Robotic-Assisted Cardiac
surgery
Currently, several cardiac operations also use
robotic surgical systems, such as patent ductus
arteriosus closure, atrial septal defect closure, ASD
closure [20], and mitral valve replacement [5, 21–
24]. Patients undergoing robotic cardiac surgery
need to be selected, especially in totally endoscopic
robotic surgery. Factors limiting the RACS include
the size of thorax and the distance between the
mediastinum and anterolateral chest wall.
Anesthetists should pay more attention to assessing
whether the patient can tolerate the effects of pneumothorax on respiration and circulation and have a
longer operation time compared to traditional
surgery.
The plan for the induction of anesthesia is
similar to the open procedure. Intraoperative
monitoring included invasive blood pressure,
pulse oximetry, EtCO2, central venous pres-
4 Pediatric Anesthesia forRobotic Surgery inChildren
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Fig. 4.3 PDA ligation assisted by robot
sure, and ECG. After the induction of anesthesia, some surgeries need one-lung ventilation; in
some research, a left-sided double- lumen endotracheal tube (DLETT) is preferred for mitral
valve replacement [25]. The inuences of OLV
are the same as those of RATS.In robotic surgeries, transesophageal echocardiography(TEE)
was routinely checked, and the probe was placed
through the surgeries. The process of placing a
special cannula for extracorporeal circulation and
cardioplegia is the same as in traditional cardiac
surgery. Patients are always in lateral decubitus
to meet the needs of surgery, and anesthetists
should understand the effect of the patients’ position, OLV, and surgical manipulation. In the same
time, every staff member should be trained to be
able to quickly remove the robotic arms from the
patient so that to convert to an open sternotomy
(Fig. 4.3).
4.5 Robotic-Assisted Surgery
inPediatric Gynecology
In the eld of pediatric gynecology, the use of
robotic-assisted surgery is not as wide as in other
departments . The use of robotic surgeries
includes ovarian cystectomy, exploration for
suspected malformation, and oophorectomy for
gonadal dysgenesis [20, 26]. During surgery, the
anesthetic considerations include the inuence of
25
patient positioning, such as Trendelenburg and
lithotomy, pneumoperitoneum, and prevention of
its associated complications [27].
4.6 Neonatal Robotic Surgery
The physiology of preterm and term neonates is
quite different from that of adults, and the function
of every system has not developed completely.
Neonates have a fast respiratory rate of approximately 40 cpm at rest. In neonates, the thorax is
cylindrical, the intercostal muscles are weak, and
breathing mainly depends on the action of the diaphragm [28, 29]. However, the diaphragm of neonates is prone to fatigue. Additionally, the
respiratory control system is immature in neonates, and the ventilation response when suffering
hypercapnia and hypoxia is incomplete [30]. In
awake neonates, functional residual capacity
(FRC) is similar to that in adults, but alveolar ventilation is doubled. The heart rate of neonates uctuates over a wide range, ranging from 90 to
160bpm, and cardiac output is exquisitely heartrate dependent. Therefore, the neonate does not
improve cardiac output by increasing heart rate or
adjusting total peripheral vascular resistance.
Circulation in the neonate is similar to the situation comparable to compensated shock in adults.
The peripheral vascular resistance of neonates is
high and cardiac output is mainly distributed in
vital organs, such as the brain and heart. In addition, in neonates, the function of the thermal regulating center is imperfect, the surface area is lager,
the layer of insulating subcutaneous fat is thinner,
and skin keratinization is lower. These factors may
result in susceptibility to perioperative hypothermia in neonates.
The considerations of neonatal robotic sur-
gery [31]:
1. The size of the surgical robot
2. Patients size: smaller cavities leading to
decreased workplace size
3. The time of docking the robot
4. The inuence of pneumoperitoneum/pneumothorax
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The main inuence of robot-assisted abdominal surgery is the pneumoperitoneum. During
surgery, because of CO2 insufation, with the
increase in IAP, respiratory function and pulmonary mechanics will be affected. Additionally,
because of the pneumoperitoneum, the diaphragm is pushed cephalad, which may reduce
respiratory compliance and functional residual
capacity [11]. Thus, it can cause atelectasis,
which may potentially result from hypoxemia
due to the neonate’s low closing volume. Headdown tilt positioning can also aggravate the loss
of FRC [32]. As CO2 is absorbed, the risk of
hypercarbia is higher in younger children than in
older children. The pneumoperitoneum might
further deteriorate V/Q mismatch. During surgery, it is necessary to limit the IAP to under
6mmHg in neonates [33] and apply an appropriate PEEP. For the sake of protecting neonates
from intraoperative hypothermia, there are several simple measures such as raising the operating room temperature to 28°C or 30°C, using a
warming blanket, warming the solution for surgical sterilization, and administering warm infusion solutions and blood [34].
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22. Cannon Jeremy W, Howe Robert D, Dupont Pierre
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