Expanding safety boundaries in pediatric robotic-assisted laparoscopic surgery: are we protecting our children?

Little is known about the effects of CO₂ insufflation (CDI) on cerebral oxygen saturation (CrSO₂) during laparoscopy in the pediatric population. In children undergoing robotic-assisted laparoscopic pyeloplasty (RALP), we prospectively assessed the effects of CDI using standard monitoring and cerebral near-infrared spectroscopy (NIRS). We also explored whether a correlation existed between CrSO₂ and parameters known to affect cerebral blood flow. Between January 2021 and September 2023, a cohort of consecutive children older than 2 years underwent RALP at Necker-Enfants Malades Hospital in Paris. A ventilation protocol aimed to prevent hypercarbia was implemented. Data collected included standard monitoring parameters and CrSO₂ by NIRS. Thirty patients (16 females), mean age 5.5 ± 3.9 (2.0-9.5) years, were included. Twenty-three patients underwent a retroperitoneal approach. The mean baseline CrSO₂ value was 83.0 ± 9.8. Mean CrSO₂ decreased during progressive CDI, never below baseline values, while standard-monitoring parameters did not significantly change. No significant correlation was detected between CrSO₂ and end tidal CO₂, or between CrSO₂ and mean arterial pressure, at any operative time. During RALP, a gradual CDI doesn't cause pathological derangements of CrSO₂. The lack of correlation between CrSO₂ and standard parameters affecting cerebral blood flow suggests the likely presence of cerebral autoregulation in our population.