Anesthetic adaptations for robotic-assisted pediatric surgery in a resource-constrained setting: a case report

Robotic-assisted pediatric surgery enhances visualization and dexterity but poses anesthetic challenges in low-resource settings. These challenges are compounded by prolonged operative times, pneumoperitoneum, and restricted patient access. This report describes the first pediatric robotic-assisted choledochal cyst excision performed at a Philippine tertiary hospital, highlighting anesthetic considerations and adaptive strategies in a resource-constrained environment.

A female child with a 2-year history of intermittent epigastric pain and no comorbidities was diagnosed with a choledochal cyst and scheduled for elective robotic-assisted excision. General anesthesia was supplemented by redundant monitors and intravenous accesses, an extended precordial stethoscope, improvised padding, cling-wrap insulation, and microwave-warmed intravenous fluids. Atracurium infusion ensured deep paralysis, while ventilatory adjustments countered the effects of pneumoperitoneum. The surgery was uneventful.

Anesthesia was complicated by altered respiratory and hemodynamic physiology, the risk of hypothermia, the need for paralysis, and limited access after docking. Careful preoperative assessment, vigilant monitoring, redundancy, and evidence-supported improvisation mitigated these risks. This case illustrates the disparity between advanced surgical technology and limited anesthetic infrastructure in developing countries.

This case highlights the conditional feasibility of pediatric robotic-assisted surgery in a resource-limited setting when performed on a carefully selected patient. Safety under such constraints depends on meticulous preparation, anticipation of physiologic challenges, monitoring redundancy, and adaptive anesthetic strategies. As robotic surgical platforms become increasingly adopted in developing countries, strengthening perioperative infrastructure and support systems remains essential to ensure patient safety.