title: Reduction in surgical fog with a warm humidified gas management protocol significantly shortens procedure time in pediatric robot-assisted laparoscopic procedures.
abstract: BACKGROUND
  The adoption of robot-assisted laparoscopic (RAL) procedures in the field of urology has occurred rapidly, but is, to date, without pediatric-specific instrumentation. Surgical fog is a significant barrier to safe and efficient laparoscopy. This appears to be a significant challenge when adapting three-dimensional 8.5-mm scopes to use in pediatric RAL surgery. The objective of the present study was to compare matched controls from a prospectively collected database to procedures that were performed utilizing special equipment and a protocol to minimize surgical fog in pediatric RAL procedures.
  
  
  METHODS
  A prospectively collected database of all patients who underwent RAL pediatric urology procedures was used to compare: procedure, age, sex, American Society of Anesthesiologists score, weight, console time, number of times the camera was removed to clean the lens during a procedure, length of hospital stay, and morphine equivalents required in the postoperative period. A uniquely developed protocol was used, it consisted of humidified (95% relative humidity) and warmed CO2gas (95 °F) insufflation via Insuflow® on a working trocar, with active smoke evacuation via PneuVIEW®XE on the opposite working trocar with a gas pass through of 3.5-5 l/min. The outcomes were compared with matched controls (Summary Fig).
  
  
  RESULTS
  The novel gas protocol was utilized in 13 procedures (five pyeloplasties, two revision pyeloplasties, three ureteroureterostomies (UU), three nephrectomies) and compared with 13 procedures (six pyeloplasties, one revision pyeloplasty, three UU, three nephrectomies) prior to the protocol development. There was no statistical difference in age (P = 0.78), sex (P = 0.11), ASA score (P = 1.00) or weight (P = 0.69). There were no open conversions, ≥Grade 2 Clavien complications, or readmissions within 30 days in either group.
  
  
  CONCLUSIONS
  This novel gas protocol yielded a statistically significant reduction in procedure time, by decreasing the number of times the camera was required to be pulled during the case by more than five occurrences, and saved approximately 35 min on average per case.
authors.affiliation: Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, OK, USA. Electronic address: Bhalaajee-meenaksi-sundaram@ouhsc.edu.
authors.forename: B
authors.initials: B
authors.lastname: Meenakshi-Sundaram
authors.affiliation: Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, OK, USA.
authors.forename: J R
authors.initials: JR
authors.lastname: Furr
authors.affiliation: Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, OK, USA.
authors.forename: E
authors.initials: E
authors.lastname: Malm-Buatsi
authors.affiliation: Product Development, Lexion Medical, St. Paul, MN, USA.
authors.forename: B
authors.initials: B
authors.lastname: Boklage
authors.affiliation: Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, OK, USA.
authors.forename: E
authors.initials: E
authors.lastname: Nguyen
authors.affiliation: Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, OK, USA.
authors.forename: D
authors.initials: D
authors.lastname: Frimberger
authors.affiliation: Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, OK, USA.
authors.forename: B W
authors.initials: BW
authors.lastname: Palmer
mesh_terms: D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D006801:Humans; D006813:Humidity / Q000517:prevention & control; D007431:Intraoperative Complications / Q000517:prevention & control; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D061646:Operative Time; D061214:Patient Safety; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects / Q000379:methods*; D011379:Prognosis; D011446:Prospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D014570:Urologic Diseases / Q000175:diagnosis / Q000601:surgery; D013520:Urologic Surgical Procedures / Q000009:adverse effects / Q000379:methods
keywords: Humidified gas; Laparoscopic; Operative time; Robotic