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Medical and feeding therapy should be the first modality of treatment in patients with laryngeal cleft type I and type II. Factors supporting surgical repair include: 1) clinically apparent aspiration with feeding, 2) severity of pulmonary status, 3) findings on modified barium swallow and chest x-ray, 4) absence of significant comorbid conditions predisposing to aspiration, 5) findings on upper aerodigestive endoscopy, and 6) poor response to medical management and feeding therapy.

To assess the application and safety of transoral robotic surgery in the pediatric airway.Design: An institutional review board-approved study. Experimental laryngeal surgery was performed on 4 pediatric cadaver larynxes as controls. Application of robotic equipment for laryngeal surgery was attempted on 5 patients.Setting: Tertiary care pediatric medical center.Patients: Five patients with laryngeal cleft and 4 pediatric cadaver larynxes.Interventions: (1) The da Vinci Surgical Robot (Intuitive Surgical Inc, Sunnyvale, Calif ) was used on 4 cadaver larynxes and assessed for the dexterity, precision, and depth perception that it allowed the surgeon during laryngeal surgery. Procedures were documented with still and video photography. (2) The da Vinci Surgical Robot was used through a transoral approach to attempt repair of a laryngeal cleft in 5 pediatric patients who were under spontaneously breathing general anesthesia.Results: (1) Use of the surgical robot on cadaver larynxes provided great dexterity and precision, delicate tissue handling, good 3-dimensional depth perception, and relatively easy endolaryngeal suturing. (2) The surgical robot could not be used for repair of laryngeal cleft on 3 patients owing to limited transoral access. However, 1 patient with a type 1 laryngeal cleft and 1 patient with a type 2 laryngeal cleft underwent transoral robotic repair with great success.Conclusions: Surgical robots provide the ability to manipulate instruments at their distal end with great precision, increased freedom of movement, and excellent 3-dimensional depth perception. The size of the equipment can be a limiting factor with regard to the application and success of the transoral approach to airway surgery. We believe that further advances in device technology and a new generation of robotic equipment will facilitate the incorporation of surgical robotics in the advancement of minimally invasive endoscopic airway surgery.

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Pediatric case time variability, unlike adult cases, is poorly explained by surgeon effect or other characteristics that are commonly abstracted from electronic records. This largely relates to the 'long-tailed' distribution of pediatric cases and unpredictably long cases. Surgeon-specific scheduling is therefore unnecessary and similar cases may be pooled across surgeons. Future scheduling efforts in pediatrics should focus on prospective identification of patient and procedural specifics that are associated with and predictive of long cases. Until such predictors are identified, daily management of pediatric operating rooms will require compensatory overtime, capacity buffers, schedule flexibility, and cost.

The evolution of diabetes care for children has made the management of perioperative blood glucose levels a greater challenge for pediatric anesthesiologists. A standardized algorithm for the perioperative management of pediatric patients with type 1 or type 2 diabetes mellitus os presented.

BACKGROUND AND OBJECTIVES: General pediatricians and hospitalists are increasingly summoned to optimize the comorbid conditions of children with medical complexity (CMC) undergoing major surgery. We assessed the relationship between specific chronic conditions of CMC and hospital resource use with spinal fusion for scoliosis, an operation with high cost and morbidity.

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