Outcomes in robotic versus laparoscopic-assisted choledochal cyst excision and hepaticojejunostomy in children

Construction of nomogram based on clinical factors for the risk prediction of postoperative complications in children with choledochal cyst

Objective

The aim of the study was to develop a prediction nomogram based on clinical factors to assess the risk of postoperative complications in children with congenital choledochal cyst.

Methods

The clinical data from 131 children who underwent choledochal cyst resection and Roux-en-Y hepaticojejunostomy in our hospital between January 2016 and December 2022 were retrospectively analyzed. The general information, clinical symptoms, procedure, biochemical indicators, and imaging data were recorded. A prolonged hospital stay induced by postoperative complications or a follow-up over 6 months was assessed as the event outcome. A logistics regression analysis was performed to screen for risk factors with statistical significance in inducing postoperative complications. Then, with the dataset split into the training group and internal validation group, the nomogram for the prediction of postoperative complications was developed based on a computer algorithm. In addition, the receiver operating characteristic (ROC) curve and calibration curve were performed for nomogram verification.

Results

Of 131 children, the multivariate logistics regression analysis suggested that age ≤2 years [odds ratio (OR) 0.93; 95% confidence interval (CI) 0.15-5.65; p = 0.938], Todani classification type 1 (OR 36.58; 95% CI 4.14-871.74; p = 0.005), cyst wall thickness >0.4 cm (OR 10.82; 95% CI 2.88-49.13; p < 0.001), with chronic cholecystitis (OR 7.01; 95% CI 1.62-38.52; p = 0.014), and choledochal cyst diameter (OR 1.01; 95% CI 0.99-1.03; p = 0.370) were predictors associated with the postoperative complications of choledochal cysts. The data were randomly divided into the training group (n = 92) and internal validation group (n = 39) to build the prediction nomogram including the appeal factors. The accuracy and discrimination of the model were evaluated using a ROC curve and calibration curve. The results showed that the nomogram area under the ROC curve [area under the curve (AUC) = 0.894; 95% CI 0.822-0.966; p < 0.001], validation (AUC = 0.844; 95% CI 0.804-0.952; p < 0.001), and Brier = 0.120 (95% CI 0.077-0.163p; p < 0.001) were indicative of the good stability and calibration of the predictive nomogram.

Conclusion

The prognosis of congenital choledochal cysts was associated with multiple aspects of clinical factors. Combined with the internal validation, the novel prediction nomogram was suitable for evaluating the individualized risk of postoperative complications of choledochal cysts. The prediction nomogram could provide a more accurate strategy of procedure and postoperative follow-up for children with choledochal cysts.

Whole-Course Intraperitoneal Robot-Assisted Choledochal Cyst Excision with a Hidden Incision in Children Under 1 Year Old

Background: Whole-course intraperitoneal robot-assisted choledochal cyst resection in children under 1 year of age is controversial due to its technical challenges. Current Pfannenstiel incision is widely used in adults for its cosmetic effects but is rarely used in children. Materials and Methods: We conducted a prospective, single-center study to assess the feasibility, safety, and cosmesis of whole-course intraperitoneal robot-assisted choledochal cyst resection with Pfannenstiel incision in children under 1 year of age. Results: Ten patients were treated with our surgical protocol, and there was no conversion to laparotomy. The average total operation time was 223 minutes. The average duration of anesthesia was 260.2 minutes. The average docking time between the robot arm and Trocar was 17.5 minutes. The average intraoperative blood loss was 16 mL. No postoperative complications occurred in the 10 patients. The mean time to start drinking water after surgery was 2.4 days. The mean postoperative drainage tube removal time was 2.6 days. The average length of stay was 8.5 days. The scar assessment scale total scores of the 2 observers were (6.8 ± 1.23) and (7.4 ± 1.84), respectively. For every patient, there are only four abdominal surgery scars of which 75% of scars were hidden by underpants and 25% of scars were not covered. Conclusion: It is feasible and safe to perform whole-courses intraperitoneal robot-assisted choledochal cyst resection with Pfannenstiel incision in children under 1 year old. It also has a hidden incision effect and is worthy of promotion.

Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions

BACKGROUND

Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software.

METHODS

We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis.

RESULTS

For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model.

CONCLUSION

For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.

Robotic Surgery for Pediatric Choledochal Cysts: An American Case Series and Literature Review

INTRODUCTION

Choledochal cysts are rare congenital biliary cystic dilations. The US incidence rate varies between 5 and 15 cases per 1,000,000 people. In contrast, Asians, which are a large subset of the population of Hawaii, have an incidence of approximately one in every 1000 births. We report our experience with robot-assisted laparoscopic surgical management with biliary reconstruction of choledochal cysts which to date is the largest American case series to be reported.

MATERIALS AND METHODS

From 2006 to 2021, patients diagnosed with a choledochal cyst(s) at a tertiary children's hospital were retrospectively reviewed. Perioperative analysis was performed. Complications were defined as immediate, early, or late. The data underwent simple descriptive statistics.

RESULTS

Nineteen patients underwent choledochal cystectomy and hepaticoduodenostomy. Thirteen underwent a robotic approach while the rest were planned laparoscopic. Eighteen of 19 were female with 15/19 of Asian descent. The ages ranged from 5 mo to 21 y. Presenting diagnoses included jaundice, primary abdominal pain, pancreatitis, and cholangitis. Sixty eight percent had type 1 fusiform cysts while the rest were type 4a. Operative time and length of stay for robotic versus laparoscopic were 321 versus 267 min and 8.2 versus 17.3 d, respectively. For the robotic group, there was one immediate complication due to peritonitis. One-year follow-up revealed two patients requiring endoscopic retrograde cholangiopancreatography with dilation/stenting for an anastomotic stricture. There were no anastomotic leaks.

CONCLUSIONS

Robot-assisted laparoscopic choledochal cystectomy with hepaticoduodenostomy is associated with overall good outcomes with the most common long-term complication being anastomotic stenosis.

Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children

BACKGROUND

Robotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years.

METHODS

Between March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed.

RESULTS

A total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years -/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years -/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications.

CONCLUSIONS

Complications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late.

LEVELS OF EVIDENCE

2B.

Total versus conventional robotic-assisted cyst excisions and hepaticojejunostomies in children with choledochal cysts: a case-control study

The current study's primary aim is to compare the safety and effectiveness between total and conventional robot-assisted cyst excisions and hepaticojejunostomies in children with choledochal cysts (CCs). Patients suffering from CCs treated with either total or conventional robot-assisted procedures (TRAS or CRAS) between December 2019 and February 2021 were analyzed retrospectively. Data collected included the characteristics, operative and postoperative details. The risk factors for conversion of TRAS to CRAS were analyzed by logistic regression analysis. There were 50 patients who underwent TRAS and CRAS, respectively, and 19 patients were transferred to CRAS. The operation time in the TRAS group was significantly higher than that of the CRAS group, while the time to taking water and hospital stay were significantly shorter (p < 0.05). No significant difference was observed in complications between the groups (p = 0.325). The risk factors for conversion of TRAS to CRAS were age ≥ 48 months, thickness of abdominal wall (TAW) ≥ 1.3 cm and upper abdominal length (UAL) ≥ 9.5 cm. Both TRAS and CRAS are safe and feasible. Performing TRAS is recommended for patients whose age ≥ 48 months, TAW ≥ 1.3 cm and UAL ≥ 9.5 cm, while for others, it is recommended to perform CRAS.

Influencing factors of parental selections of minimally invasive procedure in children's abdominal surgery: a cross-sectional study in China

The purpose of our study was to explore the influencing factors of parental selections of minimally invasive procedure including laparoscopic or robotic methods in children's abdominal surgery. The questionnaire survey was conducted among the parents of patients who received abdominal laparoscopic or robotic surgery in our hospital from December 2020 to June 2022. The contents included basic information of the patients and parents, parental educational background, monthly income, insurance details and the parental considerations. Univariate and multivariate logistic regression were applied for the influencing factors analysis. Six categories of diseases involving choledochal cyst (198 cases), spleen related diseases (31 cases), hirschsprung disease (40 cases), inguinal hernia (330 cases), adrenal tumor (15 cases) and ureteropelvic junction obstruction (73 cases) were included in this study. After univariable and multivariable logistic regression analysis accomplished, we discovered that college degree or above (OR = 0.545, P < 0.001), monthly income > 5000 RMB (OR = 0.761, P < 0.001) and involving reconstruction during operation (OR = 0.842, P < 0.001) were the influencing factors for parental selections of robotic surgery. In children's abdominal surgery, parents with college degree or above, monthly income > 5000 RMB and considering the need for reconstruction during operation are more inclined to choose the robotic surgery.

Validation and effect of the NASA-TLX score on the assessment of the workload of pediatric robotic operations

OBJECTIVE

The objective of the study was to assess the validity of the NASA-TLX score in rating the workload of pediatric robotic operations.

METHODS

The workload of 230 pediatric gastrointestinal and thoracic robotic operations was rated using the NASA-TLX score. The difference between the high workload group and the low workload group in each subscale of the NASA-TLX score was analyzed. The correlation of each subscale with the total workload score in the high workload group and low workload group was also analyzed. A logistic regression analysis was subsequently conducted to assess the effects of different factors (sex, age, weight, procedure duration, procedure specialties, combined malformation and blood loss) on the workload.

RESULTS

The average NASA-TLX score was 56.5 ± 5.1 for the total group, 56.9 ± 5.0 for the gastrointestinal group and 54.6 ± 4.8 for the thoracic group, p = 0.007. The score of the high workload group was 62.7 ± 3.2, while it was 50.6 ± 2.7 for the low workload group (p < 0.001). The score on each subscale was also significantly different between the high and low workload groups. In the high workload group, a stronger correlation was observed between the total score and TD and Fr and a lower correlation with MD and Pe. In the low workload group, all six subscales showed a moderate correlation with the total score. A multivariate logistic regression analysis revealed that the procedure duration was an independent influencing factor for a higher workload score.

CONCLUSIONS

NASA-TLX is a valid tool to rate the surgeon's workload in pediatric robotic surgery. A longer operative time contributes to a higher workload.

Choledochal Cyst Excision in Infants-A Retrospective Study

A choledochal cyst is a rare malformation primarily diagnosed in children. The only effective therapy remains surgical cyst resection followed by Roux-en-Y hepaticojejunostomy. Treating asymptomatic neonates remains a point of discussion. Between 1984 and 2021, we performed choledochal cyst (CC) excision in 256 children at our center. Out of this group, we retrospectively reviewed the medical records of 59 patients who were operated on under one year of age. Follow-up ranged from 0.3 to 18 years (median 3.9 years). The preoperative course was asymptomatic in 22 (38%), while 37 patients (62%) had symptoms before surgery. The late postoperative course was uneventful in 45 patients (76%). In symptomatic patients, 16% had late complications, while in asymptomatic patients, only 4%. Late complications were observed in the laparotomy group in seven patients (17%). We did not observe late complications in the laparoscopy group. Early surgical intervention is not followed by a high risk of complications and may prevent the onset of preoperative complications, giving excellent early and long-term results, especially after minimally invasive laparoscopic surgery.

Comparison of efficacy and safety of robotic surgery and laparoscopic surgery for choledochal cyst in children: a systematic review and proportional meta-analysis

BACKGROUND

Most commonly, cyst excision and Roux-en-Y hepaticojejunostomy reconstruction are the optimal treatment for choledochal cysts (CC). Robotic surgery (RS) is being conducted with increasing frequency to treat CC. It is unclear whether RS can overcome the limitations of laparoscopic surgery (LS) and improve the prognosis of patients. In terms of efficacy, evidence concerning which minimally invasive surgery is preferred is, however, sparse. Our objective is to further compare the efficacy of RS and LS in children with CC and draw a useful clinical conclusion.

METHODS

Studies meeting inclusion criteria were identified from a series of databases, consisting of PubMed, Embase, Scopus, Web of Science, the Cochrane Library and their reference list of articles up to May 2022. Eligible articles comprised at least five objects that were younger than 18 years of age and the language was limited to English. Two authors independently evaluated selected studies and extracted data for analysis.

RESULTS

Forty studies were selected for analysis, with thirty-six reporting data on LS and eight containing data on RS. The pooled conversion rate and pooled postoperative complication rate of RS were lower than those of LS, but none of them was statistically significant. Moreover, comparisons of the following detailed postoperative complication rates were not statistically significant, such as intestinal obstruction or ileus, anastomotic bleeding, anastomotic or bile leakage, and anastomotic stenosis. However, the intraoperative blood loss and the postoperative hospital stay in RS group were significantly lower than those in LS group.

CONCLUSIONS

RS is a safe and feasible option for children with CC. Further studies with more cases, long-term efficacy and health economics analysis are needed to confirm whether RS is more advantageous.

Robotic-assisted choledochal cyst excision with Roux-en-Y hepaticojejunostomy in children: does age matter?

BACKGROUND

Robotic-assisted surgery (RAS) is being increasingly used in pediatric choledochal cysts (CCs), but is most commonly performed in older children and adolescents. The outcomes in young infants remain to be explored. The purpose of this study is to compare outcomes in infants aged ≤ 1 year with an older cohort.

METHODS

From July 2015 to January 2020, a retrospective study was conducted to evaluate the RAS in patients with CCs at our institution. Patients were divided into two groups (group A ≤ 1 year old and group B > 1 year old). Demographics, intraoperative details, complications, and outcomes were analyzed.

RESULTS

A total of 79 patients were included in the study (28 patients in group A and 51patients in group B). The median age of patients at the surgery in group A was 4.9 months (IQR: 3.1-9.1), compared with 46.8 months (IQR: 28.5-86.5) in group B. Three patients in group A were neonates. No conversion to open surgery was required. No significant differences were found between the two groups including sex, Todani type, or diameter of the cysts. The diameter of the common hepatic duct was smaller in group A (6.0 ± 1.7 vs. 9.0 ± 3.0 mm; p < 0.001). Group A had the longer hepaticojejunostomy time [51(44-58) vs. 42(38-53) min; p = 0.013], while Group B had the longer cyst excision time [43(41-59) vs. 50(43-60) min; p = 0.005]. However, their total operative time and console time were similar. There were no statistical differences in length of hospital stay and complications between the two groups.

CONCLUSIONS

Robot-assisted cyst resection and hepaticojejunostomy are feasible and safe in infants ≤ 1 year old. Age cannot be considered an absolute contraindication for robotic surgery in patients with CCs.

Efficacy of robot-assisted hepaticojejunostomy and laparoscopic-assisted hepaticojejunostomy in pediatric congenital choledochal dilatation: a system review and meta-analysis

PURPOSE

The efficacy of robot-assisted hepaticojejunostomy (RAHJ) and laparoscopic-assisted hepaticojejunostomy (LAHJ) in children with congenital choledochal dilatation has been a topic of much debate and controversy. The purpose of this study was to evaluate the role of RAHJ and LAHJ in pediatric congenital choledochal dilatation.

METHOD

The review program has been prospectively registered (PROSPEROID: CRD42022306868). We searched the PubMed, Embase, Cochrane, CBM, VIP, Web of Science, CNKI databases, and Wanfang databases from March 2021. The Mantel-Haenszel method and a random-effects model were used to figure out the hazard ratio (95% CI).

RESULTS

Ten studies evaluated eight hundred and sixty-nine subjects (three hundred and thirty-two in the robotic group and five hundred and thirty-seven in the laparoscopic group), meeting all inclusion criteria. Compared with the laparoscopic group, robotic group demonstrated fewer postoperative complications [p = 0.0009; OR = 0.34 (95% CI, 0.18-0.64); I² = 3%], shorter postoperative hospital stay [p < 00,001; MD = - 2.05 (95% CI, - 2.40-1.70); I² = 0%], and less intraoperative bleeding [p = 0.008; MD = - 10.80 (95% CI, - 18.80-2.81); I² = 99%]. There was no significant difference in operative time between the two groups [p = 0.10; MD = 24.53 (95% CI, - 5.11-54.17); I² = 99%]. The same situation happened in short-term complication outcomes [p = 0.06; RR = 0.45 (95% CI, 0.19-1.04); I² = 0%]. However, children in the RAHJ group had significantly lower levels of long-term complications [p = 0.04; OR = 0.41 (95% CI, 0.17-0.96); I² = 0%]. Hospitalization costs were significantly higher in the RAHJ group [p < 0.00001; OR = 27,113.86 (95% CI, 26,307.24-27,920.48); I² = 0%]. For overall complications, subgroup analysis of literature published after 2020 and of literature with high quality scores showed a significant decrease in the RAHJ group.

CONCLUSION

In children with congenital choledochal dilatation, RAHJ is associated with reduced intraoperative bleeding, postoperative complications, and length of stay. Robotic surgery has a bright future in the treatment of pediatric common hepatic duct cysts and deserves to be promoted and popularized.

Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis

PURPOSE

Postoperative anastomotic stricture (PAS) is a well-known complication after correcting choledochal cyst (CC). Although the exact cause of PAS is unknown, various risk factors, such as Todani classification type IV-A, hepaticoduodenostomy, and narrow anastomosis have been reported to be associated with PAS. As far as we know, there is no report with a cumulative analysis of such risk factors of PAS. This systematic review and meta-analysis aimed to investigate the risk factors of PAS following surgical correction of CC in children.

METHODS

A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "Congenital biliary dilatation", "Congenital choledochal cyst", "Choledochal cyst", "Stenosis", "Stricture", and "Complication" for studies published between 1973 and 2022. The relevant cohorts of PAS were systematically searched for clinical presentation and outcomes.

RESULTS

The search strategy identified 795 reports. Seventy studies met the defined inclusion criteria, reporting a total of 206 patients with PAS. There is no prospective study in this search. The incidence of PAS was 2.1%. The proportion of Todani classification of the patient with PAS was higher in type IV-A with significant difference (2.0% in type I and 10.1% in type IV-A (p = 0.001)). Fourteen studies reported a comparison between hepaticojejunostomy and hepaticoduodenostomy. There was no significant difference between the two groups (p = 0.36). Four studies reported the diameter of the anastomosis at the primary surgery. The mean diameter was 12.5 mm. Nine studies reported a comparison between laparoscopic surgery and open surgery. Pooled odds ratio of PAS did not show a statistical difference (p = 0.29).

CONCLUSIONS

This study suggests that close careful follow-up is important in the patients with type IV-A of CC who underwent excision surgery, considering the possibility of PAS.

Surgical outcomes of robotic-assisted cyst excisions and hepaticojejunostomies in patients with perforated choledochal cysts: a single-center retrospective study

Perforated choledochal cysts is usually treated by open approach through a one- or two-stage procedure. Laparoscopic procedures are gradually being used more commonly with advancements in minimally invasive technology, while the level of difficulty and conversion rate are still high due to adhesions and deranged anatomy. Robot-assisted choledochal cyst excisions have been proposed as another minimally invasive procedure that is thought to improve operability and precision compared with laparoscopic surgery. However, there is still a lack about the use of robotic assistance for bilio-enteric reconstruction in pediatric patients with perforated choledochal cyst excisions. The aim of this current study was to investigate the safety and effectiveness of robotic-assisted procedures in pediatric perforated choledochal cyst excisions. Patients suffering from perforated choledochal cysts and treated with surgical procedures including open, laparoscopic, and robotic procedures between January 2009 and December 2021 were retrospectively analyzed. Robotic cyst excisions and hepaticojejunostomies were mainly used to a one-stage procedure (the pseudocyst formation or intra-mural perforation) or in stage 2 of two-stage procedures (complete perforation). Data collection included patient characteristics, intraoperative outcomes, and postoperative complications. There were a total of 64 patients suffering from perforated choledochal cysts were treated at our institution. Thirty-one cases of cyst excisions and hepaticojejunostomies were completed by open procedures. Twenty-two cases of cyst excisions and hepaticojejunostomies were completed by laparoscopic procedures and 11 cases were completed by robotic procedures. The operating times were significantly longer in the laparoscopic procedures group (214.32 ± 51.33 min) than found with either the open procedures group (130.55 ± 10.51 min) or the robot-assisted procedures group (188.82 ± 16.55 min) (p < 0.001). The time to oral intake, total complication, and hospital stay were similar among all three groups (3.53 ± 0.28 days vs 3.47 ± 0.30 days vs 3.46 ± 0.29 days, 19.35% vs 27.27% vs 18.18%, 11.48 ± 1.29 days vs 11.95 ± 2.75 days vs 11.55 ± 2.38 days, respectively) (p > 0.05). The number of biliary complications was higher in the laparoscopic procedures group (18.18%) than in both the open procedures and robot-assisted procedures groups (0.00%) (p = 0.016). Robotic-assisted cyst excision and hepaticojejunostomy procedures in patients with perforated choledochal cysts are both safe and feasible. What is more, they can achieve the same results as open procedures and also reduce the level of difficulty of operations and bring fewer biliary complications compared with laparoscopic procedures.

Outcomes and comparations of pediatric surgery about choledochal cyst with robot-assisted procedures, laparoscopic procedures, and open procedures: A meta-analysis

Background

Choledochal cysts (CC) are rare disorders characterized by congenital biliary dilatation of the intrahepatic or extrahepatic bile ducts and always relate to pancreaticobiliary maljunction. Robot-assisted surgery has been able to complete almost all pediatric endoscopic surgery nowadays. But evidence of the post-operative outcomes of robotic-assisted operation is limited, comparing with the laparoscopic operation and traditional open operation. The aim of this meta-analysis was to identify the advantages and deficiencies about robotic-assisted operation for CC.

Methods

A meta-analysis of retrospective studies published in PUBMED, MEDLINE, Web of Science and China National Knowledge Infrastructure (CNKI). No date limit was used, with the last search on April 30, 2022. No publication restrictions or study design filters were applied.

Results

Nine retrospective cohort studies with 1,395 patients [366 in the robotic-assisted operation group (RG), 532 in the laparoscopic operation group (LG) and 497 in the open operation group (OG)] were enrolled in our study. Subgroup analysis demonstrated the RG had significant longer operative time [standardized mean difference (SMD) = 1.59, 95% CI = (0.02, 3.16), P < 0.05], less blood loss [SMD = -1.52, 95% CI = (-2.71, -0.32), P < 0.05], shorter enteral feeding time [SMD = -0.83, 95% CI = (-1.22, -0.44), P < 0.001], shorter time to stay in the hospital [SMD = -0.81, 95% CI = (-1.23, -0.38), P < 0.001], fewer post-operative complications [Relative risk (RR) =1.09, 95% CI = (1.04, 1.13), P < 0.001] but higher expenses [SMD = 8.58, 95% CI = (5.27, 11.89), P < 0.001] than LG. While a significant older age [SMD = 0.46, 95% CI = (0.26, 0.66), P < 0.001], longer operative time [SMD = 3.96, 95% CI = (2.38, 5.55), P < 0.001] and shorter time to stay in the hospital [SMD = -0.93, 95% CI = (-1.62, -0.25), P < 0.05] than OG.

Conclusions

Laparoscopic and robotic-assisted procedure are both safe and minimal invasive operational strategies. Robotic-assisted procedure may slowly surpass and has a trend to replace laparoscopy for its advantages. More experiences in robotic-assisted operation should be accumulated for the unexpected complexities, so as to be more stable in the younger age of children.

Clinical efficacy and safety of robot assisted surgery for choledochal cysts excisions: a systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the safety and therapeutic effect of Robot-assisted surgery (RAS) for choledochal cysts (CCs) excisions.

RESEARCH DESIGN AND METHODS

PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and CBM were searched from database inception to 1 May 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.

RESULTS

In all, 9 studies, involving 623 patients, were analyzed. RAS compared with LAS was associated with less intraoperative blood loss, shorter time to start solid diets, shorter postoperative hospital stay, and lower complications. There was no significant difference in operative time between the two groups, but the total costs were higher in RAS. Our subgroup analysis showed that RAS had significant advantages over LAS in the child group: minor bleeding, shorter length of hospital stay, and fewer postoperative complications.

CONCLUSIONS

The available evidence indicates that the RAS system has the advantages of less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating choledochal cyst, which proves that the RAS is safely feasible. Especially in children, RAS tends to be a better choice.

Robot-assisted liver resection: the real benefit so far

BACKGROUND

Minimally invasive liver resection is associated with lower perioperative morbidity and shorter hospital stay. However, the added benefit of the robotic platform over conventional laparoscopy is a matter of ongoing investigation.

PURPOSE

The purpose of this narrative review is to provide an up-to-date and balanced evaluation of the benefits and shortcomings of robotic liver surgery for the modern hepatobiliary surgeon.

CONCLUSIONS

Advantages of a robotic approach to liver resection include a shortened learning curve, the ability to complete more extensive or complex minimally invasive operations, and integrated fluorescence guidance. However, the robotic platform remains limited by a paucity of parenchymal transection devices, complete lack of haptic feedback, and added operating time associated with docking and instrument exchange. Like laparoscopic hepatectomy, robotic hepatectomy may provide patients with more rapid recovery and a shorter hospital stay, which can help offset the substantial costs of robot acquisition and maintenance. The oncologic outcomes of robotic hepatectomy appear to be equivalent to laparoscopic and open hepatectomy for appropriately selected patients.

Comparison of outcomes and safety of laparoscopic and robotic-assisted cyst excision and hepaticojejunostomy for choledochal cysts: A systematic review and meta-analysis

Objectives

Minimally invasive cyst excision and Roux-en-Y hepaticojejunostomies include laparoscopic and robotic-assisted operations. The current systematic review and meta-analysis compared the efficacy between the 2 groups.

Methods

A systematic search of PubMed, Web of Science, Embase, Wiley, Cochrane Library and Clinical Trials was performed from May 1995 to December 2021. The primary outcome was postoperative complications, and the secondary outcomes were operative details and postoperative outcomes.

Results

The meta-analysis enrolled 6 reports including 484 patients (307 in the laparoscopic group and 177 in the robotic-assisted group). The laparoscopic group was associated with lower expenses (MD = −3851.60$, 95% CI = −4031.84 to −3671.36$, P < 0.00001). No significant difference was found in short-term complications (RR = 1.55, 95% CI = 0.74 to 3.23, P = 0.24), long-term complications (RR = 1.40, 95% CI = 0.63 to 3.10, P = 0.41), total complications (RR = 1.53, 95% CI = 0.59 to 3.94, P = 0.38), operative time (MD = −28.75 min, 95% CI = −77.13 to 19.64 min, P = 0.24), blood loss (MD = 2.28 ml, 95% CI = −13.51 to 18.06 ml, P = 0.78) or hospital stays (MD = 0.89 days, 95% CI = −0.13 to 1.91 days, P = 0.09). In subgroup analysis, the laparoscopic operation had shorter operative time (MD = −4.45 min, P = 0.009), and less blood loss (MD = −63.18 ml, P = 0.01) in adult patients.

Conclusions

Laparoscopic and robotic-assisted cyst excision and Roux-en-Y hepaticojejunostomy have comparable postoperative outcomes.

•

Comparison the efficacy of laparoscopic versus robotic-assisted operation.

•

Reviewing the robotic-assisted operation for choledochal cysts.

•

The advantages and disadvantages of two methods.

Laparoscopic surgery versus robot-assisted surgery for choledochal cyst excision: A systematic review and meta-analysis

The aim of this following study is to systematically review and analyze the published data comparing laparoscopic surgery and robotic assisted surgery for choledochal cyst excisions through the metrics of operative time, length of hospital stay and postoperative outcome. PubMed, Web of Science, Embase, Ovid, and the Cochrane Library databases were combed through and data was retrieved from the timespan between January 1995 and October 2021. The primary measures included operative time, intraoperative bleeding, hospital stay, and postoperative complications. Quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scale. Making use of random-effects models, we pooled the odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (95% CIs). Six studies comprising a total 484 patients who had undergone either laparoscopic surgery [307 (63.43%) patients] or robot-assisted surgery [177 (36.57%) patients] were included in this analysis. Three of the articles involved adults while the other three involved children. All of the studies were published after 2018 and were retrospective case-control studies. Patients undergoing robotic surgery had a shorter hospital stay (MD, 0.95; 95% CI, 0.56 to 1.35; p < 0.00001) and a longer operative time (MD, -57.52; 95% CI, -67.17 to -47.87; p < 0.00001). And there was no significant discrepancy in complications between the two groups. Compared to laparoscopic surgery, robot-assisted surgery is associated with a shorter hospital stay, scores highly in terms of both safety and feasibility, however it also results in a longer operative time. And the two procedures have the same short- and long-term results.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.