Minimally Invasive Hepatobiliary Surgery

Minimally invasive hepatopancreatic and biliary surgery in children: a large centre experience and review of the literature

BACKGROUND

Minimally invasive surgery (MIS) for hepatopancreatic and biliary (HPB) diseases has been widely used in adults, while in children, its application is limited due to its complexity. Herein, we report the experience of MIS for paediatric HPB diseases and literature review.

METHODS

All children (≤18 years-old) undergoing major HPB operations by MIS during January 2017-June 2020 in our institution were prospectively enrolled.

RESULTS

Out of 139 children operated on for HPB diseases with MIS, 26 (18.7%) patients (age: 11 (1-17) years-old; weight: 41.9 (10.7-75.5) kg) underwent major HPB surgery, including 11 pancreatic resections and 15 liver resections, all performed by a full-laparoscopic-technique. Four (15.3%) surgeries were electively converted to an open-technique for safer operative management. None required a blood transfusion. The median hospital admission was 6 days. Post-operatively, all patients had early mobilization and good recovery. Two (7.7%) patients experienced post-operative complications requiring radiological intervention. Oncological radical resection (R0) was achieved in all tumours, and after 2 years, all children were free of tumour recurrence.

CONCLUSION

MIS for HPB surgery is safe and feasible in children, with less surgical trauma, short hospital-stay and better aesthetic results. An adequate learning curve in specialized centres is essential for good outcomes.

Da vinci robotic-assisted treatment of pediatric choledochal cyst

OBJECTIVE

To evaluate the advantages and disadvantages of da Vinci robot and laparoscopy in treating pediatric choledochal cysts.

METHODS

We retrospectively analyzed clinical data from forty-two children diagnosed with choledochal cysts in our hospital from January 2018 to January 2021. Twenty children underwent da Vinci robotic surgery, and the others underwent traditional laparoscopy. We compared differences in general information and preoperative, intraoperative, and postoperative differences between the two surgical groups.

RESULTS

There was no statistically significant difference in age, gender, weight, type, maximum cyst diameter, preoperative C-reactive protein (CRP) value, postoperative complication rate, and postoperative pain score between the two surgical groups (P > 0.05). The average age of the robot-assisted group was 3.62 ± 0.71 years old (range = 1-12 years). There were nineteen cases of Todani type I, one patients of other types, and the maximum cyst diameter was 35.45 ± 9.32 mm (range = 12-56 mm). In the laparoscopic group, the average age was 3.08 ± 0.82 years old (range = 3-10 years). Twenty-one patients had Todani type I, and one had other types. The maximum cyst diameter was 31.94 ± 8.64 mm (range = 10-82 mm). The robot-assisted group had better abdominal drainage, postoperative CRP value, fasting time, and discharge time than the laparoscopic group (P < 0.05).

CONCLUSION

Compared with laparoscopy, the da Vinci system has the advantages of less tissue damage, faster recovery, and better healing in the treatment of children with congenital choledochal cysts. With technological advancements and an increased number of experienced surgeons, robotic surgery may become a new trend in surgery.

A Report of 21 Cases of Laparoscopic Liver Resection in Children

Objective: To summarize and analyze the technique and experience of laparoscopic liver resection (LLR) in children. Methods: From Dec 2015 to Dec 2018, surgical outcomes were evaluated in 30 pediatric patients with liver tumors. LLR was performed in 21 patients, including 15 males and 6 females with a mean age of 7.6 ± 3.8 years (range, 2-13 years) and a mean liver tumor diameter of 7.2 ± 2.0 cm (range, 4-10 cm). During the same period, 9 cases of traditional open liver resection were selected as controls, including 6 males and 3 females with a mean age of 7.0 ± 3.7 years (range, 2-13 years) and a mean liver tumor diameter of 7.5 ± 2.2 cm (range, 4.4-10.0 cm). Results: The mean operation time and mean hepatic inflow occlusion time were longer in the laparoscopic group, with values of 182.3 ± 66.1 minutes and 83.2 ± 38.2 minutes, respectively, than in the open group, with values of 120.0 ± 54.3 minutes and 49.6 ± 26.5 minutes, respectively. There were no significant differences between the two groups in blood loss (164.4 ± 107.4 mL versus 133.8 ± 87.1 mL), blood transfusion volume (102.2 ± 100.2 mL versus 69.2 ± 81.8 mL), and alanine aminotransferase levels 24 hours after surgery (212.0 ± 101.4 IU/L versus 173.3 ± 97.2 IU/L) and 72 hours after surgery (74.0 ± 32.5 IU/L versus 81.7 ± 57.3 IU/L). The average hospital stay in the laparoscopic group (6.2 ± 1.6 days) was significantly shorter than that in the open group (8.2 ± 2.0 days). The children in both groups recovered well after surgery without serious complications. Conclusion: LLR contributes to improved recovery of patients after surgery without increasing the incidence of complication, therefore, LLR is a safe option for liver tumors in children.

Choledochal cysts: Similarities and differences between Asian and Western countries

Choledochal cysts (CCs) are rare bile duct dilatations, intra-and/or extrahepatic, and have higher prevalence in the Asian population compared to Western populations. Most of the current literature on CC disease originates from Asia where these entities are most prevalent. They are thought to arise from an anomalous pancreaticobiliary junction, which are congenital anomalies between pancreatic and bile ducts. Some similarities in presentation between Eastern and Western patients exist such as female predominance, however, contemporary studies suggest that Asian patients may be more symptomatic on presentation. Even though CC disease presents with an increased malignant risk reported to be more than 10% after the second decade of life in Asian patients, this risk may be overstated in Western populations. Despite this difference in cancer risk, management guidelines for all patients with CC are based predominantly on observations reported from Asia where it is recommended that all CCs should be excised out of concern for the presence or development of biliary tract cancer.

[Advantages of Kasai procedure through minimally invasive approach in children with biliary atresia (in Russian only)]

AIM

To compare early and long-term results of different surgical interventions in children with biliary atresia.

MATERIAL AND METHODS

Retrospective analysis included medical records of children with biliary atresia who were treated at the Filatov Munitsipal Children's Hospital and National Medical Research Center for Obstetrics, Gynecology and Perinatology from 2000 to 2018. There were 91 patients. All patients were divided into three groups. Group 1 - conventional Kasai procedure (n=24), group 2 - laparoscopic Kasai surgery (n=45), group 3 - Kasai procedure through minimally invasive approach (n=22). Groups were comparable.

RESULTS

Duration of Kasai procedure through minimally invasive approach was 69±12,97 min that was significantly less than in groups 1 and 2 (p_1,3=0,006085; p_2,3=0,000024). ICU-stay was minimal in group 3 (1.27±0.55 days, p_1,3<0,05; p_2,3<0,05). Abdominal drainage time was maximal in group 2 (11.28±6.37 days) and minimal in group 3 (5.86±2.39 days, p_2,3=0.0002). Early and 2-year postoperative surgical efficiency was similar in all groups. There were no surgical complications in group 3. In group 2 one child had gastrointestinal bleeding followed by successful medication. There were 3 surgical complications in group 3: adhesive intestinal obstruction, small and large intestine perforation and 2 cases of gastrointestinal bleeding. There was one lethal outcome in the first group. Overall annual survival in children with native liver was 81.8%, 2-year - 51.7%.

CONCLUSION

Kasai procedure through minimally invasive approach is justified and rational method with certain benefits of open and laparoscopic interventions and can be considered as a method of choice in treatment of children with biliary atresia.