Robot-assisted laparoscopic resection of a type I choledochal cyst in a child

Comparative study of robotic-assisted single-incision-plus-one port and single-incision laparoscopic choledochal cyst excision

Objective

To compare the efficacy of robotic-assisted single-incision-plus-one-port laparoscopic choledochal cyst excision (R-SILC + 1) and single-incision laparoscopic choledochal cyst (SILC) in treating pediatric choledochal cyst (CDC).

Methods

We retrospectively analyzed the clinical data of patients diagnosed with CDC in our hospital from June 2021 to October 2023. Among them, patients underwent either R-SILC + 1 or SILC procedures. Demographic parameters, operative details, and postoperative outcomes were studied.

Results

A total of forty-nine patients were included, with 23 children undergoing R-SILC + 1 and 26 children undergoing SILC. There were no statistically significant differences in demographic data, postoperative pain scores, and postoperative complication rates between the two groups (all p > 0.05). Compared with the SILC group, the R-SILC + 1 group demonstrated less intraoperative bleeding volume (10.4 ± 3.6 vs. 15.0 ± 3.6 ml, p < 0.05), a shorter indwelling time of the abdominal drainage tube [5(5,6) vs. 7(5.8,8.3) d, p < 0.05], a shorter postoperative fasting time [4(3,4) vs. 6(5,7) d, p < 0.05], and a shorter postoperative discharge time [6(6,7) vs. 8(6,11) d, p < 0.05]. However, the R-SILC + 1 group had a longer operation time [388(295,415) vs. 341(255.8,375.2) min, p < 0.05] and higher hospitalization cost (7.9 ± 0.4 vs. 3.2 ± 0.3 ten thousand, p < 0.05).

Conclusion

Compared with the SILC group, the R-SILC + 1 group demonstrated clear advantages in treating pediatric CDC, but it is associated with a prolonged learning curve and operation time, and high costs. With improvements in physician experience and technological advancements, its potential will be further unleashed.

The SHURUI single-port robotic system for choledochal cyst excision and biliary reconstruction in children: A case report (with video)

INTRODUCTION

Total cyst excision and Roux-en-Y hepaticojejunostomy is the standard procedure for treating congenital choledochal cysts, which requires high surgical skills. Our aim is to introduce the experience with the SHURUI single-port robotic system in pediatric surgery.

PRESENTATION OF CASE

In this study, we present a case demonstrating the application of the SHURUI single-port robotic system in performing choledochal cyst excision and Roux-en-Y hepaticojejunostomy in a pediatric patients. Roux-en-Y anastomosis was constructed extracorporeally, then choledochal cyst excision and hepaticojejunostomy was performed intracorporally using the SHURUI Surgical System. Surgical complications and the wound outcomes were assessed. The total duration of the operation was 292 min, comprising an extracorporeal time of 45 min, docking time of 19 min, and intracorporal time of 183 min. The estimated blood loss was minimal at only 2 mL. The patient was discharged 6 days post-operation, and exhibited satisfactory recovery at the one-month follow-up.

DISCUSSION

This case represents an initial experience with the SHURUI Surgical System in managing a pediatric choledochal cyst. The results indicate that the system is feasible and safe for this procedure, and may have some advantages over laparoscopic and open approaches.

CONCLUSION

The SHURUI Surgical System is both feasible and safe in pediatric surgery, and it may offer certain advantages over laparoscopic and open approaches.

Robot-assisted resection of choledochal cyst in neonates

OBJECTIVE

Laparoscopic choledochectomy and hepatojejunostomy have been reported in children since 1995, but this procedure is technically demanding. Robotic surgical systems can simplify complex minimally invasive procedures. Currently, few reports have been made on neonates. We present the experience of 6 cases of neonatal CC(choledochal cysts).

STUDY DESIGN

Between January 2022 and December 2023, 6 neonates underwent robotic resection of choledochal cyst and hepaticojejunostomy using the Da Vinci surgical system at Children's Hospital, Zhejiang University School of Medicine, a high-volume hepatobiliary disease center. demographic data of the patients and surgical outcomes were collected and analyzed.

RESULTS

All 6 patients were successfully treated by robotic cystectomy and hepaticojejunostomy. The mean age was 17.3 days (range 4-25) and the mean weight was 3.6 kg (range 2.55-4.4). 5 cysts were type Ia and 1 was type Iva. The mean diameter of the cysts was 3.8 cm (range 1.25-5). The mean time to establish feeding was 4.83 days (range 4-6), and patients were discharged after a median time of 16.83 days (range 7-42) without postoperative complications.

CONCLUSIONS

This procedure is safe and effective for neonates. The authors found that the use of robot-assisted surgery has ergonomic advantages in this delicate, minimally invasive procedure.

A trans-umbilical single-site plus one robotic-assisted surgery for choledochal cyst resection in children

Objective

The purpose of this study is to compare the intraoperative and postoperative outcomes of a trans-umbilical single-site plus one robot-assisted surgery and a trans-umbilical single-site laparoscopic surgery in the treatment of choledochal cysts.

Methods

We retrospectively analyzed clinical data from 49 children diagnosed with choledochal cysts who were admitted to our hospital between June 2020 and December 2023. Among these patients, 24 underwent a trans-umbilical single-site plus one Da Vinci robot-assisted surgery (the robot group) and 25 underwent a trans-umbilical single-site laparoscopic-assisted surgery (the laparoscopic group). We compared differences in intraoperative and postoperative outcomes between the two groups.

Results

There was no significant difference between the two groups of patients in terms of gender, age, weight, clinical symptoms, maximum cyst diameter, type, postoperative complications, and facial expression, leg movement, activity, crying, and comfortability (FLACC) scoring (p > 0.05). Compared with the patients in the laparoscopic group, those in the robot group had less intraoperative bleeding [10 (8-12) vs. 15 (11.5-18) ml, p < 0.001] and required less postoperative drainage tube indwelling time [5 (4-6) vs. 7 (5.5-8) day, p < 0.001], less postoperative fasting time [4 (3-4) vs. 6 (5-7) days, p < 0.001], and less postoperative hospitalization time [6 (6-7) vs. 8 (6-10) days, p < 0.001], but they required more operative time [385.5 (317.0-413.3) vs. 346.0 (287.0-376.5) min, p = 0.050] and consumed more hospitalization expenses (79,323 ± 3,124 vs. 31,121 ± 2,918 yuan, p < 0.001).

Conclusion

The results of this study showed a shorter hospitalization time, quicker postoperative recovery, and less tissue damage but a higher cost and a longer operation time in patients who chose robotic surgery rather than laparoscopic surgery. With the continuous expansion of the scale of installed robot-assisted surgical systems and the gradual accumulation of the technical experience of surgeons, robot-assisted surgery may slowly surpass, and shows a trend to replace, laparoscopy because of its advantages.

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.

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program

BACKGROUND

Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level.

METHODS

We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression.

RESULTS

Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25 years, p = 0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p = 0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p = 0.02).

CONCLUSIONS

In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Comparison of Surgical Outcomes of Laparoscopic and Robotic Surgery in Adult Choledochal Cysts

Background: Minimally invasive surgery (MIS) for cyst excision and Roux-en-Y hepaticojejunostomy (HJ) is widely performed for adult choledochal cysts. Few articles compared the robotic and laparoscopic approaches for choledochal cysts. Methods: Between 2014 and 2022, 157 patients who underwent MIS for choledochal cysts were retrospectively analyzed. Perioperative outcomes of patients who underwent totally robotic surgery, robot-assisted surgery, and laparoscopic surgery were compared, respectively. Also, postoperative outcomes of patients with robotic reconstruction and laparoscopic reconstruction during HJ were compared. Results: Perioperative outcomes were comparable between robotic and laparoscopic groups. The suturing technique for the anterior and posterior walls of the HJ differed significantly between the robotic and laparoscopic reconstruction groups (P = .001). However, there were no significant differences in postoperative outcomes, including total complications (P = .304), major complications (P = .411), and postoperative interventions (P = .411), between the two groups. Conclusions: The robotic and laparoscopic approaches for adult choledochal cysts have comparable surgical outcomes. In the MIS era, robotic surgery could be an alternative surgical option for adult choledochal cysts.

Comparison of robotic assistance and laparoscopy for pediatric choledochal cyst: advantages of robotic assistance

AIM

Surgery for pediatric choledochal cyst (CC), complete excision (CE), and Roux-en-Y hepaticojejunostomy anastomosis (HJA) can be performed using laparoscopy (Lap), robotic-assistance (Rob; da Vinci Xi/Si), or both (Lap/Rob).

METHODS

Lap was used exclusively between 2009 and 2021 (n = 31) and Rob was introduced in 2017 (n = 23). All subjects were matched for age, weight, BMI, and episodes of preoperative pancreatitis. For Rob, the first 15/23 were Lap-CE/Rob-HJA and the last 8/23 were Rob-CE/Rob-HJA.

RESULTS

Total anastomotic time (TAT), TAT per suture during HJA, and time taken for dissection during CE were significantly shorter with less variance for Rob, although overall operative times were similar. Serum amylase on postoperative days 3, 5, and 7 were significantly higher for Lap. Times taken to ambulate, for return of bowel sounds, and discharge home were all significantly shorter for Rob. All postoperative complications occurred after Lap; HJA leak (n = 1; 3.2%), HJA stricture (n = 1; 3.2%), both treated by open re-HJA; and pancreatic fistula (n = 6; 19%), all treated conservatively.

CONCLUSION

Dissection and recovery were faster with Rob while overcoming Lap-associated shortcomings to prevent complications associated with suturing. Both CE and HJA were safer and more reliable with Rob, a reflection of Rob's superiority.

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.

Establishment of a successful robotic pediatric general surgery practice

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3 years and 76.4 kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30 days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

The safe introduction of robotic surgery in a free-standing children's hospital

The aim of this study is to report the experience of implementing a pediatric robotic surgery program at a free-standing pediatric teaching hospital. A database was created to prospectively collect perioperative data for all robotic surgeries performed by the pediatric surgery department. The database was queried for all operations completed from October 2015 to December 2021. Descriptive statistics were used to characterize the dataset, using median and interquartile ranges for continuous variables. From October 2015 to December 2021, a total of 249 robotic surgeries were performed in the department of pediatric surgery. Of the 249 cases, 170 (68.3%) were female and 79 (31.7%) were male. Across all patients, there was a median weight (IQR) of 62.65 kg (48.2-76.68 kg) and a median (IQR) age of 16 years (13-18 years). The median (IQR) operative time was 104 min (79.0-138 min). The median console time was 54.0 min (33.0-76.0 min) and the median docking time was 7 min (5-11 min). The majority of procedures were performed on the biliary tree (52.6%). In the 249 procedures, there were no technical failures of the robot and only two operations (0.8%) were converted to open procedures and one (0.4%) to laparoscopic. This study highlights the ability to successfully integrate a pediatric robotic surgery program into a free-standing children's hospital with a low conversion rate. Additionally, the program extended across multiple surgical procedures and offered real-time exposure to advanced surgical techniques for current and aspiring pediatric surgery trainees.

Robotic versus laparoscopic radical surgery for pediatric congenital biliary dilatation: a comparison of surgical outcomes of a single surgeon's initial experience

PURPOSE

This study aimed to clarify the validity of robot-assisted surgery (RAS) for pediatric patients with congenital biliary dilatation (CBD).

METHODS

We retrospectively compared RAS and laparoscopic surgery (LS) for pediatric CBD performed by the same certified surgeon between 2016 and 2022.

RESULTS

We included 6 RAS and 12 LS cases in this study. One case of RAS with laparotomy was excluded from the analysis. The patients in the two groups had comparable ages and body weights. The median surgery duration, the suture time per stitch, and the time to drain removal were 385 min, 145 s, and 5 days in the RAS group and 370 min (p = 0.28), 177 s (p = 0.03), and 6 days (p = 0.03) in the LS group, respectively. The time to create the Roux-en-Y limb was significantly longer in the RAS group. Postoperative complications occurred in one RAS case and in four LS cases.

CONCLUSIONS

Less anastomotic time per stitch and less time to drain removal suggest that RAS may contribute to accurate suturing and fine intra-pancreatic bile duct dissection. In addition, RAS requiring large movements of forceps in a large surgical field, such as Roux-en-Y creation, is inferior to LS.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Robot-assisted resection of choledochal cyst in children

Background

The emergence of the robotic surgery system has assisted the further development of minimally invasive surgery by facilitating more delicate and precise complex procedures. The purpose of this study was to present a study of robot-assisted resection of the choledochal cyst and to discuss the technical points.

Methods

In total, 133 patients who were diagnosed with a choledochal cyst and underwent surgery from April 2020 to February 2022 in the Children's Hospital, Zhejiang University School of Medicine, were retrospectively analyzed. The data were collected including the clinical information of the patients, operative details, and postoperative outcomes.

Results

Among these 133 patients, 99 underwent robot-assisted surgery and 34 underwent laparoscopic assisted surgery. The median operation time was 180 min, with an interquartile range (IQR) of 170-210 min for the robot-assisted group and 180 min with an IQR of 157.5-220 min in the laparoscopic assisted group (P = 0.290). The detection rate of 82.5% for the distal opening of the cystic type of choledochal cyst was higher in the robot-assisted group than that in the laparoscopic assisted group at 34.8% (P = 0.000). The postoperative hospital stay was shorter (P = 0.009) and the hospitalization expense was higher (P = 0.000) in the robot-assisted group than that of the laparoscopic assisted group. There was no significant difference between the two groups in terms of complications, postoperative indwelling days of the abdominal drainage tube, intraoperative blood loss, and postoperative fasting time (P > 0.05).

Conclusions

Robot-assisted resection of choledochal cyst is safe and feasible, it is ideal for the patient requiring a meticulous operation, and its postoperative recovery was shorter than for traditional laparoscopy.

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.

Initial experience with 3D laparoscopic choledochal cyst (CDC) excision and hepatico-duodenostomy (HD) in 21 children

INTRODUCTION

Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management.

AIM

To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details.

MATERIALS AND METHOD

All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied.

RESULTS

The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively.

CONCLUSION

3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery.

LEVEL OF EVIDENCE

Treatment study level IV.

[Robot-assisted choledochal cyst resection in a child]

The generally accepted method for choledochal cysts is total resection of cystic extrahepatic bile ducts and gallbladder followed by biliodigestive anastomosis. Minimally invasive interventions have recently become the «gold» standard in pediatric hepatobiliary surgery. However, laparoscopic resection of choledochal cysts has certain disadvantages related to difficult positioning of instruments in narrow surgical field. The disadvantages of laparoscopy can be compensated by surgical robots. A 13-year-old girl underwent robot-assisted resection of hepaticocholedochal cyst, cholecystectomy and Roux-en-Y hepaticojejunostomy. Total anesthesia time was 6 hours. Laparoscopic stage took 55 min, docking of robotic complex - 35 min. Robotic stage of surgery required 230 min, removal of cyst and suturing the wounds - 35 min. Postoperative period was uneventful. Enteral nutrition was started after 3 days, and drainage tube was removed after 5 day. The patient was discharged after 10 postoperative days. The follow-up period was 6 months. Thus, robot-assisted resection of choledochal cysts in children is possible and safe.

Robotic biliary surgery for benign and malignant bile duct obstruction: a case series

The majority of patients with benign or malignant biliary obstruction require surgical treatment with a bilio-enteric anastomosis. This requires fine dissection and advanced suturing. Robotic surgery may overcome some major limitations of conventional laparoscopic surgery. The precise role of robotic biliary surgery is, however, still to be defined. In our institution, patients requiring complex bile duct surgery were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System^® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed. A total number of 14 patients underwent robotic biliary surgery for a variety of benign and malignant indications between September 2020 and May 2021. Six of fourteen patients (43%) had previous open abdominal surgery. Median blood loss was 25 mL (range 10-120 mL). There were no intra-operative complications and no conversions. Length of stay was between 3 and 11 days without major postoperative morbidity. Robotic surgery for benign and malignant bile duct obstruction is efficient and safe in experienced hands. Referral to a high-volume expert center is, however, advised.

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 surgery in the pediatric surgeons' world: Current situation and future prospectives

Robotic-assisted surgery has been fully embraced by surgeons for the adult population; however, its acceptance is too slow in the world of pediatric surgeons. It is largely due to the technical limitations and the inherent high cost associated with it. In the past two decades, indeed, there has been considerable advancement in pediatric robotic surgery. A large number of surgical procedures were performed on children with the assistance of robots, even with comparative success rates to standard laparoscopy. As a newly developing field, it still has many challenges and obstacles. This work is centered on the current status and progression of pediatric robotic surgery as well as the future perspectives in the field of pediatric surgery.

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.

Application and prospects of robotic surgery in children: a scoping review

As an innovative minimally invasive surgical technology, robot-assisted surgery (RAS) has greatly improved the accuracy and safety of surgery through the advantages of three-dimensional magnification, tremor filtering, precision and flexibility, and has been carried out by an increasing number of surgeries. In recent years, robots have been gradually applied to children, bringing new ideas and challenges to pediatric surgeons. This review will describe the advantages and limitations of robotic surgery in children, summarize its application in pediatric surgery, and provide an outlook. It is believed that clinicians should actively carry out RAS under the premise of rigorously ensuring surgical indications and strive to improve the efficacy of surgical treatment for children.

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.

Our Experience with Cyst Excision and Hepaticoenterostomy for Choledocal Cyst: A Single Center Case Review of 16 Patients

Background and Objectives: Choledocal cyst is a rare congenital disease of the biliary tree defined by dilatation of the extrahepatic and/or intrahepatic biliary ducts. Untreated, it leads to complications such as cholangitis, stone formation and malignant degeneration. The standard treatment for choledocal cyst is complete excision and subsequent biliary reconstruction via hepaticojejunostomy or hepatiocoduodenostomy. Materials and Methods: We report our experience with 16 pediatric cases of choledocal cyst over a 10-year period. Results: The predominant symptoms were nausea and jaundice, both at 62.5% (n = 10), followed by abdominal pain at 56.3% (n = 9). Ultrasonography was the diagnostic method used in all patients. Computed tomography was used in 75% (n = 12) and magnetic resonance imaging in 25% (n = 4) of cases. Age at the time of intervention ranged from 2 months to 17 years with a mean of 4 years and 5 months. The open approach was used in nine patients and the laparoscopic approach was used in seven patients, with one conversion to open surgery. Complete excision of the choledocal cyst was performed in 15 cases (93.7%), and partial excision with mucosectomy was performed in one case (6.2%). Eight patients (50%) underwent hepaticoduodenostomy and eight (50%) underwent hepaticojejunostomy, out of which one was attempted laparoscopically but was converted. We had a postoperative complication rate of 12.5% (n = 2) represented by anastomotic leak and pancreatitis. Conclusions: From our experience with these cases, we concluded that a wide hepaticoduodenostomy constitutes a favorable choice over the traditional hepaticojejunostomy, being more physiological and less time consuming.

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.

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.

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.

Trans-umbilical Single-Site Plus One Robotic Assisted Surgery for Choledochal Cyst in Children, a Comparing to Laparoscope-Assisted Procedure

OBJECTIVE

We introduce the trans-umbilical single-site plus one robotic-assisted surgery for the treatment of pediatric choledochal cyst. Compare the intraoperative and postoperative outcomes between the new method and traditional laparoscopy-assisted procedure.

METHOD

We retrospectively analyzed the clinical data of 51 children diagnosed with choledochal cysts and received surgery from June 2019 to December 2020 at our department. About 24 patients who underwent the robot-assisted procedure were selected as the R group, and 27 patients who underwent the laparoscope-assisted procedure were selected as the L group. We compare the intraoperative and postoperative outcomes between the two groups.

RESULT

No significant differences were found in demographic information between the two groups (P > 0.05). The median total operative time, median port/trocar installation time, and median wound suture time of the R group were a little longer than the L group (217.63 ± 5.90 vs. 199.37 ± 5.13 min; 30.71 ± 3.18 vs. 6.11 ± 1.15 min; 30.79 ± 1.82 vs. 20.40 ± 3.12 min, respectively; P < 0.001). However, the R group had shorter choledochal cyst excision time and mean hepaticojejunostomy anastomosis time than the L group (52.04 ± 2.74 vs. 59.26 ± 3.23 min; 52.42 ± 2.72 vs. 60.63 ± 3.30 min, respectively, P < 0.001). The mean extracorporeal Roux-y jejunojejunostomy time of two groups has no remarkable difference (P > 0.05). The R group also had less mean volume of blood loss (7.04 ± 1.16 vs. 29.04 ± 18.21 mL; P < 0.001). The R group had a shorter indwelling time of gastric tube, anal exhaust time, water feeding time, solids feeding time, and hospital stay time than the L group (P < 0.05). The R group had a lower early complication rate than the L group (4.2 vs. 29.63%; P = 0.026). No statistical differences were identified between the two groups in late or any single complication (0.00 vs. 11.11%; P > 0.05).

CONCLUSIONS

A resection of the choledochal cyst and a Roux-en-Y hepaticojejunostomy can be performed much more precisely by single-site plus one robotic-assisted surgery. Patients can achieve rapid recovery, and the umbilical incision is more concealed and beautiful. Combing the experience of single-site surgery with robot-assisted surgery, the operators can implement the technique in children safely and feasibly.

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.

A narrative review of the modern surgical management of pediatric choledochal cysts

Choledochal cysts (CC) ae rare congenital dilations of the biliary tract that harbor lifelong malignancy risk. CC are treated with surgical excision and bilioenteric reconstruction. In the modern era, the surgical approach to pediatric patients has enjoyed significant innovation with regards to minimally invasive techniques. In this review, we discuss these advances, including laparoscopic, single-incision laparoscopic, and robotic strategies, with a focus on the clinical outcomes of patients undergoing these procedures. By presenting an overview of the technical pearls emphasized by pioneers of these procedures, we examine the benefits and limitations of various minimally invasive techniques and analyze the utility and effectiveness of laparoscopy and robotics in comparison to each other and open techniques. Additionally, we highlight the importance of surgeon experience and skill in the management of this rare pediatric disease and explore the significance of the surgical learning curve in minimally invasive approaches in the excision of CC. We discuss the challenge of achieving surgical competency along this learning curve, and present proposed strategies to improve skill sets in the face of low case volumes. Finally, the relative dearth of data discussing long-term follow-up in these patients is discussed, and additional research regarding outcomes, malignancy risk and surveillance, and quality of life is necessary to better understand this disease and the implications of its surgical management.

Robotic Excision of Choledochal Cyst with Hepaticoduodenostomy (HD): Report of HD Technique, Initial Experience, and Early Outcome

INTRODUCTION

 Minimal access surgical approach to choledochal cyst (CC) is becoming a standard of care in pediatric age group. Robotic-assisted excision of CC is increasingly being practiced at centers which have access to the system. We present our experience and technique of hepaticoduodenostomy (HD). Over all initial experience, short-term outcomes and complications are also presented and discussed.

MATERIALS AND METHODS

 Patients with CC and undergoing robotic excision were retrospectively studied. Patients with active cholangitis, liver dysfunction, and perforated CC were excluded for robotic procedures. All included patients were preoperatively evaluated as per the defined protocol. They underwent excision of CC with HD. The duodenal anastomosis was done after limited mobilization and emphasis was laid on anastomosing the distal D2 part to the common hepatic duct. This prevents bile reflux into stomach. The follow-up evaluation was done for these patients. Hepatobiliary iminodiacetic acid (HIDA) scan for duodenogastric reflux (DGR) was done only if patients reported symptoms related to it.

RESULTS

 A total of 19 patients (10 females) were studied. The mean age was 84 months. Type 1b was present in 12 patients and the rest were type IVb. Complete cyst excision with HD was done in all patients except conversion to open in one patient. The mean surgical time was 170 ± 40 minutes with console time of 140 ± 20 minutes. Median follow-up duration is 2.5 years (range: 3.5-0.5 years). HIDA scan was done in five patients who had reported epigastric pain. Of these five, one patient had a positive DGR. He is on conservative management.

CONCLUSION

 Robot-assisted CC excision with HD is feasible as proven by the outcome of 19 patients presented in this series. HD is to be done away from pylorus in distal part of down curving D2. This particular step prevents DGR and is the most important point of technique in doing HD. The presented series is the first report of robotic excision of CC with HD. The robot is a facilitator for complex and difficult operations as CC excision and HD.

[Surgical treatment of common bile duct malformations in children]

The review is devoted to the current classifications of common bile duct malformations, authors' opinion regarding surgical approach and reconstruction of the bile ducts. The authors describe the modern modifications of bile duct reconstructions and estimate their effectiveness. PubMed database, Google Scholar and National Scientific Electronic Library eLIBRARY.ru databases were used. We analyzed the complications in children depending on various reconstructions, anatomical form, timing of reconstructive surgery and early diagnosis of this pathology.

Total robot-assisted choledochal cyst excision using da Vinci surgical system in pediatrics: Report of 10 cases

BACKGROUND

The robotic surgery has been proposed as another adjunct for pediatric minimal surgery for choledochal cyst. However, the Roux-en-Y jejunal limb in most reports on robot-assist choledochal cyst resection is usually created extracorporeally in children. The pediatric surgery team of West China Hospital of Sichuan University had completed 10 cases of total robot-assisted choledochal cyst resection. The aim of this current study was to present our initial experience in total robot-assisted surgery and discuss the technical points.

METHODS

Between January 2015 and February 2020, patients with choledochal cysts treated with total robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details and postoperative outcomes.

RESULTS

A total of 10 episodes of patients were enrolled in the study. The median age of the patient was 69.50 months with a mean weight of 20.50 kg. The most common symptoms were abdominal pain, vomiting, and jaundice (60%, 30%, and 30%, respectively). The types of cyst included 2 Ia, 7 Ic and 1 IV. The mean operation time was 218.70 min and there were no red blood cell transfusion and conversion in the 10 patients. The mean time to taking water was 3.37 days and mean time to starting liquid diet was 3.77 days. And the average length of postoperative hospital stay was 7.92 days. All 10 patients were eventually discharged and made uneventful recoveries after the operation.

CONCLUSIONS

Total robot-assisted choledochal cyst excision comprising Roux-en-Y limb formation, excision of the cyst and hepaticojejunostomy appears to be safe and feasible in pediatrics. Our initial experience shows that it is recommended to perform total robot-assisted choledochal cyst excision for patients over 4 years while a Roux-en-Y jejunojejunal anastomosis is recommended to be performed extracorporeally by prolapsing the jejunum out of abdominal cavity for patients under 4 years old.

LEVEL OF EVIDENCE

Treatment Study.

TYPE OF STUDY

Retrospective Study.

Minimally invasive surgery for choledochal cysts: Laparoscopic versus robotic approaches

Backgrounds/Aims

Minimally invasive surgery is a widely accepted approach in hepatobiliary surgery and choledochal cyst excision has also been performed by minimally invasive methods, including laparoscopic and robotic approaches. However, only a few studies have compared laparoscopic and robotic surgery. Therefore, we performed a comparative study between two groups, including cost aspects.

Methods

We retrospectively analyzed minimally invasive choledochal cyst excision at Severance Hospital in Seoul, South Korea from January 2005 to December 2018. A total of 39 patients that underwent minimally invasive choledochal cyst excision were identified. The 23 patients (58.9%) and 16 patients (41.1%) were enrolled in laparoscopic and robotic approach, respectively. We compared the patient's characteristics, and perioperative outcomes between laparoscopic and robotic surgery groups.

Results

A comparative analysis between the two groups showed no differences in preoperative clinical characteristics. There were no significant differences in operative time, estimated blood loss, and postoperative complications, including biliary complication. The preoperative ASA score (p=0.021) and hospital stays (p=0.011) were the only clinical variables that differed between the two groups. All of the variables included in the cost analysis showed statistically significant differences (total hospital charge: p=0.035, patient's bill: p≤0.001, operation: p=0.002, anesthesia: p=0.001, postoperative management: p=0.001).

Conclusions

The overall clinical outcomes between the laparoscopic and robotic approach to choledochal cyst were comparable. The surgical approach should be balanced based on the surgeons' skill, patients' general condition, disease extent, and economic status.

Preliminary Experiences With Robot-Assisted Choledochal Cyst Excision Using the Da Vinci Surgical System in Children Below the Age of One

The purpose of this study is to introduce our preliminary experiences with using the da Vinci surgical system to treat choledochal cysts in children under 1 year old and discuss the application of this robot-assisted surgery. We retrospectively analyzed all available clinical data of children below the age of 1 who underwent surgery for choledochal cysts using the da Vinci robotic surgical system between January 2015 and December 2020. Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 8.5 months, and the average weight was 9.11 kg. Half of these patients suffered from abdominal pain, while 30% exhibited vomiting and 10% jaundice. Eight of them were type Ia, and two were Ic. The average operation time among the patients was 219.5 min. None of the 10 patients had to receive a blood transfusion or conversion. The average time of the patients' subsequent fluid diet was 3.28 days, and the solid diet was 3.76 days. Meanwhile, the average length of hospital stay was 7.6 days. All 10 patients recovered and were eventually discharged. We believe that the da Vinci surgical system is a safe and feasible form of treatment for choledochal cysts in children <1 year old.

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

BACKGROUND

Robotic-assisted surgery (RAS) is becoming more popular because of the excellent performance in anastomosis and knot tying, especially in complex surgical procedures such as hepaticojejunostomy. As for operative time and costs, laparoscopic-assisted surgery (LAS) seem to be more advantageous. To date, there are only limited studies focusing on the comparison between RAS and LAS. This study aims to investigate differences in intraoperative and postoperative outcomes between robotic and laparoscopic approaches.

METHODS

We performed a retrospective case-control study of 140 patients operated via mini-invasive approaches for choledochal cyst (CC) excision and hepaticojejunostomy at the Wuhan Union Hospital from Jun 2014 to Dec 2019. A multivariable logistic regression model for odds to having complications was built.

RESULTS

The two groups were similar in age, sex, follow-up time, and Todani modification of the Alonso-Lej classification distribution. Patients undergoing RAS had longer overall operative time, shorter cyst excision time, shorter hepaticojejunostomy time, less estimated blood loss, a smaller postoperative high fever rate, shorter postoperative LOS, and a lower postoperative complication rate. Moreover, the intraoperative anatomy structures were more explicit in group RAS, such as the exposure of left or right hepatic duct opening and intrapancreatic bile duct. Multivariable logistic regression showed that longer hepaticojejunostomy time was the only risk factor of postoperative complications.

CONCLUSION

Robotic-assisted CC excision and hepaticojejunostomy was associated with better intraoperative and short-term postoperative outcomes when compared to laparoscopic-assisted surgery.

Standardized Surgical Management for Cystic Dilation of the Bile Ducts Based on Clinical and Pathological Studies: A Narrative Review

The surgical method of complete/radical cyst excision plus Roux-en-Y hepaticojejunostomy remains the primary therapy and the only effective treatment for cystic dilation of the bile ducts (CDBDs). However, the incidence of long-term postoperative complications is still high, as is the reoperation rate, and the potential for postoperative malignant transformation still exists. In recent years, significant progress has been made in understanding the pathogenic mechanism and pathological changes of adult CDBDs. Based on which, the surgical procedures for CDBDs have been revised to further improve their effectiveness. The purpose of this review is to systematically summarize the latest concepts of the etiology and pathogenic mechanism and the pathological changes of adult CDBDs. Based on the findings of these clinical and pathological studies, a comprehensive theoretical system in the surgical treatment of CDBDs has been established, which corrects many previous theoretical misunderstandings. The specific surgical method for each type of CDBDs and the key technical notes are also described in detail. Using these principles, treatment outcomes for CDBDs can be significantly improved, and the current high complication rate, reoperation rate, and rate of postoperative malignant transformation can be reduced.

Learning curve of robot-assisted choledochal cyst excision in pediatrics: report of 60 cases

BACKGROUND

Little data are available to assess the learning curve for robot-assisted surgery on choledochal cysts. The aim of this current study is to investigate the characteristics of the learning curve for robot-assisted choledochal cyst excisions using the da Vinci (SI) surgical system in pediatrics.

METHODS

A retrospectively collected database comprising all medical records of the first 60 consecutive patients undergoing a robot-assisted choledochal cyst excision and Roux-en-Y hepaticojejunostomy using the da Vinci (SI) surgical system performed by one individual surgeon was studied. Baseline information and postoperative outcomes were collected and then learning curves were analyzed using the cumulative sum (CUSUM) method. Patients were divided into two groups including group A and group B according to the cutoff points of the learning curve. Intraoperative characteristics and short-term outcomes were compared between the two groups.

RESULTS

CUSUM plots revealed that the cutoff point of the learning curve was 14 cases. Comparison of the operative time between the two groups revealed that the total operative time (203.71 ± 15.27, 171.28 ± 3.62 min, P < 0.001), docking time (23.79 ± 5.81, 14.50 ± 0.98 min, P < 0.001), and console time (151.86 ± 9.77, 129.15 ± 2.96 min, P < 0.001) were decreased significantly. The intraoperative bleeding (20.36 ± 7.46 vs. 20.43 ± 9.18, P = 0.977), time to taking water (2.89 ± 0.22 vs. 3.04 ± 0.34, P = 0.115), time to starting solids diet (3.73 ± 0.17 vs. 3.79 ± 0.26, P = 0.387), hospital stay (7.51 ± 1.12 vs. 7.54 ± 0.95, P = 0.910), and the postoperative complications did not differ significantly between the two groups.

CONCLUSIONS

The learning curve for the robot-assisted choledochal cyst excision and Roux-en-Y hepaticojejunostomy in children is 14 cases. This learning curve can be used as the basis for performance guidance during training in future.

Thoracic surgery by minimally invasion robot-assisted in children: “experience and current status”

Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic.

Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the “da Vinci surgical system” (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery.

Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing’s tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases.

Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.

Robotic-assisted surgery for choledochal cyst in children: early experience at Vietnam National Children's Hospital

PURPOSE

We aimed to describe our robotic-assisted surgery (RAS) techniques and assess the early results of RAS for choledochal cysts in children.

METHODS

We conducted a retrospective chart review of children who underwent RAS for a congenital choledochal cyst at our institution between February 2013 and August 2016. We analyzed patient characteristics, operative data, and postoperative outcomes.

RESULTS

Thirty-nine patients underwent RAS for a choledochal cyst (female 30). The operation was performed with four robotic ports and one laparoscopic port for the assistant. The Roux loop was fashioned extracorporeally. Twenty patients (51.3%) had a Todani Type I cyst and the others had Type IV. The mean patient age and weight and choledochal cyst diameter at the time of the operation were 40.2 months (range 5-108 months), 13.4 kg (range 6.5-29 kg), and 27.2 mm (range 9-112 mm), respectively. The mean operating time was 192.7 min (range 150-330 min). There were no intraoperative complications; no conversions to laparoscopic or open surgery; and no postoperative complications, including cholangitis, cholelithiasis, or anastomotic stenosis.

CONCLUSION

Pediatric RAS CC resection is safe and feasible. The robot-assisted technique overcame technical difficulties. However, in pediatric cases, a skilled robotic surgical team and procedural modifications are needed.

Choledochal malformations: global research, scientific advances and key controversies

Choledochal malformations (CMs) represent a spectrum of relatively rare and complex congenital anomalies, characterized by abnormal dilatation of the biliary tract in the absence of any acute obstruction. Today, almost 20% of CMs can be detected in-utero using maternal ultrasonography. Formal scientometric analysis was used to identify where modern CM research is taking place and perhaps where our attention should be directed in the future. Thus, this article offers a comprehensive review of recent scientific advances relating to CMs including the current understanding of etiology and classification, whilst also discussing key controversies such as risk of malignant transformation and the role of newer modalities of surgical treatment. Although laparoscopic excision of CMs and biliary reconstruction is nowadays feasible and safe, care should be taken before dispensing with standard open techniques, which have minimal complication rates and proven long-term benefit.

Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries

Objective: We present the applications and experiences of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery. Materials and Methods: A prospective, observational, and longitudinal study was conducted from March 2015 to March 2018 that involved a non-random sample of a pediatric population that was treated with RALTS. The parameters examined were: gender, age, weight, height, diagnoses, surgical technique, elapsed time of console surgery, estimated bleeding, need for hemotransfusion, complications, surgical conversions, postoperative hospital stay, and follow-up. The Clavien-Dindo classification of complications was used. The surgical system used was the da Vinci model, Si version (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A), with measures of central tendency. Results: In a 36-months period, 186 RALTS cases were performed, in 147 pediatric patients and an adult; 53.23% were male, and the remaining were female. The average age was 83 months, ranging from 3.5 to 204 months, plus one adult patient of 63 years. The stature was an average of 116.6 cm, with a range of 55-185 cm; the average weight was 26.9 kg, with a range of 5-102 kg; the smallest patient at 3.5 months was 55 cm in stature and weighed 5.5 kg. We performed 41 different surgical techniques, grouped in 4 areas: urological 91, gastrointestinal and hepatobiliary (GI-HB) 84, thoracic 6, and oncological 5. The console surgery time was 137.2 min on average, ranging from 10 to 780 min. Surgeon 1 performed 154 operations (82.8%), and the remainder were performed by Surgeon 2, with a conversion rate of 3.76%. The most commonly performed surgeries were: pyeloplasty, fundoplication, diaphragmatic plication, and removal of benign tumors, by area. Hemotransfusion was performed for 4.83%, and complications occurred in 2.68%. The average postoperative stay was 2.58 days, and the average follow-up was 23.5 months. The results of the 4 areas were analyzed in detail. Conclusion: RALTS is safe and effective in children. An enormous variety of surgeries can be safely performed, including complex hepatobiliary, and thoracic surgery in small children. There are few published prospective series describing RALTS in the pediatric population, and most only describe urological surgery. It is important to offer children the advantages and safety of minimal invasion with robotic assistance; however, this procedure has only been slowly accepted and utilized for children. It is possible to implement a robust program of pediatric robotic surgery where multiple procedures are performed.

Paediatric robotic surgery

A review of the current status of robotic surgery use in paediatrics.

Robotic-assisted surgery for pediatric choledochal cyst: Case report and literature review

Our paper describes the key surgical points of pediatric choledochocystectomy performed completely by Da Vinci robotic system. A choledochocystectomy was safely carried out for a girl at our hospital, and without any complication. Then systematic literature review was done to discuss the methods of intestine surgery and intestinal anastomosis, the use of 3^rd robotic arm, the surgical safety and advantages comparing open and laparoscopic surgery. We systematically reviewed choledochocystectomy for children performed by robotic surgery. We included a total of eight domestic and foreign reports and included a total of 86 patients, whose average age was 6.3 (0.3-15.9) years; the male-to-female ratio was 1:3.5 (19:67). Seven patients experienced conversion to open surgery, and the surgery success rate was 91.9% (79/86). The average total operation time was 426 (180-520) min, the operation time on the machine was 302 (120-418) min, 11 cases used the number 3 arm, and the remaining mainly used the hitch-stitch technique to suspend the stomach wall and liver. Forty-seven patients underwent pull-through intestine and intestinal anastomosis, and 39 patients underwent complete robotic intestine surgery and intestinal anastomosis. The hospitalization time of robotic-assisted choledochocystectomy was 8.8 d. Eight patients had biliary fistula and were all cured by conservative treatment and continuous observation. One patient had anastomotic stenosis, and one patient had wound dehiscence, both cured by surgery. Choledochocystectomy for children performed by completely robotic surgery and Roux-en-Y hepaticojejunostomy is safe and feasible. The initial experience shows that this surgical approach has a clearer field than the traditional endoscopy, and its operation is more flexible, the surgery is more accurate, and the injury is smaller. With the advancement of technology and the accumulation of surgeons’ experience, robotic surgery may become a new trend in this surgical procedure.