Robot-assisted resection of choledochal cysts in children weighing less than 6 kg

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.

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.

Non-stapled, total laparoscopic Roux-en-Y anastomosis: A safe and effective procedure for radical pediatric choledochal cyst excision

Background

Laparoscopic or robot-assisted surgery has become the main pediatric minimal invasive surgery for a choledochal cyst (CDC). However, the Roux-en-Y jejunal limb was created extracorporeally in most reports and intracorporeally in a few reports using an endoscopic stapler.

Objectives/methods

To investigate the safety and feasibility of non-stapled laparoscopic Roux-en-Y reconstruction in the radical treatment of congenital choledochal cysts (CDC). Between January 2019 and February 2023, 40 patients diagnosed with CDC underwent non-stapled laparoscopic Roux-en-Y reconstruction (non-stapled totally laparoscopic radical treatment, NTLR), 40 patients underwent conventional reconstruction (conventional laparoscopic radical treatment, CLR) included as control. Their clinical data such as intraoperative blood loss, proportion of transit laparotomy, length of operation, postoperative fasting times, postoperative drainage time, postoperative hospital stay, hospitalization cost, and postoperative complications were retrospectively analyzed.

Conclusion

non-stapled laparoscopic Roux-en-Y reconstruction is feasible and safe in total laparoscopic radical treatment of CDC. It may have the following advantages: rapid recovery of postoperative gastrointestinal function, short hospitalization, no age limit on the patient and no additional hospitalization costs, which is worthy of promotion and application.

Robot-assisted resection of benign splenic tumors in children

PURPOSE

Robotic surgery is becoming increasingly widely used in the field of pediatric surgery. The present study aimed to evaluate the safety and feasibility of robot-assisted resection of benign pediatric splenic tumors and to discuss the technical points.

METHODS

A total of 32 patients who were diagnosed with benign splenic tumors and underwent minimally invasive surgery from January 2017 to September 2023 were included in the study. The clinical data including demographic criteria, operative details, and postoperative outcomes were analyzed retrospectively.

RESULTS

Thirteen patients underwent robot-assisted surgery, and 19 patients underwent laparoscopic surgery. The median operation time was 150 min, with an interquartile range (IQR) of 120 to 200 min for the robot-assisted group and 140 min with an IQR of 105 to 180 min in the laparoscopic group (P = 0.318). Despite four cases in the laparoscopic group (21%) being converted to laparotomy because of intraoperative bleeding, compared with none in the robot-assisted group, there was no significant difference between two groups (P = 0.128). The intraoperative volume of blood loss was significantly less (P = 0.041), and the hospitalization expense was significantly higher (P = 0.000) in the robot-assisted group than for the laparoscopic group. There was no significant difference in patients' age, tumor size, postoperative feeding time, and the postoperative hospitalization time between two groups (P > 0.05).

CONCLUSION

Robot-assisted benign splenic tumor resection was safe and feasible, and it reduced surgical trauma for the pediatric patient.