Robot-assisted complete excision of choledochal cyst type I, hepaticojejunostomy and extracorporeal Roux-en-y anastomosis: a case report and review literature

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.

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.

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 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.

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Comparison the efficacy of laparoscopic versus robotic-assisted operation.

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Reviewing the robotic-assisted operation for choledochal cysts.

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The advantages and disadvantages of two methods.

Total robotic choledochal cyst excision with Roux-en-Y hepaticojejunostomy in adults

INTRODUCTION

Choledochal cyst (CDC) excision with bilio-enteric anastomosis has been reported by a laparoscopic approach. With the advent of robotic surgery, it is likely to simplify the performance of such complex procedures. Herein, we present our technique of total robotic CDC excision with intra-corporeal Roux-en-Y hepaticojejunostomy (RYHJ).

METHODS

The patient was placed in a reverse Trendelenburg position. The robotic ports were placed in a "C"-shaped manner, with the camera port placed ~2 cm below the umbilicus. A 12-mm assistant port was placed in between the camera and the left-sided robotic port. Robotic dissection and excision of extrahepatic part CDC were performed, and subsequently, intra-corporeal robotic RYHJ with jejunojejunostomy was completed. Intra-operatively, indocyanine green dye was used to delineate the biliary anatomy and to check the anastomotic integrity.

RESULTS

All three patients were female with a median age of 21 (18-34) years. Two patients had type IVa, and one had a mixed variant of type I(C) with type VI. The median operative time was 420 min, whereas docking and console time was 22 (20-25) min and 400 (360-450) min, respectively. The median blood loss and length of hospital stay were 50 (50-100) ml and 6 (5-6) days, respectively. One patient has mild acute pancreatitis in the post-operative period, which was managed conservatively.

CONCLUSION

Robotic CDC excision and reconstruction seem to be a safe, feasible, and effective surgical option that provides the benefits of minimal access surgery but also greatly aids in complex dissection and reconstruction.

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 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.

Comparison of robotic versus laparoscopic hepaticojejunostomy for choledochal cyst in children: a first report

AIM

We compared robotic hepaticojejunostomy anastomosis (RHJA) with laparoscopic hepaticojejunostomy anastomosis (LHJA) in children undergoing complete excision of choledochal cyst.

METHODS

Difficulty of suturing (DOS) during anastomosis was scored blindly, from intraoperative video recordings, using: 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; and 1 = easy. A panel of fiveindependent surgeons was also asked to compare RHJA with matched LHJA and score + 1 if RHJA appeared superior to LHJA, 0 if RHJA appeared equivalent to LHJA, and - 1 if RHJA appeared inferior to LHJA.

RESULTS

RHJA (n = 10) was performed between 2017 and 2019; LHJA (n = 27) was performed between 2009 and 2018. LHJA cases were matched for age, weight, and anastomosis diameter to RHJA cases. Complete excision was performed laparoscopically in both groups. DOS was lower in RHJA with less variance. The panel all scored RHJA as + 1. Total anastomotic time (TAT) and TAT per suture were significantly shorter for RHJA. Times taken to ambulate and for return of bowel sounds postoperatively were significantly shorter for RHJA. There was one anastomotic leak with LHJA (3.7%) and no anastomotic complications with RHJA.

CONCLUSIONS

RHJA is a more stable anastomosis that can be performed quicker, and thus, would appear to be superior to LHJA.

Laparoscopic Surgery in the treatment of children with Choledochal Cyst

OBJECTIVE

To evaluate the clinical effectiveness of laparoscopic surgery in the treatment of children with choledochal cyst.

METHODS

Seventy-six children with congenital choledochal cyst who were admitted to our hospital between February 2016 and April 2017 were selected as research subjects. They were evenly divided into an observation group and a control group using random number table, 38 each group. Patients in the observation group underwent laparoscopic surgery, while patients in the control group underwent the traditional laparotomy. Surgery related indicators and prognosis were compared between the two groups.

RESULTS

The incision size and intraoperative bleeding volume of the observation group were significantly smaller than those of the control group (P<0.05). The time of passage of flatus and time to take food of the observation group were easier than those of the control group, and the duration of hospitalization and parenteral nutrition of the former was significantly shorter than those of the latter, and the difference had statistical significance (P<0.05). The incidence of postoperative complications in the observation group was 2.6%, significantly lower than that in the control group (10.5%) (P<0.05). There was no recurrence in the observation group during the follow-up period, but there were 5 cases of recurrence (13.1%) in the control group; the difference was statistically significant (P<0.05).

CONCLUSION

Compared with the traditional laparotomy, laparoscopic surgery conforms more to the concept of modern medical minimally invasive treatment and has a significant clinical effect in the treatment of congenital choledochal cyst in children. It can effectively promote the disappearance of clinical symptoms and signs, reduce the incidence of postoperative complications and disease recurrence, and improve the surgical efficacy, suggesting high clinical significance and application values.

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.

Comparison of surgical outcomes of intracorporeal hepaticojejunostomy in the excision of choledochal cysts using laparoscopic versus robot techniques

Purpose

Increasing surgical expertise in minimally invasive surgery has allowed laparoscopic surgery to be performed in many abdominal surgeries. Laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy are challenging and sophisticated surgeries because of the difficult anastomosis. Recent advances in robotic surgery have enabled more delicate and precise movements, and Endowrist instruments allow for securing sutures during anastomosis. This study aimed to compare surgical outcomes of laparoscopic and robotic hepaticojejunostomy in choledochal cyst excision.

Methods

Sixty-seven patients who underwent laparoscopic or robotic-hybrid choledochal cyst excision from 2004 to 2016 were retrospectively analyzed and compared. In robotic surgery, dissection was performed laparoscopically, and hepaticojejunostomy was performed using a robotic platform.

Results

The mean operative time was significantly longer in robotic surgery than in laparoscopic surgery (247.94 ± 54.14 minutes vs. 181.31 ± 43.06 minutes, P < 0.05). The mean estimated blood loss (108.71 ± 15.53 mL vs. 172.78 ± 117.46 mL, respectively, P = 0.097) and postoperative hospital stay (7.33 ± 2.96 days vs. 6.22 ± 1.06 days, P = 0.128) were comparable between procedures. Compared to the laparoscopic approaches, robotic surgery had significantly less short-term complications (22.4% vs. 0%, P = 0.029). There were more biliary leakage (n = 7, 14.3%) observed during the first 30 days after surgery in laparoscopy while none were observed in the robotic method.

Conclusion

Robotic surgery allow for more precise and secure sutures during anastomosis thereby reducing biliary complications. With expanding knowledge and expertise, robotic surgery may offer more advantages over laparoscopy in the era of minimally invasive surgery.

Robotic assisted excision of type I choledochal cyst with Roux-en-y hepaticojejunostomy reconstruction

Choledochal cyst is a relatively rare congenital disease. The current standard treatment of choice for choledochal cyst is complete excision with Roux-en-y hepaticojejunostomy due to possible associated complications if left untreated, such as cholangitis, pancreatitis, cirrhosis, portal hypertension, and biliary malignancy. Traditionally, the resection for choledochal cyst is carried out with open surgery because of complex dissection and bilioenteric reconstruction. Recently, minimal invasive approach has gain wide interest, especially with the use of robotic surgical systems which can facilitate complex minimal access procedures. Herein, we present a case of robotic assisted excision of type I choledochal cyst in a young lady with complete intracorporeal reconstruction of Roux-en-y hepaticojejunostomy. Robotic-assisted surgery can be safely applied to the resection of type I choledochal cyst and also provide a complex suturing technique for reconstruction with Roux-en-y hepaticojejunostomy. Although the total operating time for robot-assisted resection of choledochal cysts and hepaticojejunostomy is relatively long for this initial experience, the young lady and family are pleased with the cosmetic results.

Early experience of robotic surgery for type I congenital dilatation of the bile duct

Laparoscopic surgery for this disease is not widely spread due to difficulties in its procedure. We started a laparoscopic procedure for this disease since 2011, and the robotic surgery since 2012. The aim of this study is to assess early results of these procedures. We have operated seven cases from September 2011 through December 2013. First two cases were performed by laparoscopic procedure, and following cases were done by robotically assisted surgery. Of these cases, the perioperative outcome and short-term postoperative morbidity were evaluated. Their average age was 43.6 years old (20-64 years old), and male-female ratio was 2:5. Todani classification was type 1 in all cases. The operation time was 321 min in laparoscopic cases, while 489 min in robotic surgery cases. One case of robotic surgery developed postoperative intestinal obstruction of the biliary limb, requiring laparoscopic adhesiolysis. Pancreatic fistula and anastomotic leakage have not been observed. The robotic surgery for the congenital dilatation of the bile duct is feasible and is a theoretically useful option, especially for hepatico-jejunostomy. On the other hand, the limitation of energy devices, high running cost, and time consumption remain questionable.

Retrospective assessment of the validity of robotic surgery in comparison to open surgery for pediatric choledochal cyst

PURPOSE

We evaluated the validity of robotic surgery (RS) for pediatric choledochal cyst (CC) in comparison to open surgery (OS).

MATERIALS AND METHODS

From January 2009 to April 2013, clinical data from 79 consecutive pediatric patients with CC, who underwent RS (n=36) or OS (n=43) performed by a single pediatric surgeon, were analyzed retrospectively.

RESULTS

In the RS group, the age of the patients was significantly older, compared to the OS group. Operation and anesthesia times were significantly longer in the RS group than the OS group. Fluid input rates to maintain the same urine output were significantly smaller in the RS group than the OS group. The American Society of Anesthesiologists (ASA) physical status, length of postoperative hospital stay, and the incidence of surgical complications did not differ significantly between the two groups.

CONCLUSION

Although early complications could not be avoided during the development of robotic surgical techniques, RS for pediatric CC showed results comparable to those for OS. We believe that RS may be a valid and alternative surgery for pediatric CC. After further development of robotic surgical systems and advancement of surgical techniques therewith, future prospective studies may reveal more positive results.

Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction

INTRODUCTION

To report our experience in palliative hepaticojejunostomy for advanced malignant biliary obstruction by means of robotic approach

METHODS

Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction was performed in nine patients from May 2009 to April 2014.

RESULTS

During the study period, robotic hepaticojejunostomy for advanced malignant biliary obstruction was completed successfully in nine patients. Roux-en-Y hepaticojejunostomy and double (hepaticojejunostomy, and gastrojejunostomy) bypass were performed in five and four patients, respectively. The mean operating time was 212.8 minutes. The mean blood loss was 38.7 mL. The overall complication rate was 22.2%. Bile leak complication occurred in one patient only. There was no procedure-related mortality. The mean postoperative hospital stay was 13.3 days. Five patients received palliative systemic chemotherapy after bypass surgery. The mean survival time was 11.1 months. During follow up, only three patients with cholangiocarcinoma had recurrent biliary obstruction after end-to-side hepaticojejunostomy due to tumor progression, and needed percutaneous transhepatic biliary drainage. Among these nine patients, there were a total of eight episodes of readmission in four patients due to tumor-related symptoms or complications.

CONCLUSIONS

Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction had a low complication rate and was associated with an improved quality of life.

Hybrid laparoscopic-robotic management of type IVa choledochal cyst in the setting of prior Roux-en-Y gastric bypass: video case report and review of the literature

BACKGROUND

Choledochal cysts are rare congenital disease of the biliary system. The recommended treatment of these lesions is surgical excision with biliary enteric reconstruction. In patients with normal anatomy, Roux-en-Y hepaticojejunostomy is preferred. However, different options in biliary reconstruction must be entertained in those with abnormal anatomy.

METHODS

Our patient is a 39-year-old female, who during workup for bariatric surgery two years prior to presentation, was found to have a 6 cm dilation of her common bile duct. She underwent a laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2011 at an outside facility, with no planned intervention on her biliary tree. Ultimately, she developed right upper quadrant pain two years following her RYGB. Upon further workup including right upper quadrant ultrasound, an extrahepatic choledochal cyst was confirmed and she was referred to our institution for definitive care.

RESULTS

The patient was taken to the operating room for resection of the choledochal cyst with hepatoenteric reconstruction. The dissection and resection of the cyst commenced laparoscopically. After performing a generous Kocher maneuver, we demonstrated that there was adequate mobilization of the duodenum to perform a tension free hepaticoduodenostomy, which was performed robotically. Her postoperative course was uneventful, and she was discharged home on postoperative day 3. At one month follow up, the patient was doing well with symptom resolution. Her final pathology revealed a choledochal cyst which was negative for dysplasia or carcinoma. Long-term follow up has been recommended with yearly alkaline phosphatase levels.

CONCLUSIONS

Here we present a video of the technical considerations during a robot-assisted laparoscopic biliary reconstruction in a patient with a prior Roux-en-Y gastric bypass with a type IVA choledochal cyst.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Mid-term Outcomes of Laparoscopic Versus Open Choledochal Cyst Excision in a Tertiary Paediatric Hospital

Introduction: Paediatric laparoscopic choledochal cyst excision has increasingly gained acceptance as an alternative to open excision. Laparoscopic excision is feasible and safe in the short term, but long-term outcomes are not as well established. KK Women’s and Children’s Hospital started performing laparoscopic choledochal cyst excision in children since 2007. In this paper, we report our experience with the laparoscopic approach, and the early and mid-term outcomes in comparison with the conventional open approach. Materials and Methods: Thirty-five consecutive cases by a single surgeon between May 2006 and April 2012 were retrospectively reviewed. Patient characteristics and surgical outcomes were analysed. Results: There were 13 laparoscopic and 22 open cases. Baseline patient characteristics were similar. Operative time was longer in the laparoscopic group. Three cases in the laparoscopic group were converted to open in our early experience. There were no differences in time to feeds or length of hospitalisation. One laparoscopic case developed minor bile leak that resolved on conservative management. There were no complications in the laparoscopic group on median follow-up of 35 months. In the open group, there was 1 case of pancreatitis, cholangitis, and hypertrophic scarring respectively. There were 3 cases of suspected adhesive colic that resolved without surgery. Conclusion: Laparoscopic choledochal cyst excision enjoys excellent early and mid-term outcomes compared to open excision, even in centres with smaller patient volume. It should be the approach of choice where technical expertise is available. Key words: Hepaticojejunostomy, Minimally invasive, Postoperative outcomes

Robot-assisted resection of choledochal cysts and hepaticojejunostomy in children

PURPOSE

Choledochal cysts have traditionally been treated as an open procedure. However, recent publications from some large volume centres show that minimally invasive surgery has become their standard approach. Robotic surgical systems facilitate a surgeon's ability to undertake complex procedures. We present our experience of using robot assistance to treat choledochal cysts.

METHODS

Children admitted with a choledochal cyst from March 2009 to Nov 2012 were included. There were 27 patients (20 females). Mean age 5.4 years (range 0.3-15.9). Mean weight 21.9 kg (range 5.9-78.8); 10 weighed <10 kg. The choledochal cysts were types 1c(12), 1f(10) and 4(5). The da vinci Surgical System was used for the robot-assisted resection of the choledochal cyst and hepaticojejunostomy. Roux loop was fashioned extra-corporeally. Mean follow-up is 2.7 years (range 0.9-4.7).

RESULTS

22 cases were completed successfully with robotic assistance. Five open conversions were for anatomical concerns or technical reasons. One child had three complications (omental hernia, anastomotic stricture and subsequent bile leak). Patients were on full feeds by a median of 5 days (range 3-6) and discharged after 6 days (range 4-7).

CONCLUSION

Robotic-assisted resection of choledochal cysts in children is safe. They made a rapid recovery with a good cosmetic outcome.

Role of laparoscopy in treatment of choledochal cysts in children

Laparoscopy enables surgeons to approach the surgical conditions from a new perspective. Laparoscopic surgery has revolutionized the treatment of choledochal cysts (CDC). Yet, this new technique requires objective evaluations. We have examined the controversies about the CDC dissection, distal common bile duct ligation, ductoplasty for hepatic duct stenosis, intrahepatic duct and common channel protein plug clearance, timing of surgery for antenatally diagnosed CDC, and the Roux loop length in CDC children. In the hands of experts, laparoscopic excision of the cyst and Roux-en-Y hepaticojejunostomy is a safe and effective approach. We provide our opinions on these issues based on our experience and publications. We conclude that the main outcomes comparable to those of the open surgery. The better wound cosmesis and reduction of surgical trauma are the advantages.

Laparoscopic Management of an Adult Choledochal Cyst Using the E.K. Glove Port as Wound Protector for Extracorporeal Roux-en-Y Anastomosis and Optical Port

Laparoscopic surgery has come to replace many conventional abdominal surgeries because of its outstanding advantages, including a better cosmetic result, faster recovery, and lesser postoperative pain. We present a case of laparoscopic-assisted total excision of Todani type I(B) choledochal cyst and biliary reconstruction in a 24-year-old female patient. Dissection of the cyst was done laparoscopically using the monopolar diathermy energy source. An end-to-side hepaticojejunostomy was created intracorporeally using 3-0 Vicryl suture, and end-to-side enteroenterostomy was completed outside the abdominal cavity using the E.K. glove port as wound protector. A new pair of gloves was then used to construct the glove port that served as the optical port. Additional instruments for retraction and suturing were deployed through the port whenever necessary. The use of the glove port also eliminated the need to suture the umbilical port before the completion of surgery. No intraoperative complications or technical problems were encountered using this technique. The use of the E.K. glove port makes it more a convenient and cost-effective procedure in a country like India.

Robotic resection of choledochocele in an adult with intracorporeal hepaticojejunostomy and Roux-en-Y anastomosis: encouraging progress for robotic surgical treatment of biliary disease

BACKGROUND

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to hepatobiliary surgeons. Previous reports of robotic choledochocele resections in adults have detailed extracorporeal jejunojejunostomies. We describe a total robotic excision of a choledochal cyst with hepaticojejunostomy and intracorporeal Roux-en-Y anastomosis.

METHODS

A 58-year-old woman underwent a robotic excision of a small choledochocele with hepaticojejunostomy and intracorporeal Roux-en-Y.

RESULT

Port placement was determined via collaborative surgical discussion and previously reported robotic right hepatectomies. Total operative time was 386 min and total robot working time was 330 min. The hepaticojejunostomy was performed using 5-0 PDS suture with parachute-style back wall and running front wall sutures. The jejunojejunostomy was a stapled anastomosis. Estimated blood loss was less than 100 mL. The patient was ambulating and tolerating oral intake on post-operative day 1, and was discharged home on post-operative day 2.

CONCLUSIONS

Robotic resection of choledochal cyst with intracorporeal Roux-en-Y anastomosis is feasible, with advantages over open surgery such as superior visualization, precision, and post-operative patient recovery.

Lessons and tips from the experience of pediatric robotic choledochal cyst resection

PURPOSE

The laparoscopic surgery for a choledochal cyst in children is technically challenging because of its high degree of complexity despite its possibility. In an attempt to overcome this laparoscopic weakness and to facilitate the difficult steps in the minimally invasive surgery for choledochal cyst resection in children, we have performed the robot-assisted resection of the choledochal cyst. The aim of this study is to report lessons and tips obtained from our experience of the robot-assisted choledochal cyst resection in children.

PATIENTS AND METHODS

From July 2008 to October 2011, we have attempted robot-assisted resections of choledochal cyst for 14 children using the da Vinci Robotic Surgical System(®) (Intuitive Surgical, Sunnyvale, CA). We analyzed retrospectively reviewed medical records for patients' clinical characteristics, operative methods, and postoperative outcomes including operative time, hospital days, and complications.

RESULTS

In 3 early consecutive cases, we encountered serious technical problems and complications. However, after the operator underwent the robot system off-site training program, complete resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy were performed successfully without difficulty and any complication in the 11 later consecutive cases. The important technical developments of our late-period operations include placing the patient's body above the operative table, performing the extracorporeal jejunojejunostomy through an umbilical incision, omitting the operative cholangiography with magnetic resonance cholangiopancreatography substitution, exposure of the porta hepatis by lateral retractions of the gallbladder and the falciform ligament with anchoring sutures to the abdominal wall, and using a third robotic arm for counter-traction of tissues for careful dissection.

CONCLUSION

We believe that the techniques of pediatric robotic choledochal cyst resection have evolved from the previous experiences to be safer and easier.

Clinical Analysis of 221 Cases of Adult Choledochal Cysts

Choledochal cyst, usually recognized as a problem in infants, is increasingly reported in adult patients. The aim of this study was to share our experience in treating adult patients with choledochal cysts. Two hundred twenty-one adult patients with choledochal cysts who were treated in our hospital from January 2002 to December 2010 were enrolled. The clinical data were retrospectively collected and analyzed. There were 168 Type I, three Type II, three Type III, 26 Type IV, and 21 Type V cysts. The presentations were nonspecific with 177 patients having abdominal pain and a few patients having other rare symptoms including back pain, cirrhosis, occupying lesions, or spontaneous rupture. The cysts were completely removed in 169 patients, and 36 patients required liver resection. There was one death resulting from abdominal bleeding. Morbidity was limited to 27 patients, 11 of whom underwent invasive interventions. Choledochal cysts remain an interesting clinical problem. In some adult cases, the diagnosis is very difficult. Treatment is type-dependent, complete removal of the cysts is widely accepted, and lifelong follow-up for these patients is recommended.