Robot-assisted resection of choledochal cysts and hepaticojejunostomy in children

Comparison of robotic versus laparoscopic cyst excision and hepaticojejunostomy for choledochal cyst in children: a propensity score-matched study

BACKGROUND

Minimally invasive surgery (MIS) has become a standard approach in pediatric surgery, including for the treatment of choledochal cysts (CC). This study compared the long-term outcomes of laparoscopic (LA) and robot-assisted (RA) surgeries for pediatric CC. Propensity score matching (PSM) was used to control for potential confounding variables that could influence surgical outcomes.

METHODS

A retrospective review of 159 pediatric patients who underwent MIS for CC at our tertiary referral center between June 2008 and December 2020 was conducted. PSM was used to minimize selection bias, resulting in 63 matched pairs of patients in the RA and LA groups. Key outcomes, including operative time, complication rates, and post-operative recovery, were compared between the two groups.

RESULTS

After PSM, the RA group had a longer mean operative time compared to the LA group (359 vs. 319 min, p = 0.006). However, the RA group had a significantly lower incidence of anastomotic leaks (0% vs. 7.9%, p = 0.023). There were no statistically significant differences between the groups in terms of conversion to open surgery, length of hospital stay, or severe complications. The RA group had a shorter time to start feeding and to achieve full feeding postoperatively.

CONCLUSION

RA significantly enhances the quality of anastomosis, contributing to more secure anastomoses compared to LA, and provides the benefit of faster bowel movement recovery in pediatric choledochal cysts.

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.

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.

Single-port-plus-one robot-assisted laparoscopic modified Lich-Gregoir direct nipple ureteral extravesical reimplantation in children with a primary obstructive megaureter

Purpose

To introduce a new technique of single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation and ascertain its validity in the treatment of pediatric primary obstructive megaureter.

Methods

Between January 2021 and November 2021, we retrospectively analyzed the clinical data of 12 children with primary obstructive megaureter who were admitted to the Department of Pediatric Surgery of Fujian Provincial Hospital. All 12 children were treated with single-port-plus-one robotic laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation. Five of them were female and seven were male, including nine cases were simple obstructive type, while the remaining three cases were obstructive with reflux type. The mean age of the children was 17.33 ± 6.99 (10-36) months and the mean follow-up time was 14.16 ± 1.75 (12-17) months. Changes in preoperative and first-year postoperative parameters were compared.

Results

The mean operative time for all 12 children was 123.58 ± 10.85 (110-145) min, with a mean internal operative time of 101.42 ± 0.85 (90-120) min, a mean operative bleeding time of 2.42 ± 0.67 (2-4) ml, and a mean hematuria duration of 16.08 ± 1.44 (14-19) h. The mean indwelling catheterization time was 2.25 ± 0.45 (2-3) days and the mean hospitalization time was 3.83 ± 0.39 (3-4) days. At the postoperative first year, the ureteral diameter, calyceal diameter, and anterior-posterior renal pelvic diameter were found to be significantly smaller than at the preoperative period (18.83 ± 3.21 mm vs. 6.83 ± 1.27 mm, 13.99 ± 3.58 mm vs. 3.5 ± 2.90 mm, and 34.92 ± 4.25 mm vs. 10.08 ± 1.88 mm, P < 0.001). There was a significant increase in renal cortical thickness and the percentage of differential renal function (3.63 ± 1.66 mm vs. 5.67 ± 1.88 mm, 33.75 ± 2.77 mm vs. 37.50 ± 1.31 mm, P < 0.001). The resolution rate of obstruction was 100% and no child developed DeNovo vesicoureteral reflux.

Conclusion

The technique of modified Lich-Gregoir direct nipple ureteral extravesical reimplantation can help maintain the physiological direction of the ureter and at the same time enhance the effectiveness of antirefluxing in robotic surgery. The design of a single-port-plus-one wound can produce a cosmetic appearance by concentrating and hiding the wound around the umbilicus. This modified reimplantation procedure has the potential to become a promising technique in the robot-assisted treatment of primary obstructive megaureter.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVELS OF EVIDENCE

2B.

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.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Laparoscopic Treatment of Choledochal Malformation in Europe: A Single-Center Experience and Review of the Literature

BACKGROUND

 Numerous studies from Asian countries, including large collectives, have reported excellent results after laparoscopic resection of choledochal malformation (CM). However, the role of laparoscopic CM resection is still controversial outside Asia. We aimed to analyze the outcome of laparoscopic CM resection in our institution and to compare our outcome with the data reported in the literature.

METHODS

 All patients who underwent laparoscopic CM resection in our pediatric surgical department from 2002 to 2019 were retrospectively analyzed for surgical details and postoperative complications, which were graded according to the Clavien-Dindo classification. A systematic literature search identified all reports on over 10 cases of laparoscopic pediatric CM resection and surgical details, follow-up, and complication rates were extracted.

RESULTS

 Fifty-seven patients (72% female) with a mean age of 3.6 + 4.1 years underwent laparoscopic CM resection in our department. Conversion rate was 30%. Total complication rate was 28%. The rate of major complications (Clavien-Dindo grade III or more) was 16% and included stricture of the biliodigestive or enteric anastomosis (n = 4), adhesive ileus (n = 3), portal vein thrombosis (n = 1), and recurrent cholangitis with consecutive liver transplantation (n = 1). With increasing experience, complication rates decreased. The majority of publications on laparoscopic CM resections originated from Asia (n = 36) and reported on low complication rates. In contrast, publications originating from non-Asian countries (n = 5) reported on higher complications following laparoscopic CM resection.

CONCLUSION

 Our data indicate that laparoscopic CM resection can be safely performed. The learning curve in combination with the low incidence calls for a centralization of patients who undergo laparoscopic CM resection. There seems to be a discrepancy on complications rates reported from Asian and non-Asian countries following laparoscopic CM resection.

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.

Conversions in pediatric robot-assisted laparoscopic surgery

BACKGROUND

New technology attracts necessary concerns regarding safety and effectiveness, including the risk and circumstances of conversions. This study analyses our 11-year experience of conversions from a dedicated pediatric robot-assisted laparoscopic surgery service.

METHODS

Consecutive patients were evaluated from a prospective database for the period March 2006 to May 2017. Descriptive and quantitative data for conversions were analysed. Variables were investigated including year of surgery, patient age, operation type, surgeon, and experience.

RESULTS

A total of 539 children underwent 601 procedures. There were 45 different types of procedures. Mean (± SD) age was 7.0 ± 5.2 years, and youngest 4 weeks old. There were 31 conversions (5.8%). Conversion rates were significantly higher in younger children, with rates of 10.0%, 6.1% and 4.2% for age groups 0-2, 2-6, and 6-18 years respectively (p = 0.01). There was a significant difference in conversion rates amongst procedures (p<0.001). Intravesical (9/26, 34.6%), liver cyst (2/8, 25.0%) and choledochal cyst (8/60, 13.3%) procedures were the highest. The most frequent reason for conversion was anesthetic related issues caused by dilated intestine and/or inadequate muscle relaxation (16/31, 52%). Three conversions were attributable to mechanical failures, none attributed to intraoperative complication.

CONCLUSIONS

Conversion rates are low even in the learning phase and comparable favourably to conventional laparoscopy, supporting the safety and effectiveness of robot-assisted technology for advanced laparoscopy in children. The importance of optimization of surgical conditions cannot be overemphasised.

Controversies in Choledochal Malformation in Children: An International Survey among Pediatric Hepatobiliary Surgeons and Gastroenterologists

BACKGROUND

While congenital choledochal malformation (CCM) is relatively well known within the pediatric surgical and pediatric gastroenterological communities, many controversies and questions remain.

METHODS

In this paper, we will discuss the results of an international Delphi survey among members of the European Reference Network RARE-LIVER and of the faculty of the Biliary Atresia and Related Diseases (BARD) network to identify the most common practices as well as controversies regarding diagnosis, treatment and follow-up of this still enigmatic disease.

RESULTS

Twenty-two individual respondents completed the survey. While there seems to be agreement on the definitions of CCM, preoperative workup, surgical approach and follow-up still vary considerably. The mainstay of treatment remains the removal of the entire extrahepatic biliary tract, clearance of debris both proximally and distally, followed by reconstruction with (according to 86% of respondents) a Roux-en-Y hepaticojejunostomy. Nonetheless, both laparoscopic and robotic-assisted resections are gaining ground with the suggestion that this might be facilitated by concentration of care and resources in specialized centers. However, long-term outcomes are still lacking.

CONCLUSIONS

As even post-surgical CCM has to be considered as having premalignant potential, follow-up should be well-organized and continued into adulthood. This seems to be lacking in many centers. International cooperation for both benchmarking and research is paramount to improving care for this rare disease.

Comparison of 2K and 4K imaging systems for laparoscopic repair of choledochal cyst in children

AIM

The safety and success of laparoscopic choledochal cyst surgery (LapCC) depends upon two critical elements during the hepaticojejunostomy anastomosis (HJA). These may be termed the Difficulty of Differentiation (DOD) and the Difficulty of Suturing (DOS). The type of imaging system (2 or 4 K) used may influence either of these. We compared outcomes of LapCC using 2 or 4 K imaging systems.

METHODS

LapCC were performed at a single institution by the same team using a 2 K system (2009-2018; n = 26) and a 4 K system (2018-2019; n = 11) were compared. 4 K cases were chosen to match 2 K cases to minimize bias. Five independent senior pediatric surgeons scored DOD and DOS blindly from intraoperative video recordings of LapCC using a subjective 5-point scale (5: impossible, 4: difficult, 3: tedious, 2: slow, and 1: easy) and rated their over all impression as +1 if 4 K was better, 0 if they were the same, and -1 if 4 K was worse. Total HJA anastomosis time (TAT) and TAT/suture were also calculated.

RESULTS

LapCC was performed in 37 age/weight/HJA diameter matched children. Scores for DOD (p<0.001) were lower with 4 K with less variance, although there was no difference in DOS (p = 0.08). Operative time (p = 0.03) and duration of hospitalization (p < 0.001) were significantly shorter with 4 K. 4 K was rated +1 unanimously. There was no difference in TAT (p = 0.17) and TAT/suture (p = 0.22). There was one HJA leak with 2 K (3.8%) and no complications with 4 K.

CONCLUSIONS

Improved resolution with 4 K improved the progress of surgery as reflected by shorter operative time and duration of hospitalization, enhancing the performance of LapCC in children.

LEVEL OF EVIDENCE

III.

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 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.

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.

Long-term morbidity and follow-up after choledochal malformation surgery; A plea for a quality of life study

Much about the aetiology, pathophysiology, natural course and optimal treatment of choledochal malformation remains under debate. Surgeons continuously strive to optimize their roles in the management of choledochal malformation. Nowadays the standard treatment is complete cyst excision followed by Roux-en-Y hepaticojejunostomy, be it via a laparotomy, laparoscopy or robot-assisted procedure. Whatever surgical endeavor is undertaken, it will be a major operation, with significant morbidity. It is important to realize that especially in asymptomatic cases, this is considered prophylactic surgery, aimed at preventing symptoms but even more important the development of malignancy later in life. A clear overview of long-term outcomes is therefore necessary. This paper aims to review the long-term outcomes after surgery for choledochal malformation. We will focus on biliary complications such as cholangitis, the development of malignancy and quality of life. We will try and identify factors related to a worse outcome. Finally, we make a plea for a large scale study into quality and course of life after resection of a choledochal malformation, to help patients, parents and their treating physicians to come to a well-balanced decision regarding the treatment of a choledochal malformation.

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.

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.

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.

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.

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.

Robotic Surgery of the Liver and Biliary Tract

BACKGROUND

The laparoscopic methods for major abdominal surgery are gaining increasing acceptance worldwide. Despite its relatively recent introduction in clinical practice, robotics has been accepted as an effective option to perform high-demanding procedures such as those required in hepatobiliary surgery. Some potential advantages over conventional laparoscopy have been suggested, but its actual role in clinical practice is still to be defined.

METHODS

The objective of this work is to critically review the available evidence on the application of robotic surgery to the liver and biliary tract. PubMed, Embase, and the Cochrane Library electronic databases were systematically searched for studies reporting on robotic hepatobiliary surgery with or without comparison with open surgery or conventional laparoscopy.

RESULTS

This review provides a comprehensive snapshot of the current application of the robot to the surgery of the liver and biliary tract. The overall available data show the noninferiority of the robotic system to conventional open and laparoscopic surgery. A number of studies suggest some potential advantages in performing high-demanding procedures in a minimally invasive fashion.

CONCLUSIONS

The robot can be used to perform various types of liver surgeries quite safely and competently, although the lack of randomized control trials, comparing it with open and laparoscopic surgery, precludes the possibility to reach definitive conclusions.

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.

[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

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.

Minimally Invasive Hepatobiliary Surgery

Comparative studies and large-scale case series that confirm the advantages of laparoscopy in children with hepatobiliary diseases are scarce, and the use of laparoscopy remains a matter of debate. This article reviews the current literature on the role of laparoscopic and robotic surgery in pediatric patients with choledochal cyst, biliary atresia, gallbladder diseases, and hepatobiliary malignancies. Studies were identified through a search of the MEDLINE database. Laparoscopy may be beneficial for resection of choledochal cyst and cholecystectomy. However, more data are required before recommendations on the use of minimally invasive techniques for other hepatobiliary conditions can be published.

Laparoscopic management of choledochal cysts: is a keyhole view missing the big picture?

In recent years, numerous articles have promoted laparoscopic surgical treatment of choledochal cysts in children. Most of these reports assert that laparoscopic excision and biliary reconstruction are as safe as open surgery and achieve equivalent or better results. However, these conclusions are based on retrospective analyses with median follow-up periods that rarely exceed 5 years. Closer scrutiny of the laparoscopic literature indicates that the optimum procedure for treating type I and most type IVa choledochal cysts, namely radical excision of the extrahepatic bile ducts and reconstruction by wide hilar hepaticoenterostomy, preferably hepaticojejunostomy, is not being carried out in most cases. Performing a less radical excision exposes patients to a greater long-term risk of a bilioenteric stricture and its complications and malignant change in residual extrahepatic bile ducts. Currently, the long-term outcomes of surgery for choledochal cysts are being eclipsed by the short-term gains of laparoscopic techniques. The prime objective in the surgical management of choledochal cysts is the long-term health of the patient; laparoscopic techniques are simply another method of performing the surgery and they should not become the standard of care unless long-term outcomes are similar to best practice open surgery.

Choledochal Cyst Disease in a Western Center: A 30-Year Experience

BACKGROUND

The aim of this study was to report a Western experience in the diagnosis and management of choledochal cyst disease.

RESULTS

Sixty-seven patients were identified including 15 children and 52 adults; 76.1 % were females. The median age at diagnosis was 3 [inter-quartile range (IQR) = 6.0-0.7] years for children, and 46 [IQR = 55.6-34.3] years for adults. Forty-eight patients (72 %) were symptomatic. Types of choledochal cyst included: I (n = 49, 73.1 %), II (n = 1, 1.5 %), IV (n = 9, 13.4 %), and V (n = 8, 12 %). The median diameter of the type I choledochal cyst was 35 [IQR = 47-25] mm. All 48 patients underwent excision of cyst with Roux-en-Y hepaticojejunostomy, and eight underwent resection with hepaticoduodenostomy. Six patients underwent liver resection, and five patients underwent orthotopic liver transplantation. Malignancy was concomitant in five adult patients, being identified on preoperative imaging in three cases; and atypia was seen in three additional patients. Early morbidity included Clavien-Dindo classification grades III (n = 7) and II (n = 5), while long-term complications consisted of Clavien-Dindo grades V (n = 5), IV (n = 2), III (n = 18), and II (n = 1).

CONCLUSIONS

Presentation and management of choledochal cyst is varied. Malignant transformation is often detected incidentally, and so should be the driving source for resection when a choledochal cyst is diagnosed.

Current status and future perspective of laparoscopic surgery in hepatobiliary disease

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Robotic liver resection for malignancy: Current status, oncologic outcomes, comparison to laparoscopy, and future applications

Utilization of robotic techniques for resection of the liver is slowly gaining acceptance in specific situations and is now being applied to more challenging endeavors, such as major hepatectomy for cancer. This review provides a summary of robotic applications in liver surgery, with specific attention perioperative outcomes, oncologic outcomes, cost, and comparison to conventional laparoscopic techniques of liver resection. We also discuss future applications of robotic-assisted liver surgery.

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.