Laparoscopic surgery versus robot-assisted surgery for choledochal cyst excision: A systematic review and meta-analysis

Minimally invasive surgery in the operating rooms near you

PURPOSE OF REVIEW

This review delineates the benefits of minimally invasive surgery (MIS) and its utilization at surgical centers and our institution. It further explores the literature for comparative outcomes of performing MIS to traditional open surgery for a variety of surgical subspecialties.

RECENT FINDINGS

In addition to its proven safety when compared to the open surgical technique, MIS has broad applications in many surgical subspecialties to enhance perioperative outcomes in both pediatric and adult patients.

SUMMARY

Although there are certain disadvantages with regard to cost of implementation in nascent communities and total operating time when the surgical complexity increases (such as utilizing a robotic approach), the added benefit of improved patient outcomes due to smaller incision sites is repeatedly proven in the literature making this technique globally essential.

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.

Risk factors for postoperative stone formation in pediatric choledochal cysts: a study of 457 cases

Postoperative bile duct stones, including intrahepatic bile duct (IHD) stones and remnant distal common bile duct (remnant intrapancreatic common bile duct, RIPD) or common channel duct (CCD) stones, are long-term complications following choledochal cyst (CC) excision. We aimed to retrospectively review occurrence, associated factors, and treatment of postoperative bile duct stones. Records of 457 pediatric patients who underwent CC excision at Asan Medical Center (1992-2021) were retrospectively reviewed. Data on cholelithiasis, operation, and outcomes were analyzed. Overall, 457 pediatric patients underwent CC excision, with 21 developing intrahepatic duct (IHD) stones, primarily associated with Todani type IVa cysts, especially Tsuchida types 2 or 3, which are often linked to IHD dilation and upstream stenosis. Patients with RIPD/CCD stones were all identified with complicated Komi types, and the impact of pancreas divisum itself was unclear. Early surgery even before 6 months of age is associated with improved prognosis regarding the occurrence of IHD stones, but not related with RIPD/CCD stones. This is the largest retrospective study to date, comprising 21 IHD and 18 RIPD/CCD stones from 457 pediatric patients with CCs and their clinical outcomes. We found that the structural characteristics of the bile duct influence stone formation. In addition, our findings indicate the need for more systematic and long-term follow-up of patients with CCs after surgery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.