Experience in the Treatment of Choledochal Cyst with Robot-Assisted Surgery in Children: and "The Current State of Minimally Invasive Surgery in this Anomaly”

Abstract

Report our experience in the treatment of choledochal cyst with robot-assisted surgery in children and perform a current analysis of both approaches of minimally invasive surgery, for this anomaly. Results:We treated 4 patients with choledochal cyst, relation 1:3 female, the averages was in age 3 years, weight 15 kg and height 94.2 cm. Type 1-A cysts were three and one 1-C, the average size of the cysts, 9.6 cm. Clinically, they presented: abdominal mass 3, jaundice episode 3 and fever 2. The following are average values of: total surgical times 360 min and console surgery time 230 min, bleeding 32.5 ml, and postoperative stay 4.7 days. Conversions, complications and mortality 0%. Follow-up average 29 months, and all patients are asymptomatic. Currently, the number of children with choledochal cyst treated with robotic surgery, barely reaches about 3%, in relation to those treated with conventional laparoscopy. The initial experience was published with laparoscopy in Oct-1995 and with robotic surgery in Apr-2006. Conclusions: Our results are encouraging, and show the advantages of robotic surgery, although our experience is limited to a few cases. Robotic surgery for the treatment of choledochal cyst is feasible and safe. The current results with both minimally invasive approaches are very similar, but we consider that it represents an important bias, the great advantage in the application that conventional laparoscopy takes to robotic surgery. To date, very few pediatric surgeons in the world have applied robotic surgery to the choledochal cyst. Material and Methods:Study observational, prospective, and longitudinal, in pediatric patients with choledochal cyst treated with robotic-assisted surgery, from Jul-2016 to Apr-2019. The diagnosis was made with laboratory studies, USG and cholangioresonance.The surgery performing one part by laparoscopy, the extracorporeal Roux-en-Y, and other part with robotic assistance (cholecystectomy, retrocolic Roux-en-Y, and the hepaticojejunostomy). We use 5 trocars, 4 robotics and a laparoscopic. Registered variables: demographic data, cysts according to Todani's classification, size, clinic, total and robotic surgery time, bleeding, conversions, complications, postoperative stay and follow-up. We carry out a detailed non-systematic review of previous publications on this pathology with conventional laparoscopic and robotic surgery. A choledochal cyst is a rare congenital cystic dilatation of the extra or intrahepatic biliary tract or both. It was first described by Vater and Ezler in 1723 [1].Choledochal cysts have an incidence of 1 in 100,000-150,000 live births in the western population, but reported to be as high as 1 in 13,500 live births in the United States and 1 in 15,000 in Australia. The incidence is higher in Asian population with an incidence of 1 in 1000, of which about two-third cases are reported from Japan. Choledochal cysts are diagnosed in childhood about 75%, also have an unexplained female:male preponderance, commonly reported as 4:1 to 3:1 [2].

Robotic-Assisted Minimally Invasive Surgery in Children

“…Hepatopancreatobiliary RAS in children inevitably involves high complexity, such as Kasai portoenterostomies and choledochal cyst resection [108][109]. Furthermore, liver resection, robot-assisted generally indicated for treatment of tumors [110].…”

“…In 2006, the first pediatric RAS choledochal cyst resection was reported [116]. Since that time and up to 2019, several authors have reported cohorts of 1 to 39 pediatric patients undergoing RAS choledochal cyst resection [109]. A recent publication informed 70 cases with RAS and 70 cases by conventional laparoscopy, and concluded that RAS choledochal cyst excision and hepaticojejunostomy were associated with better short-term intraoperative and postoperative outcomes, and proved the safety and feasibility of RAS in children with choledochal cysts [117].…”

“…The ideal treatment for children with choledochal cyst, nowadays, is MIS, laparoscopic, through expert pediatric surgeons or RAS, in institutions where technology is available. But, if one or another situation is not present, the author recommends continuing with the open approach to offer children the greatest safety and effectiveness [109].…”

“…Previously, we published our experience with RALTS, the first 186 surgeries [14], the first 4 cases of choledochal cyst resection [109], redo Nissen fundoplication [114] and in thoracic surgery [133].…”

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

“…This also happened to Meehan and Sandler [27] . Robotic assistance is ideal for complex hepatobiliary cases and thoracic surgery, particularly for solid mass resection [35,36] .…”