Robotic Single- and Multisite Cholecystectomy in Children

Introduction

The advantages of robotic surgery are well known: better visualization through the use of a three-dimensional camera and complete camera control, as well as enhanced dexterity and precision through tremor filtering and articulated instrumentation.^1–3 These features address the limitations of standard laparoscopy: a two-dimensional operative field, as well as limited range of wrist motions and dexterity. Despite this potential, however, there have only been a few studies and case reports demonstrating the use of robots in pediatric general surgery.^4–9 Perhaps it is not so hard to imagine why, comparing the sheer size of the nearly 6-foot-tall, 567-kg Da Vinci^® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) robot next to an infant or even a teenager. ⁸ Here we present a single-institution experience of elective robotic cholecystectomies, a simple and high-volume procedure in a pediatric population, to suggest that not only is it safe and efficacious, but moreover it can serve as an excellent introductory procedure for pediatric surgeons considering the development of a pediatric robotic surgery program.

Materials and Methods

With the institutional review board's approval (Institutional Review Board exemption number 3997), we performed a retrospective review of our first nine children who underwent elective robotic cholecystectomy at Albany Medical Center (Albany, NY) over a 2-year period between early 2013 and late 2014. The diagnoses for the procedures were symptomatic cholelithiasis and biliary dyskinesia.

For multiport robotic cholecystectomy, a 10-mm camera port was placed by cutdown at the umbilicus. Two 8-mm ports were placed for robotic instruments in the right and left upper quadrants, plus one 5-mm assistant port on the right side. The robotic camera affords three-dimensional visualization. Pneumoperitoneum was created with CO₂ insufflation to 15 mm Hg pressure. The gallbladder fundus was retracted over the hepatic margin and held by an assistant. For multiport cholecystectomy, the operating instruments were wristed instruments with a full range of motion. The structures of the triangle of Calot's were dissected using hook cautery, and the cystic duct and artery were each controlled with locking clips, two clips on the patient side. The specimen was dissected out of the gallbladder fossa with hook cautery. The umbilical port site fascia was closed with polyglactin 910 (0-Vicryl^®; Ethicon, Somerville, NJ) suture.

For single-site cholecystectomy, an incision was made through half the circumference of the umbilicus. The fat and subcutaneous tissues were divided sharply, and the umbilical stalk was detached from the midline fascia, which was then incised vertically for 2.5 cm. Marking sutures of 0-Vicryl were placed in the fascial edges to facilitate closure. The Da Vinci Single-Site^® port was then placed in the incision, and the abdomen was insufflated to 15 mm Hg pressure. All instruments and optics were then placed via this single site. A 5-mm camera was introduced, as well as two instruments for dissection and cautery, and one 5-mm standard laparoscopic grasper for retraction by an assistant. The Single-Site dissecting and cautery instruments do not have wristed action. The Da Vinci computer software allows the surgeon to control the dissection in a natural intuitive fashion because each hand controls the instrument on its own side without the need for crossing over. Dissection was with hook cautery as described above. The midline fascia was closed with interrupted polydioxanone (0-PDS^®; Ethicon) sutures.

All procedures were performed with the standard Da Vinci Si surgical robot. The console surgeon was the attending pediatric surgeon, proctored by an experienced robotic general surgeon. The bedside assistants were second through fourth year surgical residents and a surgical physician assistant. Using the medical records of these 9 patients we reviewed their demographics, comorbidities, anesthesia time, surgery time, console time, treatment outcome, and complications.

Results

There were 9 patients who underwent elective robotic cholecystectomy between March 2013 and late 2014. The first 4 patients had robotic multiport cholecystectomy, and the last 5 had robotic single-site cholecystectomy. Eight were girls. Ages ranged from 10 to 18 years, with a median of 14 years. Five patients had a diagnosis of biliary dyskinesia, and 4 patients had symptomatic cholelithiasis. Median body mass index was 24.9 (range, 20.2–43.8) kg/m². Median anesthesia time for multiport cholecystectomy was 139 (range, 120–162) minutes; median anesthesia time for single-site cholecystectomy was 169 (range, 122–180) minutes. Median console time for multiport cholecystectomy was 47 (range, 44–58) minutes; median console time for single-site cholecystectomy was 69 (range, 66–86) minutes. Eight of the 9 patients went home on the day of surgery, and 1 stayed overnight. Patients were seen at 13–20 days after surgery (median, 14 days). There were no complications. The conversion rate to open surgery was 0% for both single-site and multiport surgery. There were no conversions from single-site to multiport surgery.

Discussion

Despite the initial learning curve of robotic surgery, cholecystectomy is a safe operation that provides a low rate of conversion to open surgery and little risk of complications. Robotic cholecystectomy has outcomes similar to those of standard laparoscopic cholecystectomy, ¹⁰ with reduction in length of stay reported in one large series, albeit with increased costs. ¹¹ In single-site robotic cholecystectomy, the instruments are all inserted through one port at the umbilicus, and the computer software in the Da Vinci Surgical System robot renders the image at the console so that the surgeon can control the instruments with the left and right hands in an intuitive fashion without the need for crossing hands, unlike non–robotic single-incision surgery. It offers the possibility of scarless surgery and has been found to be as safe as multiport robotic cholecystectomy. ¹² Between the multiport versus single-port surgeries, we found that there were no differences in outcome in terms of open surgery conversion rate or complication rate. Although the single-port method may yield more cosmetically attractive results, it had both longer anesthesia and console time, and the operating surgeon found the multiport operations to be easier in general.

Robotic surgery has yet to establish a high-volume use in pediatric general surgery, but the technology has been applied to a variety of procedures in children, including gastrointestinal, thoracic, and oncologic procedures.^4–9 Its widespread adoption has been hindered by the perceived difficulty of using such a large device on small children and the already good outcomes from standard minimally invasive techniques. As the technology matures, it is to be expected that robotics will be very useful in complex pediatric surgery, especially as surgeons perform more demanding reconstructive procedures such as esophageal atresia repair. We seek to expand the use of the technology in pediatric surgery at our institution, and we felt that adopting it for cholecystectomy would be a good entry-level procedure on which to learn to use the device. We already have well-established robotic programs at our institution, and we benefited from this institutional expertise. The approach has been safe in our hands, and outcomes have been good. We also had the opportunity to use the Da Vinci Single-Site platform, which offers intriguing possibilities for the future of surgery, although at this time we still find the multisite robotic technique to be easier and quicker.