Minimally Invasive Pediatric Cholecystectomy: A Comparison of Robotic and Laparoscopic Single and Multiport Techniques

Introduction

Laparoscopic surgery has become an essential skill set of the pediatric surgeon with a push to continue to reduce the invasiveness of operative approaches. Fewer and or smaller incisions can improve cosmesis and long-term scarring, but may also decrease postoperative pain and shorten recovery time. Traditional multiport techniques are being challenged by single-incision interventions proven safe and feasible with comparable operative times and complication rates.^1,2 Meanwhile, technological advances offer increased operative options. Robotics specifically is gaining popularity with wristed instrumentation and three-dimensional optics.^3,4 Adult studies report the potential for decreased postoperative pain and improved patient satisfaction with the robotic platform despite an increase in operative times and costs.^5,6 While comparisons between minimally invasive techniques exist, no current study in the literature compares laparoscopic and robotic single- and multiport techniques in a head-to-head manner.

As a children's hospital with a growing robotics program we sought to evaluate current minimally invasive surgical interventions. We chose cholecystectomy as a common procedure with an element of technical difficulty that would help differentiate the techniques. We examined both single-site and multiport methods for both laparoscopic and robotic platforms.

Materials and Methods

All cholecystectomies performed at a single tertiary-care center were retrospectively analyzed over a 4-year period from October 2010 to December 2014. Cholecystectomies were performed through laparoscopic multiport (LMP), laparoscopic single-incision (LSI), robotic multiport (RMP), and robotic single-incision (RSI) techniques, with and without intraoperative cholangiogram. LMP was performed using two 5 mm working ports and a 5 mm umbilical port that was subsequently enlarged to 10 mm size to accommodate gallbladder extraction. RMP used an 8 mm umbilical port and two 5 mm working ports. LSI and RSI utilized a single 2 cm incision at the umbilicus. Fascial closure was performed with interrupted 0-Vicryl suture for all techniques. Data were collected through chart review and included patient characteristics, operative technique, operative times, medications, and postoperative course. Variability in operative technique was accounted for by including only subjects operated on by a single surgeon. Additional exclusion criteria included cholecystectomies performed in conjunction with another procedure. Data were analyzed using a Kruskal–Wallis test secondary to the non-normality of the data. Significance was determined to be P < .05.

Results

Eighty-three patients were eligible for the study. After application of exclusion criteria, 71 subjects were eligible for analysis. Thirty underwent LMP cholecystectomy, 20 LSI, 11 RMP, and 10 RSI. Patient demographics did not differ significantly between age, sex, and weight (Table 1). The mean age in years was 13.4 (±3.5) for LMP (range 3–19), 13.9 (±2.7) for LSI (range 7–18), 14.7 (±1.8) for RMP (range 12–17), and 13.8 (±3.0) for RSI (range 9–17) (P = .8043). The percent female was 80% for LMP, 90% for LSI, 82% for RMP, and 90% for RSI (P = .7374). The mean weight in kilograms was 68.5 (±26.0) for LMP, 65.3 (±18.1) for LSI, 80.3 (±22.3) for RMP, and 66.2 (±15.9) for RSI (P = .3249). Outcomes of interest were obtained through electronic medical record chart review. Operative time data were missing on one RSI patient and these data were not included in analysis. Electronic medical records were reviewed at the time of data collection for a postoperative range of approximately 6 months to 4.3 years. No patient returned to the operating room for surgical correction of postoperative complications.

Discussion

The variability in operative platforms available to the pediatric surgeon is vast. Minimally invasive and robot techniques can be customized with multiport or single-incision access sites. In the laparoscopic arena, Ponsky et al. published a report of 72 single-incision surgeries without any intraoperative complications and a mean operative time for cholecystectomy of 99 minutes, which decreased to 43 minutes by the end of the study as learning curves were overcome. ¹ A larger study out of Birmingham documented 1322 single-incision surgeries with operative times and complication rates comparable to published standards of their multiport counterparts. ² LSI interventions, however, are technically challenging procedures due to loss of ergonomics and counterintuitive instruments. ⁷ The robotics platform attempts to overcome these obstacles mostly by computerized inversion that eliminates the contralateral handedness of the instruments. ⁸

Attention to operations specifically designed for cholecystectomy has broadened our understanding of techniques for this cohort.^5,8–15 As one of the most common interventions performed by pediatric surgeons, minimally invasive cholecystectomy provides an ideal operation for comparison. ¹⁶ The basic tenets of the procedure are widely practiced and understood; however, the proximity to other important structures requires significant technical expertise.

Single-incision laparoscopic cholecystectomy has been proven to be a safe and feasible option with a significant decrease in operative time as surgeons become more familiar with the technique.^13,14 A study by Chandler and Danielson demonstrated no significant difference in operative time or length of stay between LMP and single-incision interventions. ¹¹ A similar study that same year out of California also found no difference in length of stay but did document a shorter operative time for the multiport technique. ¹² Our results confirm the similarity in length of stay and did encounter a statistical difference in operative time indicating that the LSI technique was significantly longer than the other cohorts.

Robotic cholecystectomy has also demonstrated safety and feasibility in the pediatric population.^8,15 Single-incision and multiport options are available, but the comparison of these two techniques in children is sparse in the literature. One study by Ahn et al. noted a median console time of 47 minutes for multiport and 69 minutes for single-incision interventions with all but one of the patients discharged on the day of surgery. ⁹ A low study population of just nine patients was one major limitation of this review. Our series documents 21 robotic cases and to our knowledge is one of the largest series in the pediatric literature. Our robotic single incision cohort had a shorter operative time and was comparable to laparoscopic multiport. In addition, the RSI group had a decreased overall length of stay highlighting one benefit to the robotic technique. As more and more programs are moving to same day discharge for uncomplicated cholecystitis,^17,18 further investigation is needed to determine if this shorter length of stay seen in our study will correlate to an increase in the percentage of patients meeting the same day discharge criteria and, alternatively, if robotic interventions will minimize hospital duration for those with complicated cholecystitis.

While our study specifically examined clinical data points, another consideration is cost. In a comparison of the direct cost associated with each procedure at our institution we did not identify a large difference between techniques. LMP and LSI were similar at approximately $4000, while RMP was close to $4500 and RSI $3600. These estimates evaluated direct costs only and were based on a cost to charge ratio; these values did not include indirect costs such as overhead or facility costs. The gross similarity between these values underscores the importance of assessing the other outcomes of our study, especially those that can impact total cost such as length of stay and operative time.

Our data demonstrate that application of single- or multiport cholecystectomy in both laparoscopic and robotic modalities is a feasible option for the pediatric surgeon. In addition, our research appears to be the first in the pediatric literature to directly compare all four techniques of LMP, LSI, RMP, and RSI. Our findings conclude that RSI and LMP have the shortest operative times, and RSI has the shortest length of stay.

Conclusion

With the predominance of cholecystectomy in a pediatric surgeon's practice, a safe feasible technique is paramount. Newer adaptations to the tried-and-true LMP approach are gaining favor, but are yet to prove superiority. Our study adds to the body of evidence that LSI interventions can be more time consuming than other minimally invasive techniques. Our demonstration of an equally short operative time for RSI compared to LMP adds another option to the surgeon's armamentarium. Couple this finding with a shorter length of stay for RSI cholecystectomy and a potential advantage for robotics is seen. Ultimately, we hope our assessment provides an incentive to continue to explore new minimally invasive techniques.