Robotic-Assisted and Laparoscopic Splenectomy in Children: A Single Center Comparative Study

Abstract

Background:

To explore the safety, efficacy, advantages, and disadvantages of robotic-assisted splenectomy (RS) in children by analyzing and comparing the clinical data of RS and laparoscopic splenectomy (LS).

Methods:

The clinical data of 35 children who underwent laparoscopic or RS or partial splenectomy from February 2010 to October 2022 were included. A retrospective analysis based on general information, clinical data, and prognosis were performed.

Results:

Among 35 cases, 14 cases, and 21 cases underwent RS and LS, respectively. The average operation time was 167 (120–224) minutes in the RS group and 176 (166–188) minutes in the LS group. The intraoperative blood loss was significantly larger in LS group than RS group (P = .0009). The length of hospital stay was significantly longer in LS group than RS group (P = .0015), and the hospitalization cost was significantly higher in RS group than LS group (P < .0001). There were no cases of conversion to laparotomy in the RS group, but two cases in the LS group. In terms of postoperative complications, there were one and three cases in the RS and LS groups, respectively.

Conclusion:

The Robotic Surgical System was safe and feasible in pediatric splenectomy or partial splenectomy which was an alternative to laparoscopic surgery.

Introduction

Splenectomy is often used to treat splenic tumors, blood diseases, and hypersplenism. Before the application of robot-assisted technology, laparoscopic splenectomy (LS) was the preferred choice in clinical practice, which has been widely applied clinically. But it is still a complicated and difficult operation, which has a high requirement for an experienced user with good laparoscopic skills. With the promotion of robot-assisted technology in clinical applications, many complicated and difficult surgical operations have become simple and easy. The most widely used surgical robot system currently is the da Vinci robotic surgical system. Since its introduction in January 1999,¹ the system has been developed to the fourth-generation and as a result, has become more widely used for pediatric surgery.

Although robotic-assisted splenectomy (RS) has gained wide application in pediatric surgery in recent years, most studies have small sample size and lack of comparison with LS. This study analyzed and summarized the clinical data of 35 children who underwent LS or RS in this hospital from February 2010 to October 2022 and compared the safety, effectiveness, advantages, and disadvantages of RS with LS.

Materials and Methods

Clinical data

The clinical data of 35 cases of minimally invasive splenectomy and partial splenectomy in this hospital from February 2010 to October 2022 was analyzed. There were 14 cases and 21 cases in the RS and LS groups, respectively, where the choice of protocol was made voluntarily. All guardians signed the informed consent documents.

The collected data included age, sex, weight, diagnosis, surgical approach, operation time, intraoperative blood loss, conversion to laparotomy, postoperative complications, length of hospital stay (LOS), and hospitalization cost. The operation was performed by the same general surgical team.

Statistical analysis

Statistical analysis was made using SPSS 23.0 and GraphPad Prism 6 software. The one-sample Kolmogorov–Smirnov test was used for normal distribution test of all continuous data, and P > .05 was regarded as the data conforming to the normal distribution. If the normal distribution was met, the continuous data are expressed as mean ± standard deviation; otherwise, it was expressed as median with an interquartile range. A nonparametric t-test was used for continuous variables, and P < .05 indicated that difference was statistically significant.

Results

All 14 cases in the RS group successfully completed da Vinci XI-assisted splenectomy or partial splenectomy, and there was no case of conversion to laparotomy. Eight cases were diagnosed with splenic tumors and six cases with spherocytosis. There were seven males and seven females in the RS group, with an average age of 10.1 years old, ranging from 9.1 to 11.1 years and an average weight of 38.4 kg, ranging from 37.6 to 40.2 kg (Table 1). The average operation time was 167 (120–224) minutes, of which the average installation time of Da Vinci XI system was 12 minutes, ranging from 9 to 15 minutes. The average intraoperative blood loss was 20 (8.7–27.5) mL and the average LOS was 8 days, ranging from 7 to 9.25 days. The follow-up period ranged from 2 to 28 months. Postoperative complications included 1 patient with a splenic cyst that experienced local encapsulation of an effusion after surgery and the condition improved after four episodes of local puncture and drainage. There was no abdominal bleeding, incision infection, pancreas injury, thrombosis, and other complications. The average hospitalization cost was 69 (67–71) thousand renminbi (RMB) (Table 2).

Table 1.

Patient Characteristics

	LS (n = 21)	RS (n = 14)	P
Age (years)	8.6	10.1	.0067
Gender (F:M)	12:9	7:7	.739
Weight (kg, IQR)	32.4 (29.9–34.1)	38.4 (37.5–40.2)	<.0001

IQR, interquartile range; LS, laparoscopic splenectomy; RS, robotic-assisted splenectomy.

Table 2.

Comparison of Outcomes Between Laparoscopic and Robotic Splenectomy

	LS (n = 21)	RS (n = 14)	P
Operation time (minutes, IQR)	168 (156–176)	167 (120–224)	.7968
Intraoperative blood loss (mL, IQR)	51 (23–62)	20 (8–27)	.0009
Complications
Intraoperative	3 (14.3%)	0	/
Postoperative	3 (14.3%)	1 (7.1%)	/
Length of hospital stay (days, IQR)	10 (9–12)	8 (7–9.3)	.0015
Hospitalization cost (RMB, IQR)	32124 (31233.5–34212.5)	68511.5 (67454–71239)	<.0001

LS, laparoscopic splenectomy; RMB, renminbi; RS, robotic-assisted splenectomy; IQR, interquartile range.

In the LS group, 18 out of 21 cases underwent LS or partial resection, and 3 cases were converted to laparotomy due to intraoperative bleeding. Primary diseases included 7 cases of splenic tumors, 11 cases of spherocytosis, 1 case of thrombocytopenic purpura, and 2 cases of hypersplenism. There were 9 males and 12 females with an average age of 8.6 years, ranging from 7.9 to 9.2 years, with an average weight of 32.4 kg, ranging from 29.9 to 34.1 kg. The average operation time was 176 (166–188) minutes. The average intraoperative blood loss was 51 (23.5–75.5 mL), and average the LOS was 10 (9–12) days. The patients were followed up for 3 to 12 years. There were three cases of postoperative complications including one case of residual abdominal infection, one case of peritoneal encapsulated effusion, and one case of abdominal hemorrhage. The average hospitalization cost was 32 (31–34) thousand RMB (Table 2).

Discussion

The use of LS has occurred for more than 30 years since Delaitre and Maignien reported it in 1991,² and Tulman et al. applied LS to pediatric surgery in 1993.³ Compared with traditional surgery, LS had the advantages of less surgical trauma and faster postoperative recovery. It has been widely promoted in clinical practice and is currently the first choice for splenectomy. However, LS is still a laparoscopic surgery with high risk and difficulty, and it requires high surgical skills and a clinically experienced surgeon.

The da Vinci Robotic Surgery system is an upgraded intelligent laparoscopic system, which can greatly reduce the difficulty of complex operations in minimally invasive surgery and simplify complex operations through high-definition 3D images, flexible robotic arms, and advanced control system. In 2003, Talamini et al.⁴ first reported the application of robotic systems in splenectomy. Among the seven reported cases, two cases were converted to laparotomy, so at that time, it was considered that splenectomy was not an ideal indication for robotic surgery. In the field of pediatric surgery, Mbaka et al.⁵ summarized and reported 32 cases of RS in children in 2017, showing that the surgical time of RS was shorter than that of LS, and there was no significant difference in postoperative complications between them. This study compared and analyzed 35 cases of splenectomy or partial splenectomy, including 14 cases of RS and 21 cases of LS.

Operation time

Previous studies showed that RS was associated with a longer operation time,⁶ associated with the cumbersome installation process and long installation time in the third generation or earlier da Vinci SI system, which led to the prolongation of overall operation time. The fourth-generation da Vinci XI system has simplified the installation process and halved the installation time to around 12 minutes. In this study, the operation time in the RS group was slightly shorter than that in the LS group and closely related to the size of the spleen, which reduces operational space for splenomegaly and significantly increasing operation time. The operation time of partial splenectomy is also significantly longer than that of full splenectomy.

Single-center comparative studies by Mbaka et al.⁵ and Shelby et al.⁷ both found that in the case of large spleen volume, the operation time of RS was shorter than that of LS. Shelby et al. reported that the average operation time of RS was 140.5 minutes, which was shorter than 154.9 minutes for the LS group, and in the comparative study by Mbaka et al., the average operation time was significantly shortened from 182.4 minutes of LS to 159.6 minutes for RS. In this study, all 14 children successfully completed da Vinci XI-assisted full or partial splenectomy. The average operation time was 167 minutes, which was shorter than 176 minutes in the LS group, although not significant (P = .79) and increased spleen volume increased the difference in the operation time between RS and LS.

There are several reasons to explain this difference. The fourth-generation da Vinci XI Robotic System is easier to install than the third-generation or earlier SI system, reducing from more than 30 to 12 minutes in the da Vinci XI system. The da Vinci XI Robotic System significantly improves the operation efficiency. Anatomical separation, ligation, hemostasis, as well as the overall operation time has been shortened, particularly in the splenomegaly operation, although the small sample number did not allow statistical significance analysis, and of course, the improvements in surgical skills of surgeons have a significant impact on reducing the operation time. It is hypothesized that with the update of the system to the fourth generation, operation time is no longer a factor to hinder the application of robot in splenectomy, and the robot-assisted surgery even has the advantage of reducing operation time in splenomegaly surgery.

Intraoperative blood loss

Both the da Vinci XI and laparoscopic systems rely on a lens to provide the surgical field of view. Their ability to deal with hemorrhage that influences the field of view as well as major abdominal hemorrhage is inferior to traditional laparotomy, so fine dissection is the most effective way to prevent and control intraoperative bleeding. The visual field of the wound and the efficiency of electrocoagulation will be affected by intraoperative bleeding in da Vinci system, and it requires washing of the wound to maintain a clear field of view and exposes the precise location of hemorrhage. Because the suction fluid is often a mixture of flushing fluid and blood, coupled with factors such as residual fluid in the peritoneal cavity, the amount of hemorrhage cannot often be accurately estimated and is generally estimated by subtracting the amount of rinsing fluid from the total amount of suction fluid.

In partial splenectomy, there is often oozing blood from the wound surface of the residual spleen, and the intraoperative blood loss is often more than that in full splenectomy. Qureshi et al.,⁸ Rescorla et al.,⁹ Hassan and Al Ali,¹⁰ Xu et al.,¹¹ Xi, et al.¹² reported a total of 186 cases of LS, with an average bleeding volume of 52 mL. Bhattacharya et al.¹³ compared the data of 202 cases of RS and 258 cases of adult LS through meta-analysis and found that the intraoperative blood loss in the RS group was significantly lower than that in the LS group. The data from this study showed that the average blood loss in the RS group was 20 mL, which was significantly less than 51 mL in the LS group. However, due to the small sample size and the significant impact of blood loss during partial splenectomy on statistical results, a larger sample size is needed to compare intraoperative blood loss between robotic-assisted and LS in the future.

Intraoperative and postoperative complications

Intraoperative and postoperative complications include major intraoperative bleeding, conversion to laparotomy, postoperative incision infection and abdominal cavity residual infection, recurrence, pancreatic injury, and postoperative portal vein thrombosis, with complications caused by primary diseases as well as other internal diseases beyond the scope of this article. Mbaka et al.⁵ reported 32 cases of robot-assisted splenectomy, and there was no postoperative complication case, while 2 of 23 cases of LS had major postoperative bleeding and conversion to laparotomy. Shelby et al.⁷ reported 10 RS cases and 14 LS cases, and there were no perioperative complications in either group. The study of Bhattacharya et al.¹³ did not find a significant difference in intraoperative and postoperative complications in adult RS and LS patients. Ghidini et al.¹⁴ analyzed the data of 80 pediatric RS cases, and their study showed that there was no significant difference in postoperative complications and conversion to laparotomy between the RS and LS groups.

In this cohort, there was one case of splenic encapsulation effusion in the RS group and each case of abdominal cavity residual infection, peritoneal encapsulation effusion, and peritoneal hemorrhage, as well as three cases of conversion to laparotomy were all caused by uncontrollable major intraoperative bleeding in the LS group. The RS and LS groups had no significant difference in postoperative complications, and the RS group had a lower rate of conversion to laparotomy (P < .05). We believe that robotic surgery is more precise in dissecting splenic vessels which can reduce the risk of conversion to laparotomy by improved control of intraoperative bleeding. However, the reliability of data comparison studies is limited due to the small sample size and large time span. Further studies with larger sample sizes are needed to improve the statistical power and draw more robust conclusions.

Length of hospital stay

There is a difference in LOS reported in domestic and foreign literature. In the study by Mbaka et al.,⁵ LOS in the RS group was 3.93 days, which was longer than that in the LS group at 2.9 days. More severe primary disease in the RS group may explain the longer LOS in the RS group. Shelby et al.⁷ reported the opposite result where LOS was 2.1 days in the RS group, which was shorter than 3.2 days in the LS group. In China, Tang Yong et al.¹⁵ reported 31 adult RS cases with 9.4 ± 1.9 days of LOS. Qureshi et al.⁸ reported that the LOS in LS surgery was 1.4 to 4.5 days. In this study, the mean LOS of the RS group was 8 and 10 days for the LS group. There was no statistical significance between the two groups (P > .05), but the LOS in our cohort was longer than that reported in other literature. It is hypothesized that the surgical approach may have a limited effect on LOS, while other factors such as variations in medical environment, concept of enhanced recovery after surgery, and the standard of discharge between China and Western countries affected LOS more significantly.

Hospitalization cost

The da Vinci XI robotic system operation and instrument cost were higher than the traditional laparoscope. In our cohort, the average hospitalization cost was 69,000 RMB in the RS group and 32,000 RMB in the LS group. The former was twice as high as the latter, and the difference was statistically significant (P = .0001). In the United States, Shelby et al.⁷ reported that the average hospitalization cost of RS surgery was 44,000 U.S. dollars and 30,000 U.S. dollars for LS surgery, which also showed a significant difference. The high cost of robot-assisted surgery mainly results from two aspects. The first is the high investment and maintenance cost of robotic equipment, up to 20 times higher than ordinary laparoscopy. The second is the depreciation of the robotic equipment. Robotic systems have a limited number of uses and the cost per use is much higher than that of ordinary laparoscopy. The da Vinci XI robotic surgery will increase the financial burden of patients, so it is more viable for wealthy patients or patients with medical insurance.

Conclusions

The da Vinci XI Robotic System is safe and feasible for splenectomy in children and delivers similar results to our laparoscopic surgery in pediatric splenic surgery. To confirm its advantages of reducing operation and hospitalization time, blood loss, conversion to laparotomy, and postoperative complications, a larger sample size and longer follow-up time will be required.

Footnotes

Acknowledgment

We thank International Science Editing (www.internationalscienceediting.com) for editing this manuscript. A preprint can be seen on

Authors' Contributions

Q.C.: Review and editing. Y.Z. and S.Z.: Conceptualization; writing—original draft; formal analysis. D.C. and W.L.: Software; writing—review and editing. Y.J.: Methodology; writing—review and editing. Z.G.: Conceptualization; Writing—original draft; writing—review and editing. (doi: 10.21203/rs.3.rs-2716971/v1)

Ethics Approval

This study was carried out in accordance with the recommendations of the Ethics Committee of the Children's Hospital, Zhejiang University School of Medicine [2021-IRBAL-180] with written informed consent in accordance with Declaration of Helsinki. The protocol was approved by the Ethics Committee of the Children's Hospital, Zhejiang University School of Medicine, and informed consent was obtained all from their parents.

Consent to Participate

Written informed consent was obtained from the parents.

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Clinical Medical Research of Minimally Invasive Diagnosis and Treatment of Abdominal Organs in Zhejiang Province [grant number: 01492-02]. Health Science and Technology Plan of Zhejiang Province (2022RC201); Zhejiang Provincial Natural Science Foundation Project (LY20H030007).

References

Wilson

. The evolution of robotic general surgery. Scand J Surg, 2009; 98(2):125–129; doi: 10.1177/145749690909800208

Delaitre

, Maignien

. Splenectomy by the laparoscopic approach. Report of a case. La Presse Méd, 1991; 20(44):2263; PMID: 1838167.

Tulman

, Holcomb

, Karamanoukian

, et al. Pediatric laparoscopic splenectomy. J Pediatr Surg, 1993; 28(5):689–692; doi: 10.1016/0022-3468(93)90033-h

Talamini

, Chapman

, Horgan

, et al. A prospective analysis of 211 robotic-assisted surgical procedures. Surg Endosc, 2003; 17(10):1521–1524; doi: 10.1007/s00464-002-8853-3

Mbaka

, Robl

, Camps

. Laparoscopic versus robotic-assisted splenectomy in the pediatric population: Our institutional experience. Am Surg, 2017; 83(9):358–359; PMID: 30454351.

Giza

, Tudor

, Roxana

, et al. Robotic splenectomy: What is the real benefit?. World J Surg, 2014; 38(12):3067–3073; doi: 10.1007/s00268-014-2697-6

Shelby

, Kulaylat

, Villella

, et al. A comparison of robotic-assisted splenectomy and laparoscopic splenectomy for children with hematologic disorders. J Pediatr Surg, 2021; 56(5):1047–1050; doi: 10.1016/j.jpedsurg.2020.08.031

Qureshi

, Ergun

, Sandulache

. Laparoscopic splenectomy in children. JSLS, 2005; 9(4):389–392; PMID: 16381351.

Rescorla

, Breitfeld

, West

, et al. A case controlled comparison of open and laparoscopic splenectomy in children. Surgery, 1998; 124(4):675–676; doi: 10.1067/msy.1998.91223

10.

Hassan

, Al Ali

. Massive splenomegaly in children: Laparoscopic versus open splenectomy. J Soc Laparoendosc Surg, 2014; 18(3):e2014–e2245; doi: 10.4293/JSLS.2014.00245

11.

Bing

, Bing

, Liming

, et al. Laparoscopic splenectomy in children. J Clin Pediatr Surg, 2005; 12:216–218; doi:10.3969/j.issn.1671-6353.2013.03.016

12.

, Cui

, Wang

, et al. Application of fractional ligature of splenic stalk in laparoscopic splenectomy in Children. J Clin Pediatr Surg, 2010; 9:184–185; doi: 10.3969/j.issn.1671-6353.2010.03.011

13.

Bhattacharya

, Phelan

, Fisher

, et al. Robotic vs. laparoscopic splenectomy in management of non-traumatic splenic pathologies: A systematic review and meta-analysis. Am Surg, 2022; 88(1):38–47; doi: 10.1177/0003134821995057

14.

Ghidini

, Bisoffi

, Gamba

, et al. Robot-assisted versus laparoscopic approach for splenectomy in children: Systematic review and meta-analysis. J Laparoendosc Adv S, 2022; 32(11):1203–1210; doi: 10.1089/lap.2021.0882

15.

Yong

, Wang

. Robotic-assisted laparoscopic splenectomy using “the tunnel-building technique”: A report of 31 patients. Chin J Hepatobil Surg, 2019; 25:768–770; doi: 10.3760/cma.j.issn.1007-8118.2019.10.012