Comparison of Surgical Outcomes of Laparoscopic and Robotic Surgery in Adult Choledochal Cysts

Abstract

Background:

Minimally invasive surgery (MIS) for cyst excision and Roux-en-Y hepaticojejunostomy (HJ) is widely performed for adult choledochal cysts. Few articles compared the robotic and laparoscopic approaches for choledochal cysts.

Methods:

Between 2014 and 2022, 157 patients who underwent MIS for choledochal cysts were retrospectively analyzed. Perioperative outcomes of patients who underwent totally robotic surgery, robot-assisted surgery, and laparoscopic surgery were compared, respectively. Also, postoperative outcomes of patients with robotic reconstruction and laparoscopic reconstruction during HJ were compared.

Results:

Perioperative outcomes were comparable between robotic and laparoscopic groups. The suturing technique for the anterior and posterior walls of the HJ differed significantly between the robotic and laparoscopic reconstruction groups (P = .001). However, there were no significant differences in postoperative outcomes, including total complications (P = .304), major complications (P = .411), and postoperative interventions (P = .411), between the two groups.

Conclusions:

The robotic and laparoscopic approaches for adult choledochal cysts have comparable surgical outcomes. In the MIS era, robotic surgery could be an alternative surgical option for adult choledochal cysts.

Introduction

Choledochal cyst is a rare congenital dilatation of the biliary tract. It is known to occur more frequently in women and in Asian populations.¹ It is most often diagnosed in children, but can also be diagnosed in adults during health screening or in the presence of symptoms such as abdominal pain, jaundice, and fever.^2,3 Although choledochal cyst is usually a benign condition, it can cause symptoms and potentially be a malignancy risk. Standard treatment is therefore surgical excision of the choledochal cyst followed by Roux-en-Y hepaticojejunostomy (HJ).⁴

In 1995, Farello et al. first reported laparoscopic surgery for choledochal cyst, and in 2006, Woo et al. first reported robot-assisted surgery for the condition.^5,6 But whether laparoscopic or robotic, minimally invasive surgery (MIS) is now being widely used for choledochal cysts. At our institution, laparoscopic surgery has been performed since 2009 and robotic surgery has been performed since 2014 for choledochal cysts in adults. We previously reported the initial experience of robotic and laparoscopic surgery for such patients.⁷ Since then, several studies of MIS for choledochal cyst have been published, but no large comparative evaluations of the robotic and laparoscopic approaches have been reported.^7–9 In this study, we compared the long-term outcomes of 157 MISs performed for choledochal cyst during an 8-year period. To the best of our knowledge, this report analyzes the highest number of robotic surgeries for choledochal cyst in adults to date.

Methods

Patient selection

Data on all adult patients (age: >18 years) with choledochal cyst who underwent MIS between January 2014 and November 2022 at Asan Medical Center (Seoul, ROK) were collected and retrospectively analyzed. Before surgery, blood tests, magnetic resonance cholangiopancreatography, or endoscopic retrograde cholangiopancreatography, and computed tomography (CT) to evaluate the extent and classification of the choledochal cyst, anomalous union of the pancreaticobiliary duct, and associated conditions were performed for all patients. Patients who simultaneously underwent resection of liver or other organs were excluded from the study.

All surgeries were performed by seven experienced surgeons having variable familiarity with MIS in hepatobiliary-pancreatic diseases. The patients receiving robotic surgery were divided into one of two groups: Robot-assisted surgery, in which the choledochal cyst dissection was performed by laparoscopy and the Roux-en-Y HJ anastomosis was performed using the robot; and totally robotic surgery, in which both the dissection and the anastomosis were performed using the robot. The selection of a robotic or laparoscopic approach was determined by combination of discussion with the patient, considering private insurance and financial status and the surgeon's preference. All patients included in the study provided written informed consent before surgery and were analyzed in accordance with the intention-to-treat principle. The study was approved by the Institutional Review Board of the Asan Medical Center (no. 2023-0409).

Surgical procedures

The totally robotic and laparoscopic surgical techniques were similar and have previously been described.^7,10 In robotic-assisted surgery, choledochal cyst dissection was performed by laparoscopy, and Roux-en-Y HJ anastomosis was performed by using robotic platform. The positioning of the trocar varied slightly depending on the surgeon's preference, but basically, a 12 mm trocar for the camera port and four additional trocars (one 12 mm and three 5 mm trocars) were inserted. As previously described,¹⁰ the choledochal cyst dissection and resection were performed laparoscopically, and then the 5 mm trocars are replaced with an 8 mm trocar for robot docking to perform the HJ reconstruction (Supplementary Videos S1 and S2). After robot docking, the HJ anastomosis was performed as totally robotic surgery.⁷ All robotic techniques were performed using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA).

Postoperative management and follow-up

On postoperative day 4 or 5, patients usually underwent CT imaging to check for complications such as fluid collection or bile leakage. At 2 weeks after discharge, patients visited the outpatient clinic for follow-up. If no specific problem was identified, patients returned again at 3 months and then every 6–12 months for CT imaging and laboratory tests to monitor for postoperative complications. In this study, early complications were defined as those diagnosed within 30 days of surgery, and late complications were defined as those diagnosed at 30 days or more after surgery.

Statistical analysis

Categorical variables were analyzed using the chi-squared or Fisher exact test, and continuous variables were analyzed using the Student t-test or Mann–Whitney U-test. In addition, depending on the normality of the variable, either one-way analysis of variance or the Kruskal–Wallis test was used to assess the statistical significance of differences between the study groups. Significance was accepted at a P value of <.05. The IBM SPSS Statistics software application (version 21; IBM, Armonk, NY) was used to analyze the data.

Results

Clinical characteristics

We identified 160 patients who underwent surgery for choledochal cyst, 3 of whom simultaneously underwent liver resection and thus were excluded, leaving 157 patients for the analysis. In that cohort (135 women [86%], 22 men [14%]), mean age was 39.0 ± 10.9 years, mean body mass index was 23.3 ± 3.8 kg/m², and mean cyst size was 3.2 ± 1.3 cm. The measured American Society of Anesthesiologists physical status was less than III in 156 patients (99.4%). The Todani classification was Ia in 49 patients (31.2%), Ib in 6 (3.8%), and Ic in 58 (36.9%); II in 1 patient (0.6%); and IVa in 42 patients (26.8%) and IVb in 1 (0.6%). Previous abdominal surgery was reported in 25 patients (15.9%). The surgical methods were laparoscopic surgery in 62 patients (39.5%), robot-assisted surgery in 31 (19.7%), and totally robotic surgery in 64 (40.8%). In 4 patients, laparoscopic surgery had to be converted to an open procedure because of bleeding, severe pancreatitis, multiple bile duct openings, and tension on the Roux limb. In 1 patient, gallbladder cancer was diagnosed on pathology examination of the surgical specimen (Table 1).

Table 1.

Baseline Characteristics of 157 Patients with Choledochal Cyst

Characteristics	Value
Mean age (years)	39.0 ± 10.9
Sex (N men/women)	22/135
Mean body mass index (kg/m²)	23.3 ± 3.8
Mean cyst size (maximum diameter, cm)	3.2 ± 1.3
ASA physical status (N [%])
<III	156 (99.4)
≥III	1 (0.6)
Todani classification, N (%)
Ia	49 (31.2)
Ib	6 (3.8)
Ic	58 (36.9)
II	1 (0.6)
IVa	42 (26.8)
IVb	1 (0.6)
AUPBD, N (%)	114 (72.6)
Previous abdominal surgery, N (%)	25 (15.9)
Surgical procedure, N (%)
Laparoscopic	62 (39.5)
Robot-assisted	31 (19.7)
Totally robotic	64 (40.8)
Pathology findings, N (%)
Benign	156 (99.4)
Biliary tract cancer	1 (0.6)

ASA, American Society of Anesthesiologists; AUPBD, anomalous union of the pancreaticobiliary duct.

The clinical characteristics of the patients and their perioperative outcomes based on the surgical methods are presented in Table 2. Clinical characteristics in the three groups were comparable. There were no significant differences in perioperative outcomes, such as operation time, postoperative hospital stay, and reoperation.

Table 2.

Clinical Characteristics and Perioperative Outcomes of 153 Patients with Choledochal Cyst, by Surgical Methods

Variable	Surgical methods			P
Variable	Totally robotic (N = 64)	Robot-assisted (N = 31)	Laparoscopic (N = 62)	P
Mean age (years)	37.5 ± 10.7	41.6 ± 11.0	39.4 ± 10.9	.222
Sex (N men/women)	7/57	4/27	11/51	.535
Mean body mass index (kg/m²)	23.1 ± 3.8	24.1 ± 4.4	23.2 ± 3.4	.449
Cyst size (maximum, cm)	3.3 ± 1.5	3.0 ± 1.1	3.3 ± 1.3	.407
ASA physical status, N (%)				.463
<III	64 (100)	31 (100)	57 (98.3)
≥III	0 (0)	0 (0)	1 (1.7)
Todani classification, N (%)				.781
Ia	24 (37.5)	7 (22.6)	18 (29.0)
Ib	2 (3.1)	2 (6.5)	2 (3.2)
Ic	21 (32.8)	14 (45.2)	23 (37.1)
II	1 (1.6)	0 (0)	0 (0)
IVa	16 (25)	8 (25.8)	18 (29.0)
IVb	0 (0)	0 (0)	1 (1.6)
AUPBD, N (%)	48 (75)	23 (74.2)	43 (69.4)	.758
Operation time (minutes)^a	220 (188–254)	199 (182–225)	226 (195–280)	.397
Postoperative hospital stay (days)^a	6 (5–7)	7 (7–8)	7 (7–9)	.836
Readmission, N (%)	18 (28.1)	6 (19.4)	15 (24.2)	.643
Open conversion, N	0	0	4

Data expressed as the median (interquartile range).

AUPBD, anomalous union of the pancreaticobiliary duct.

Postoperative outcomes of robotic and laparoscopic reconstruction

After excluding the 4 patients converted from a laparoscopic to an open procedure, 153 HJ anastomoses were available for analysis, of which 95 (62%) were robotic reconstructions and 58 (38%) were laparoscopic reconstructions. The posterior wall HJ suturing used the interrupted technique in 56 of the robotic cases (58.9%) and in 16 of the laparoscopic cases (27.6%). The anterior wall suturing used the interrupted technique in 85 of the robotic cases (89.5%) and in 38 of the laparoscopic cases (65.5%). The suturing technique for the anterior and posterior walls of the HJ was statistically significantly different between the groups (P = .001; Table 3).

Table 3.

Suturing Technique During Hepaticojejunostomy, by Reconstruction Methods

HJ	Suture type	Reconstruction methods		P
HJ	Suture type	Robotic (N = 95)	Laparoscopic (N = 58)	P
Posterior	Interrupted	56 (58.9)	16 (27.6)	.001
Posterior	Continuous	39 (41.1)	42 (72.4)	.001
Anterior	Interrupted	85 (89.5)	38 (65.5)	.001
Anterior	Continuous	10 (10.5)	20 (34.5)	.001

HJ, hepaticojejunostomy.

Total complications were fewer in the robotic group, with 28 cases (29.5%), compared to the laparoscopic group, which had 24 cases (38.7%). Major complications (Clavien–Dindo classification III or higher) were also fewer in the robotic group, with 17 cases (17.9%) compared to the laparoscopic group, which had 16 cases (25.8%). However, there were no significant differences between the groups (total complications, P = .304; major complications, P = .411; Table 4).

Table 4.

Postoperative Complications and Management Following Reconstruction Methods During Hepaticojejunostomy

Variable	Reconstruction methods		P
Variable	Robotic (N = 95)	Laparoscopic (N = 62)	P
Total complications	28 (29.5)	24 (38.7)	.304
Major complications (CDC≥III)	17 (17.9)	16 (25.8)	.411
Early complications (<30 days)	14 (14.7)	9 (14.5)	1.000
Bile leakage	7 (7.4)	3 (4.8)	.764
Bile duct stricture	3 (3.2)	1 (1.6)	.934
Bleeding	1 (1.1)	1 (1.6)	1.000
Fluid collection	2 (2.1)	1 (1.6)	1.000
Others	1 (1.1)	3 (4.8)	.340
Late complications (≥30 days)	21 (22.1)	16 (25.8)	.732
Bile duct stricture	15 (15.8)	11 (17.7)	.919
Bile duct stone	6 (6.3)	8 (12.9)	.259
Liver abscess	4 (4.2)	1 (1.6)	.659
Other^a	3 (3.2)	4 (6.5)	.561
Postoperative interventions	18 (18.9)	16 (25.8)	.411
Radiologic	18 (18.9)	13 (21.0)	.916
Endoscopic	0 (0)	2 (3.2)	.301
Surgical	1 (1.1)	2 (3.2)	.707

Includes fluid collection, ileus, wound problems, portal vein thrombus, pancreatitis, and A-loop obstruction.

CDC, Clavien–Dindo classification.

Early complications were diagnosed in 9 laparoscopic cases (14.5%) and in 14 robotic cases (14.7%), which showed a nonsignificant difference (P = 1.000). The most common early complication was bile leakage in both the laparoscopic group (N = 3, 4.8%) and the robotic group (N = 7, 7.4%). Other early complications in the robotic group were bile duct stricture (N = 3, 3.2%), bleeding (N = 1, 1.1%), fluid collection (N = 2, 2.1%), and a wound problem (N = 1, 1.1%). Other early complications in the laparoscopic group were bile duct stricture (N = 1, 1.6%), bleeding (N = 1, 1.6%), fluid collection (N = 1, 1.6%), ileus (N = 1, 1.6%), portal vein thrombus (N = 1, 1.6%), and pancreatitis (N = 1, 1.6%).

Late complications were diagnosed in 16 laparoscopic cases (25.8%) and 21 robotic cases (22.1%), a nonsignificant difference (P = .732). The most common late complication was bile duct stricture in both the laparoscopic group (N = 11, 17.7%) and the robotic group (N = 15, 15.8%). Other late complications in the robotic group were bile duct stones (N = 6, 6.3%), liver abscess (N = 4, 4.2%), fluid collection (N = 2, 2.0%), and A-loop syndrome (N = 1, 1.0%). Other early complications in the laparoscopic group were bile duct stones (N = 8, 12.9%), liver abscess (N = 1, 1.6%), ileus (N = 3, 4.8%), and pancreatitis (N = 1, 1.6%).

Postoperative interventions for major complications were relatively less frequent in the robotic group (N = 18, 18.9%) than in the laparoscopic group (N = 16, 25.8%), but the difference was statistically nonsignificant (P = .411). In the laparoscopic group, most interventions were radiologic (N = 13, 21.0%, including percutaneous transhepatic biliary drainage, pigtail drainage, and embolization), but some were also endoscopic (N = 2, 3.2%) or surgical (N = 2, 3.2%). One patient underwent embolization for jejunal branch bleeding and an HJ revision for bile duct stricture at different times. In the robotic group, most interventions were also radiologic (N = 18, 18.9%); just one was surgical (1.1%). One patient underwent both percutaneous transhepatic biliary drainage for bile duct stricture and reoperation for A-loop syndrome. Median follow-up was longer in the laparoscopic group than in the robotic group (44 versus 33 months).

Discussion

Choledochal cysts are usually found in children, but are occasionally diagnosed in adults,⁴ with a prevalence in young women. MIS is becoming the predominant treatment in adult choledochal cysts, given its advantages of better cosmetic outcome, early recovery, and less postoperative pain.^11,12 Also, because choledochal cysts are typically benign, the postoperative complications of the surgery are more important than potential oncologic outcomes. Laparoscopic surgery became the alternative to open surgery for choledochal cysts as the related surgical equipment and experience developed after its first description in 1995.

Laparoscopic surgery has the advantages of better postsurgical cosmesis and magnified surgical views. However, despite the recent development of the three-dimensional camera and articulating laparoscopic instruments, limitations of instrument movement in the laparoscopic approach create technical difficulties in biliary-enteric reconstruction, which requires precise sutures and tension-free knots. In particular, the technique of laparoscopic suturing for a small-diameter bile duct is not easy and requires considerable practice.

The most common complications after surgery for choledochal cyst are biliary complications related to the HJ anastomosis.^13–16 According to the literature, bile leaks occur in 2.3%–5.6% of cases and bile duct stricture occurs in 3.7%–8.0% of cases after HJ anastomosis.^13,17–19 Those complications prolong the hospital stay and, when major, require postoperative intervention. The safety and quality of biliary-enteric reconstruction are therefore the most important aspect of surgery for choledochal cyst.

Robotic platforms are useful for overcoming the limitations of laparoscopic surgery during intracorporeal anastomosis. The advantages of robotic surgery are its three-dimensional high-definition view, freedom of movement and angulation, and features that provide natural dexterity and tremor filtering. Those advantages permit precise and stable suturing during the anastomosis procedure.^20–22 In addition, learning curve by surgeons of anastomotic technical skills is known to be shorter with robotic than with laparoscopic surgery.^23,24 However, the absence of the tactile sense is one disadvantage of robotic surgery that can affect the fine dissection and traction of tissue. Another disadvantage is the high cost, which might influence the choice of surgical approach solely because of the patient's financial and insurance status.

Few studies have compared laparoscopic and robotic surgery to determine which MIS approach might be more appropriate for choledochal cyst in adults, and most were limited by a small sample size. Yoon reported that there was no difference in postoperative complications and operative time between the two groups.⁹ However, Lee reported that the laparoscopic group had a shorter operation time and a higher postoperative complication rate compared to the robotic group.⁸ The perioperative outcomes of robotic and laparoscopic surgery are controversial in several studies. In our previous study, there were no differences in operation time and length of hospital stay between the two groups performed during the same period.⁷ Since then, long-term follow-up data on more than 150 patients who underwent MIS have been collected. However, in this study, there were no significant differences in perioperative outcomes such as operation time, length of hospital stay, and readmission rate between the robotic and laparoscopic groups.

Given that the suturing technique is an important component of the HJ anastomosis, we also compared robotic with laparoscopic reconstruction, finding significant differences between the groups. Interrupted sutures were more often used on both the anterior and posterior walls in the robotic group than in the laparoscopic group. The analysis of complication rates between suturing techniques in HJ has been controversial.^25,26 In general, the operation time and difficulty are known to be relatively higher when interrupted sutures rather than continuous sutures are used, because more sutures and knot tying are required.²⁶ The ergonomics of robotic surgery presumably enable more comfortable suturing and knot tying in anastomosis procedures.

Biliary problems such as bile leaks, bile duct stricture, and bile duct stones were the most common causes of early and late complications in both our study groups, all being related to the HJ anastomosis. The comparisons of biliary complications between the groups therefore have some significance in confirming the safety of the HJ. However, there were no significant differences in postoperative outcomes, including total complications (P = .304), major complications (P = .411), and postoperative interventions (P = .411) between the two groups. Although robotic surgery has advantages in the anastomosis procedure, no differences in postoperative outcomes between the groups have yet been confirmed. That result seems to be related to laparoscopic surgeries being performed by experienced surgeons who have mastered the learning curve. Moreover, our study included our institution's initial experience of robotic surgery because all MISs were performed during a period that started in 2014, when the robotic platform was introduced.

Our study has some limitations. First, as a retrospective single-center study, it has inherent biases and might be difficult to generalize despite the participation of seven experienced surgeons. Second, follow-up was shorter in the robotic group than in the laparoscopic group. Further follow-up study is therefore needed to evaluate the safety of robotic surgery. Lastly, the sample size was relatively small. Because choledochal cyst is a rare condition, collecting a large sample size in a single center was difficult. Further multicenter studies with long-term follow-up are needed for a comparison of complication rates in robotic and laparoscopic surgery.

Conclusions

The robotic and laparoscopic choledochal cyst excision and Roux-en-Y HJ had comparable surgical outcomes including complication rates, operation time, length of hospital stay, and readmission rate in adult choledochal cysts. The robotic approach was as safe and technically feasible as the laparoscopic approach. In the MIS era, robotic surgery could be an alternative surgical option for adult choledochal cysts.

Footnotes

Authors' Contributions

J.H.H.: Visualization, data curation, writing—original draft preparation, Software. J.H.L.: Conceptualization, writing—reviewing, and editing, methodology, resources. B.J.K.: Formal analysis, resources. W.H.L., Y.J.P.: Resources. K.B.S.: Visualization, resources. D.W.H.: Supervision, resources. S.C.K.: Conceptualization, supervision, resources.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

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