Abstract
Abstract
Introduction:
Modifications to conventional laparoscopic cholecystectomy are aimed to decrease abdominal pain and improve cosmetic results. Single-port robotic cholecystectomy is a safe and feasible approach that has been reported in adults, though reports are limited in children. This study aims to report our experience with single-port robotic cholecystectomy in children, and to evaluate the safety, feasibility, and outcomes of this approach.
Methods:
After single-port robotic approach was available at our institution, we prospectively followed our patients who underwent a single-port robotic cholecystectomy from March 2013 to May 2015 in our children's hospital.
Results:
There were 14 patients [female 11 (79%) versus male 3 (21%)], the average age was 12.20 ± 4.97 years, with a mean body mass index of 28.01 ± 8.57 m/kg2. Of the 14 patients, 4 (29%) had cholelithiasis with choledocolithiasis and had undergone an endoscopic retrograde cholangiopancreatography before the operation, 6 (43%) had symptomatic cholelithiasis, and 4 (28%) had acute cholecystitis. The median operative room time was 125 minutes (range 60–202), the median time of operation was 77.5 minutes (range 64–169), the median estimated blood loss was 2 mL (range 2–25), and a median length of stay was 1 day (range 0–2). There were no conversions to another approach. The median follow-up was 7 months (range 3–22). One patient (7%) developed an umbilical port site seroma, which was managed conservatively, no other complications occurred.
Conclusions:
Single-port robotic cholecystectomy is a feasible and safe approach for cholecystectomy in the pediatric population. More studies are required to compare it to different approaches.
Introduction
L
The first laparoscopic cholecystectomy reports in children were in 1991,6–10 and the first comparison between open and laparoscopic approach was reported in 1997 by Al-Salem et al. 11 Emami et al. in 2011 reported their experience with single-incision laparoscopic (SIL) cholecystectomy as a feasible and safe approach.
The first less invasive laparoscopic cholecystectomy was in 1995 where three port laparoscopic cholecystectomy was reported by Slim et al. 12 In 1997, Navarra et al. 13 reported a SIL cholecystectomy using transabdominal wall sutures. It was followed in 1999 by Piskun and Rajpal 14 who describe a single-incision transumbilical laparoscopic cholecystectomy. Of these, SIL surgery has been supported due to decreased trauma and improved cosmesis, though this has not widely been accepted due to difficulty achieving triangulation with camera and instruments, limited critical view due to single-axis dissection, steeper learning curve due to the complexity of surgical instruments, and the implicated instruments costs.15,16
Most recently robot-assisted surgery was introduced, and it has slowly transitioned as the new platform. Initial reports in children with this approach were reported in the first decade of 200017–19 ; though in the last years this approach has gained popularity in this age group due to cosmetic results.20–22
In our institution we started using the da Vinci® Surgical System for cholecystectomies in 2013. Due to the limited data on single-port robot-assisted cholecystectomy, we decided to report our experience in pediatric patients with this minimally invasive approach using a single port.
Materials and Methods
All patients that required cholecystectomy between March 2013 and May 2015 were prospectively selected to undergo a single-port robotic cholecystectomy, though data was retrospectively collected for analysis. No exclusion criterion was applied. All surgeries were performed in our institution by the senior author. The robot used for these operations was the da Vinci Si Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). The single port used was the da Vinci Single-Site®. We collected demographic, operative, pathology, and post-operative data.
Operative technique
The patient was positioned supine with arms tucked. Access to the abdomen was obtained through transumbilical incision, the fascia incision was extended to fit a da Vinci Single-Site port. The robot was placed at the patient's right side. The instruments used were as follows: a robotic fundus grasper, a hook monopolar electrocautery, and an 8-mm da Vinci zero degree high-definition three-dimensional (3D) laparoscope that was introduced through the camera port. The gallbladder was removed via a standard laparoscopic approach. The gallbladder was removed through the port. Careful attention was given to the umbilical incision closure to avoid future umbilical hernias.
Results
Demographics
There were 14 patients [female 11 (79%) versus male 3 (21%)], with an average age of 12.20 ± 4.97 years, mean body mass index of 28.01 ± 8.57 m/kg2. No other comorbidities or past medical history were identified.
Operation data
Overall, the median operation time was 82 minutes (range 64–169), the median estimated blood loss was 2 mL (range 2–25), and the median length of stay after the operation was 1 day (range 0–2). There were no conversions to laparoscopic or an open approach. Results are summarized in Table 1.
Data reported either as median (range).
BMI, body mass index.
Taking in consideration the innate learning curve of a procedure, we compared the patients at the first versus second half of this period. The median operative time of the procedures performed at the beginning was 118 minutes (range 96–202) and at the end 134 minutes (range 119–196). The median estimated blood loss was 3 mL (range 2–5) at the beginning and 2 mL (range 2–25) at the end. The median length of stay was 1 day (range 0–2) and 0.5 day (range 0–1), at the beginning and end, respectively.
Also, we wanted to assess whether the case complexity affected the procedures outcomes; for this reason we analyzed the subset of patients with acute cholecystitis. In this group the median operative time was 110.5 minutes (range 96–169), median estimated blood loss was 7.5 mL (range 3–25), and the median length of stay was 1 day (range 1–1).
Pathology results
Of the 14 patients that underwent the procedure, four (29%) had cholelithiasis with choledocolithiasis, seven (50%) had symptomatic cholelithiasis, and three (21%) had acute cholecystitis.
If the laboratory and imaging findings were consistent with choledocolithiasis, patients underwent a magnetic resonance cholangiopancreateography and/or endoscopic retrograde cholangiopancreatography (ERCP) performed by a gastroenterologist at our institution. All 4 patients with choledocolithiasis underwent an ERCP and had stone retrieval with sphincterotomy.
Follow-up
All patients were seen postoperatively in clinic. The median follow-up was 7 months (range 3–22). During this period, 1 patient (7%) with symptomatic cholelithiasis developed an umbilical port site seroma, which was managed conservatively and subsequently drained spontaneously. There were no other complications during this follow-up period.
Discussion
In the past years all surgical specialties have or tried to transition from open to a laparoscopic surgery, with some new modifications to improve cosmetic results. One of this is single-port technique through laparoscopic or robotic approach, though literature reporting results in the latter approach is limited. It is important to mention that laparoscopic cholecystectomy is the gold standard approach both in children and adults, though literature on single-port robotic cholecystectomy in children is limited. Therefore, this study reports our experience using single-port robotic cholecystectomy, and shows that this is a safe and feasible approach with adequate cosmetic results.
Single-port laparoscopic surgery requires a steeper learning curve due to instrument designs and limited visualization that demands more advanced laparoscopic skills. Therefore, the use of the da Vinci Surgical System resolves these technical barriers, allowing the practice of laparoscopic basic principles, though still improving cosmetic results.
Overall in our series, the median operative time was 82 minutes (range 64–169), median estimated blood loss was 2 mL (range 2–25), and the median length of stay was 1 day (range 0–2). These results are similar to Jones, 23 which are acceptable and comparable to both laparoscopic and SIL cholecystectomy.
Nougues et al. 24 from the Children's Hospital of Alabama reported the first 25 cases using the single-incision cholecystectomy approach. Their mean operative time was 73 minutes and length of stay was 1 day. On the other hand, Chandler and Danielson 25 compared children who underwent SIL cholecystectomy with traditional cholecystectomy. They did not find statistical differences on mean operative time, length of stay, intravenous analgesia, or operative costs.
Salas de Armas et al. 26 from the Texas Children's Hospital reported their Triport experience in children, which included appendectomies and cholecystectomies; the later had a mean operative time of 156 minutes, there were no complications and had excellent cosmetic results. Also, Mesas Burgos et al. 21 reported there experience performing SIL cholecystectomy in children, the mean age was 10 years, mean operative time was 122 minutes, and mean length of stay was 2 days. There were no complications. In correlation to our findings these reports showed acceptable outcomes with single-incision surgery, though our operative approach was robotic, our time and length of stay were shorter.
Though we did not objectively measure cosmetic results, this benefits have already been reported by Ostlie et al. 27 in their randomized trial comparing single-site and traditional laparoscopic cholecystectomy. Our incisions were transumbilical and limited to the umbilical ring, and to allow port placement if needed we extended the fascial incision. Therefore, the surgical scar hides within the umbilicus limiting its visualization and allowing great cosmetic results. Also, family members verbalized their satisfaction with cosmesis.
Even though our procedure was performed by a single incision using a robotic approach, our results are comparable to the results by Emami et al. 22 who evaluated the outcomes of the SIL cholecystectomy compared to the standard four-incision laparoscopic cholecystectomy in children. There mean operative time for SIL was 79.2 minutes versus 63 minutes in the SL group (P < .006). The average length of stay was 1.9 days for the SIL group versus 2.3 days in the SL group (P < .24). The mean intravenous narcotic use was 1 dose in the SIL group versus 2.9 doses in the SL group (P < .007).
Vidovzky et al. reported their experience of patients who underwent robotic cholecystectomy on adults. Their mean operative time was 77 minutes. They concluded that robotic cholecystectomy offers significant advantages such as 3D view, easier instrument manipulation, and possibility of remote site surgery. The reported learning curve to reduce operative time and decreasing setup was between 16 and 32 procedures. Our results are from children but our operative times are similar. We reported our experience with 14 procedures, and these results are equivalent to other robotic approach reports, it could be that the number of procedures required is less and with a less steep learning curve.
Moreover, Joseph et al. 28 analyzed the learning curve for residents and their effect on operation room efficiency during SIL cholecystectomy. They reported that residents can safely learned SIL cholecystectomy, though residents who are proficient in laparoscopic surgery were able to transition quickly to a SIL cholecystectomy. Therefore, if the da Vinci robot allows for better ergonomics, respects laparoscopic principals, and offers a better visualization than the SIL approach, this approach should be more easily learned.
Regarding pain scores between SIL cholecystectomy and standard laparoscopic cholecystectomy, Tsimoyiannis et al. reported a reduced pain score, whereas Philipp et al. 16 reported a greater tendency for pain. Our patients were managed with the same pain management for laparoscopic cholecystectomy, which includes oral acetaminophen (15 mg/kg/dose), oral ibuprofen (10 mg/kg/dose), or intravenous ketorolac (0.1 mg/kg/dose), and if needed breakthrough intravenous morphine (0.1 mg/kg/dose).
The main limitation of our project is the size of our sample, though conclusions could be drawn. Ideally, a prospective randomized trial between standard, single incision and robotic single incision is warranted.
Conclusions
We demonstrated that robotic single-incision cholecystectomy in children with acute cholecystitis, symptomatic cholelithiasis, and choledocolithiasis is a feasible, safe approach with excellent cosmetic results. If the robotic system is available in the institution, this approach could be used as an alternative approach to SIL cholecystectomy.
Footnotes
Disclosure Statement
No competing financial interests exist.