PDF
Citation
Print
INTRODUCTION
Laparoscopic cholecystectomy (LC) was first introduced in pediatric patients in the early 1990s [123]. Cholecystectomy in children is typically performed for conditions such as symptomatic cholelithiasis, biliary dyskinesia, and acute or chronic cholecystitis that fail medical management [45]. The incidence of cholecystectomy among children has significantly increased over the past 2 decades [67]. Recent studies report an increase in cholecystectomy rates during the coronavirus disease-2019 pandemic, partly due to lifestyle changes. These changes may have influenced the incidence of gallbladder disease requiring surgical intervention in pediatric patients [8]. Since 2010, the adoption of robot-assisted cholecystectomy (RC) has gradually increased alongside LC in tertiary centers [9]. Key advantages of RC include stereoscopic imaging, which enhances intraoperative visualization, and improved instrument articulation through wristed tools, enabling greater precision. Additionally, single-incision RC offers significant cosmetic benefits by minimizing visible scarring, making it an appealing option for patients who prioritize aesthetic outcomes.
However, studies comparing outcomes between RC and LC in pediatric populations are limited and often have matched designs to control for confounding variables. Therefore, this study aims to investigate differences in outcomes between RC and LC in pediatric patients using a matched design based on 3 critical variables: age, body mass index (BMI), and total bilirubin levels. Controlling these factors could offer a more accurate and clinically meaningful comparison of outcomes between these 2 surgical techniques.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of Asan Medical Center (No. 20240743). Informed consent was waived due to the retrospective design, and all procedures adhered to the ethical principles outlined in the Declaration of Helsinki.
Study population and data collection
We conducted a retrospective matched cohort study using data extracted from the institutional electronic medical record system for all pediatric patients who underwent cholecystectomy at Asan Medical Center Children’s Hospital between January 1, 2010, and December 31, 2024. Pediatric patients were defined as those aged <18 years. Initially, 109 patients were identified; however, 5 who underwent open cholecystectomy were excluded from the analysis. Among the remaining 104 patients, 15 with a history of previous abdominal surgery were excluded, resulting in a final cohort of 89 patients. These patients were individually matched based on age, BMI, and total bilirubin level to ensure group comparability. Following matching, 59 patients underwent LC, and 8 underwent RC (Fig. 1). Surgical techniques were classified based on operative reports. RC was performed using the Da Vinci Si System (Intuitive Surgical) via a single-site approach, while LC was conducted using a single-port or multi-port technique, depending on surgeon preference and gallbladder condition. In the RC group, a single umbilical incision of approximately 4–5 cm was made to accommodate the single-site port. In the LC group, multiple ports (one 10–12-mm and two or three 5-mm trocars) were used, resulting in a total incision length of approximately 2.5–3.5 cm. All RCs were performed by 3 surgeons with over 30 prior robotic cases, while LCs were conducted by 5 surgeons with over 100 LC experiences. Comprehensive demographic and clinical data were collected for all patients, including documented comorbidities and postoperative analgesic use. Postoperative evaluations were conducted by the operating surgeon 2 weeks after surgery to assess patient recovery, monitor for complications, and evaluate cosmetic outcomes.
Outcome measures
Primary outcomes evaluated in this study included length of hospital stay, operative time, complication rates, need for additional medical intervention, and use of analgesic medications during hospitalization. Length of stay was defined as the number of days from the day of surgery to the day of discharge. Specifically, the total doses of both narcotic and non-narcotic analgesics administered during the postoperative period until discharge were recorded. Opioid doses were converted to morphine milligram equivalents (MME) using standard IV conversion factors (fentanyl 100 µg = 10 MME; hydromorphone 1 mg = 4 MME; pethidine 25 mg = 2.5 MME). Non-opioid analgesics (e.g., acetaminophen/Tylenol [McNeil Consumer Healthcare], Keromin [Hana Pharmaceutical], Tarasyn [ZP Therapeutics Korea], Denogan [Yungjin Pharmaceutical], Caldolor [Korea DP Pharm], Tridol [Uhan Corporation]) were summarized in milligrams.
Statistical analysis
All analyses were performed using IBM SPSS Statistics ver. 27 (IBM Corp.). Among patients who underwent cholecystectomy, categorical variables were summarized using frequencies and proportions, while continuous variables were reported as medians with interquartile ranges (IQRs). Group comparisons were performed using t-tests for continuous variables; however, nonparametric methods were applied for bilirubin levels due to their non-normal distribution. The chi-square and Fisher exact tests were used to analyze categorical variables, while the Wilcoxon 2-sample tests were applied to continuous variables to assess differences in patient characteristics by surgical technique. A 2-sided P-value <0.05 was considered statistically significant. No adjustment for multiple comparisons was applied in this study. To examine the relationship between operative time and surgical approach while accounting for the matched design, a linear mixed-effects model was employed. The model included the surgical approach as a fixed effect and subclass (representing matched pairs or groups) as a random effect to control for within-group variability. A generalized estimating equation model with a logit link function was employed to evaluate the association between the surgical approach and 2 binary outcomes: re-intervention (procedure) and postoperative analgesic use. The matched design was accounted for by specifying the subclass variable, representing matched groups, as the clustering variable to control for within-group correlation.
RESULTS
Between 2010 and 2024, 109 patients underwent cholecystectomy at our institution. To facilitate a valid comparison between the RC and LC groups, 15 patients with a history of prior abdominal surgery were excluded. Given the limited sample size, variable-based matching was performed using age, BMI, and total bilirubin level in place of propensity score matching. After matching, 59 patients in the LC group and 8 in the RC group were included in the final analysis. Outcomes were analyzed based on the variables previously described. Table 1 summarizes the patient demographics and clinical characteristics. Sex distribution showed similarity between the groups, with females comprising 47.5% of the LC group and 50.0% of the RC group (P > 0.999). The median age was 11.00 years (IQR, 6.0–14.0 years) in the LC group and 13.00 years (IQR, 9.75–13.25 years) in the RC group, with no statistically significant difference (P = 0.684). The median BMI was 18.11 kg/m2 (IQR, 15.96–21.22 kg/m2) in the LC group and 18.85 kg/m2 (IQR, 17.44–23.20 kg/m2) in the RC group, with no statistically significant difference (P = 0.417). Median total bilirubin levels were 0.50 mg/dL (IQR, 0.40–0.70 mg/dL) in the LC group and 0.65 mg/dL (IQR, 0.30–1.53 mg/dL) in the RC group, with no statistically significant difference (P = 0.545). Table 2 illustrates that the mean operative time was 99.00 minutes (IQR, 80.00–128.00 minutes) for the LC group and 109.00 minutes (IQR, 96.50–123.75 minutes) for the RC group, with no statistically significant difference (P = 0.374). Analgesic use was reported in 86.4% of patients in the LC group and 100% of those in the RC group, with no statistically significant difference (P = 0.597). Postoperative analgesic consumption was higher in the RC group in both opioid and non-opioid categories. Opioid doses, converted to MME, were greater in the RC group (median, 10.0; IQR, 10.0–10.6) than in the LC group (median, 2.5; IQR, 0.0–10.0; P = 0.005). Non-opioid doses (mg) were also higher in the RC group (median, 445.0; IQR, 18.8–1,900.0) compared with the LC group (median, 30.0; IQR, 0.0–120.0; P = 0.044). The rate of postoperative intervention was 5.1% in the LC group compared to 25.0% in the RC group, showing a higher trend in the RC group; however, the difference showed no statistical significance (P = 0.195). The complication rate was 3.4% in the LC group and 25.0% in the RC group, indicating a higher trend in the RC group; however, the difference was not statistically significant (P = 0.104). Four postoperative complications occurred, all classified as Clavien-Dindo grade IIIa and managed endoscopically. In the LC group, 1 patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic nasobiliary drainage (ENBD) insertion, and 1 patient underwent ERCP with endoscopic sphincterotomy (EST) plus biliary stent insertion. In the RC group, 1 patient underwent ERCP with EST and stone removal, and 1 patient underwent ERCP with ENBD insertion followed by pancreatic duct stent placement due to ductal stricture. The median length of hospital stay was 4.0 days (IQR, 3.00–7.00 days) in the LC group and 4.5 days (IQR, 4.00–8.25 days) in the RC group, with no statistically significant difference (P = 0.353).
Tables 3 and 4 present the results of the regression analysis. The difference in operative time between the 2 surgical groups was 3.19 minutes, which was not statistically significant (P = 0.859). The average length of hospital stay was 1.26 days shorter in the RC group than in the LC group; however, this difference was not statistically significant (P = 0.720). The risk of requiring a postoperative procedure was 6.22 times higher in the RC group than in the LC group; however, this result showed no statistical significance (P = 0.072). In contrast, the likelihood of postoperative analgesic use was significantly higher in the RC group (P < 0.001). Furthermore, the risk of postoperative complications was 9.5 times greater in the RC group than in the LC group, and this difference was statistically significant (P = 0.040).
DISCUSSION
Robot-assisted surgery is a relatively recent advancement that has progressively gained acceptance as a viable surgical platform. Early reports documenting its use in pediatric patients emerged in the early 2000s [1011]. However, recent studies demonstrate that single-site RC has gained popularity among this age group due to its cosmetic benefits [12]. While RC has been increasingly adopted in pediatric practice, studies directly comparing it with conventional LC are limited. Matched analysis that controls for confounding variables remains rare. The findings contribute to the growing literature on minimally invasive pediatric surgery by highlighting both the potential benefits and limitations of robotic-assisted techniques in this population.
The baseline characteristics of the RC and LC groups were well-matched, ensuring a meaningful comparison of outcomes. No statistically significant differences were observed in operative time, length of hospital stay, or the rate of postoperative interventions. However, RC demonstrated specific trends and challenges that require further investigation. While the median operative time for RC was slightly longer than that for LC, the difference was not statistically significant. This finding suggests that the use of robotic techniques does not significantly prolong operative duration in pediatric cholecystectomy. While robotic systems may require additional setup time [9], this study revealed no statistically significant difference in operative time between the RC and LC groups.
Existing studies comparing LC and RC report conflicting findings regarding postoperative pain. While some trials demonstrate lower pain scores following RC [1314], others indicate no significant difference between the 2 techniques [15]. However, in this study, the likelihood of postoperative analgesic use was significantly higher in the RC group (P < 0.001). Both groups were managed using identical perioperative pain control protocols. Although RC is generally associated with longer docking and operative times, no statistically significant difference in operative time was observed between the 2 groups (99.00 minutes for LC vs. 109.00 minutes for RC, P = 0.374). RC was associated with slightly longer operative times overall, which may lead to prolonged pneumoperitoneum and extended tissue exposure, potentially exacerbating visceral pain pathways. Although the RC procedure was performed through a single incision, the length of this incision (approximately 4–5 cm) was greater than the total incision length in LC (approximately 2.5–3.5 cm). This difference in incision size may partially explain the higher postoperative analgesic use observed in the RC group. Additionally, the robotic single-port approach may increase abdominal wall tension compared to the multi-port traction technique of the LC, potentially contributing to greater port-site discomfort. The complication rate was significantly higher in the RC group than in the LC group (P = 0.04). While the RC sample size was small (n = 8), the findings highlight the potential concerns regarding the safety profile of robotic surgery in pediatric patients. Contributing factors, such as surgeon experience, technological limitations, and patient-specific characteristics, warrant further investigation in future studies. Cosmetic outcomes were not quantitatively assessed in this study; however, the single-incision technique used in RC offers distinct aesthetic benefits, which may be particularly valued by pediatric patients and their families. These benefits should be considered in the context of the higher complication rates observed.
The small sample size of the RC group limits the generalizability of these findings and increases the potential for statistical bias. Larger, multicenter studies are necessary to validate these results and provide more definitive conclusions.
The results suggest that while RC is feasible and offers comparable outcomes to LC regarding operative time and hospital stay, the method is associated with higher complication rates and postoperative analgesic use. These findings highlight the need for careful patient selection and comprehensive surgeon training when adopting robotic techniques in pediatric cholecystectomy. Additionally, the cosmetic benefits of RC may make it an appealing option for specific patients, particularly those who prioritize aesthetic outcomes. However, these advantages must be balanced against the associated risks.
To address the limitations identified in this study, future research should prioritize larger, multicenter studies to enhance statistical power and generalizability. Additionally, efforts should focus on identifying factors contributing to the higher complication rates observed in RC and developing targeted strategies to mitigate these risks. Further investigation into advancements in robotic technology that may enhance surgical safety and efficiency is necessary. Long-term outcomes, including patient satisfaction with cosmetic outcomes and recurrence rates of gallbladder-related conditions, should be evaluated.
In conclusion, RC presents a promising alternative to LC in pediatric patients; however, it poses unique challenges that require careful consideration. While its feasibility and cosmetic benefits are well recognized, the observed increase in complication rates highlights the need for continued refinement of both surgical techniques and robotic technologies. Future studies involving larger sample sizes are necessary to establish a more comprehensive understanding of its clinical utility and to determine its optimal role in pediatric surgery.
XML Download