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11 Robotic-Assisted Ligation of ThePatent Ductus Arteriosus
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Fig. 11.7 The assistant helped the surgeon cut the tail line short
were not ligated. The tails of the second line
short are also cut off (Fig.11.7). Intrathoracic
bleeding was checked, and then the operation
was ended.
11.6 Technical Points andSkills
Arranging the operating holes: For small patients,
the instruments and mirror hole are placed in the
fourth rib gap of the axillary front, the fth rib
gap of the axillary midline and the sixth intercostal space of the scapular midline. For older children, the right trocar hole was in the fth rib gap
of the scapular midline.
Arterial duct ligation: It is best to tighten the
wire knot at the upper and lower windows of the
PDA.Importantly, the surgeon ensures that the
PDA is not pulled or raised.
ceral chest and parietal pleura along the longitudinal axis of the aorta and close to the side of the
aorta. The purpose of doing this is to make it easier for the assistant to assist the surgeon in exposing the PDA.In addition, it can better protect the
vagus nerve and recurrent laryngeal nerve.
11.7 Postoperative Complications
Postoperative complications included pneumothorax, hoarseness caused by recurrent laryngeal
nerve injury, and chylothorax. The incidence of
postoperative complications is very low.
Exposure PDA: It is best to separate the vis-
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11.8 Comparisons
withConventional
Thoracoscopic Surgery
Compared with conventional thoracoscopic surgery, the new generation Da Vinci robotic surgery
system has advanced characteristics [8, 9]: (1)
accurate three-dimensional eld of vision: the
ordinary cavity mirror is a two-dimensional plane
eld of view, which cannot accurately locate the
distance in the two-dimensional eld of view,
while the eld of view of robot is a three-dimensional eld of view, which simulates human eyes,
can see more clearly and locate the distance more
accurately; (2) intelligent action: the action of the
manipulators hand and wrist can be transformed
into accurate mechanical action in real time,
which coincides with the action of the knife operation; (3) motion correction and shake ltering
function: the degree of bending and rotation of
the surgical instrument with a rotatable wrist far
exceeds the limit of the human hand. Trembling
ltering and intuitive movement can make the
doctors’ operation stable and natural; (4) remote
control: the operator does not have to go to the
operation table to save space; (5) reduce operator
fatigue: compared with traditional surgery and
endoscopic surgery, good three-dimensional
vision, simplied cooperation mode and ergo-
nomically designed doctor consoles can minimize doctor fatigue and physical injury.
References
1. Lindsay FE, William BK, Hugh DA, etal. Patent ductus arteriosus. Pediatr Rev. 2021;42:632–4.
2. Burak DO, Unal A, Ersin K, etal. Totally endoscopic
robotic-assisted cardiac surgery in children. Artif
Organs. 2019;43:342–9.
3. Tang ST. Robot-assisted surgery in children: current
status and prospects. Chin J Robot Surg. 2021;2:241–7.
4. Zhang SH, Gao ZG, Tou JF, etal. Current plications of
robotic procedures in pediatric surgery. J Clin Ped Sur.
2021;20:701–7.
5. Yoshihiro S, Bassem NM, Tomislav M, etal. Totally
endoscopic robotic-assisted repair of patent ductus
arteriosus and vascular ring in children. Ann Thorac
Surg. 2005;80:2309–13.
6. Ying LY, Liu XW, Tan Z, et al. Application of Da Vinci
robot assisted endoscopic technique in the tretment of
patent ductus arteriosus in children.J Clin Ped Surg.
2021;20:1179–82.
7. Le Bret E, Papadatos S, Folliguet T,et al.et.al.
Interruption of PDA in children: robotically assisted
versus videothoracoscopic surgery. J Thorac
Cardiovasc Surg. 2002;123:973–6.
8. Li S, Tang ST. Application status and prospects of
robotic surgery system in pediatric thoracic surgery.
Chin J Robot Surg. 2021;2:272–6.
9. Ying LY, Wang XK, Liu XW, et al. Application of
robot-assisted endoscopic technique in the treatment of
patent ductus arteriosus in 106 children. J Robot Surg.
2023. https://doi.org/10.1007/s11701-023-01537-7.
Robotic-Assisted Congenital
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Choledochal Cyst Radical Surgery
ZhigangGao andDuoteCai
12
12.1 Introduction
Choledochal cysts are common abnormal dilatations of the biliary tree in pediatric surgery [1],
and 80% of these cases are diagnosed before the
age of 10years. In Asia, the incidence of this disease is as high as 1:1000–13,000, signicantly
higher than that in Europe and the United States
[2–4]. In 1995, Farello et al. for the rst time,
applied the laparoscopic technique to complete
the choledochal cyst radical surgery [5], then in
2002, Li et al. improved this technique to shorten
the operative time and decrease the difculty of
the surgery [6]. In the following decades, through
the unremitting efforts of pediatric surgery colleagues, laparoscopic radical choledochal cystectomy has been gradually applied in major medical
centers in China, and in recent years, it has basically replaced the traditional open surgery. There
has been a consensus among experts that laparoscopic technique is superior to traditional open
surgery in terms of operative time and perioperative complications. However, while laparoscopic
technique is still on the rise, da Vinci robotic-
assisted technique is impacting the eld of pediatric surgery with the momentum of high-precision
technology. Woo et al. performed the rst da
Vinci robotic-assisted choledochal cyst radical
surgery in 2006 [2], and Wong et al. performed
this surgery rstly in China in 2009 [7]. Since
then, various hospitals in China have been gradually trying to perform this surgery. Currently, the
da Vinci III (da Vinci Si system) and da Vinci IV
(da Vinci Xi system) are mostly commonly used
in China to perform da Vinci robotic-assisted
choledochal cyst surgery. Compared with the da
Vinci III, the da Vinci IV has been greatly
improved in terms of loading time and intraoperative instrument replacement, which effectively
shorten the operative time. In clinical practice,
the da Vinci IV has gradually replaced the da
Vinci IV.Therefore, this chapter will discuss the
robotic-assisted choledochal cyst radical surgery
based on the da Vinci IV system.
12.2 Indications
andContraindications
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 981- 19- 9693- 1_12.
Z. Gao (*) · D. Cai
Department of General Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: ebwk@zju.edu.cn; cdt1240@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_12
The da Vinci technique can theoretically be
applied to pediatric choledochal cysts. Previously
reported, the da Vinci-assisted Kasai surgery can
be performed in neonates up to 4 kg [8]. The
youngest child who underwent da Vinci-assisted
choledochal cyst surgery in our hospital was 42
days with a weight of 3.5 kg [9]. Compared with
conventional laparoscopic surgery, there are no
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Z. Gao and D. Cai
absolute contraindications for da Vinci roboticassisted choledochal cyst radical surgery, but the
following relative contraindications should be
noticed: (1) unstable vital signs; (2) weight less
than 5 kg or age less than 3 months; and (3)
severe cardiopulmonary insufciency. For children with the above- mentioned relative contraindications, a careful preoperative discussion by
experienced senior clinicians is required to assess
the suitability of the da Vinci surgery in terms of
the child’s cardiopulmonary tolerance, the degree
of abdominal adhesions, the technical level of the
surgical team, the probability of transition to
open surgery, the economic conditions and the
surgery expectations of the family.
12.3 Preoperative Preparation
The preoperative preparation for da Vinci- assisted
choledochal cyst radical surgery includes bowel
preparation, psychological preparation, blood
preparation, and preoperative antibiotic administration. Bowel preparation includes eating easily
digestible food, cleansing enema 24hours before
surgery, fasting for 8 hours, and water- free for
2 hours before surgery. On the day of surgery,
based on the situation of defecation and abdominal distension, Glycerine enama can be given to
make intraoperative intestinal conditions suitable
for surgery as much as possible. Psychological
preparation includes preoperative doctor-patient
communication and nursing education to help the
guardians understand the procedure, possible
complications and precautions during the perioperative period, so as to alleviate the anxiety of the
family. Regarding blood preparation, with the
maturity of choledochal cyst surgery in recent
years, intraoperative blood transfusion is rarely
required, but due to the risk of large vessel injury
in the hilar anatomy, preoperative preparation of
red blood cells and plasma is still routinely
required. Choledochal cyst surgery requires preoperative antibiotics and empirical antibiotics
should be selected according to whether the child
has biliary tract infection and the severity of the
infection before the operation. For children without infection, the second- or third-generation
cephalosporins can be selected. Preoperative antibiotics should be administered 30minutes before
surgery, intravenously, and titrated within 30minutes to achieve effective concentrations of antibiotics in the serum and biliary tract. Depending on
the half- life of the selected antibiotics and the
length of surgery, the drugs can be administered
intraoperatively to ensure that the effective concentration of drugs covers the entire procedure.
12.4 Position andDocking
Hole position: (1) Make a midline incision
(8mm) at the umbilical area to establish a pneumoperitoneum, insert da Vinci Trocar into the
abdomen (Fig.12.1 Point 3). (2) Make a vertical
line (Fig.12.1 Line b) to the line connecting the
umbilicus and the surface projection point of the
hepatic porta (Fig. 12.1 Line a). (3) Mark one
point on each side of line b about 8cm from the
umbilicus (Fig.12.1 Points 2 & 4 , the distance is
at least 3cm), then make 8mm incisions at each
point, insert trocar. (4) Make a vertical line at the
midpoint of the line connecting the umbilicus
and point 4 (Fig.12.1 Line c). (5) Make a 5mm
incision at the lower part of the line about 3–5cm
from the intersection point (Fig.12.1 Point 5). (6)
Insert a standard lumpectomy Trocar for use as
an auxiliary hole.
Docking: (1) Adjust the child’s position to a
head-high and foot-low position (note: Unless
the da Vinci Xi integrated operating table is congured, this step is very important, and the
patient’s position cannot be adjusted after installation). (2) Establish the pneumoperitoneum via
the umbilical trocar. (3) Set the host “upper
abdominal surgery” mode, leave the “arm 1”
empty, connect the “arm 3” to the umbilical trocar, use the main view mirror to determine the
surgical eld, press and hold the “targeting” button to adjust the other robotic arms. (4) “Arm 2”
and “arm 4” are connected to the trocar at point 2
and point 4 respectively. The operating instruments are installed under the main viewer’s
supervision. (5) Place the dissector into the trocar
at point 2. (6) Place a needle holder or electrocoagulation hook into the trocar at point 4.
ab
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Fig. 12.1 The layout of the Trocar for da Vinci choledochal cyst surgery. (a) The body surface marker points of
Trocar; (b) After Trocar placement. Points 3, 2 and 4 are
the positions of trocar holes, which are located at the midpoint and both ends of line b, respectively. Point 5 on the
12.5 Surgical Steps
The robotic-assisted choledochal cyst radical surgery (4-hole method) consists of the following
ve steps:
Step 1 Position and docking (see Position and
docking section for details).
Step 2 Ex vivo jejunal Roux-Y anastomosis: The
operators hold a da Vinci primary viewer,
which enters the abdomen via the umbilical da
Vinci Trocar to monitor the abdominal cavity.
After revealing the Treitz ligament, the operators grasp and control the 20 cm jejunum
under the treitz ligament using the 2,4,5 trocar
lumpectomy grasping clamp, then turn off the
air and close the umbilical trocar. The umbilical incision can be enlarged appropriately
according to the situation. The jejunum can be
dragged out through the umbilicus. The operators complete the jejunal Roux-Y anastomosis
invitro.
line c is the auxiliary hole position of standard Trocar.
Line a is the line connecting the surface projection point
of the hepatic porta and the umbilicus (point 3). Line b is
perpendicular to line a, line c is perpendicular to the midpoint of the line connecting points 3 and 4
Step 3 Docking: See position and docking sec-
tion for details.
Step 4 Laparoscopic surgery: The primary sur-
geon controls the robot arm at the surgeon’s
console to complete the dissection of the biliary tract, the resection of the common bile
duct cyst and gallbladder, and the anastomosis
of the jejunal biliary branch of the hepatic
duct (Fig. 12.2). The assistant, on the operating table, should control the auxiliary grasping forceps, suction or hemolock via the 5 mm
Trocar as needed, to help the primary surgeon
exposing the surgical eld, passing stitches,
and handling stulas, as well as da Vinci operating instrument changes. The main surgeon
and assistant need to communicate verbally in
a timely manner during surgery, and the main
surgeon’s instructions and assistant feedback
must be clear and unambiguous.
Step 5 End of surgery: After completing the
biliary- enteric anastomoses, the No. 2 arm
should be removed rst, the abdominal drain-
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Z. Gao and D. Cai
J
Fig. 12.2 (a) Disconnection of cystic artery; (b) Dissect
gallbladder to the neck; (c) Dissociate the anterior wall of
the choledochal cyst; (d) Open the anterior wall of the
common bile duct, explore whether there are gallstones,
and determine the location of the left and right hepatic
ducts; (e) Flush the distal end of the common bile duct to
ensure no residual stones; (f) Dissect the distal end of
common bile duct; (g) Clipping distal common bile duct
by Hemolock; (h) Dissect the posterior wall of chole-
dochal cyst, and pay attention to the operation close to the
cyst wall to avoid damage to the portal vein; (i) The proximal end of the choledochal cyst was cut off to expose the
opening of the common hepatic duct; (j)
Hepaticojejunostomy: from left to right (subject to the left
and right sides of the child’s body) continuous suture, followed by anterior wall and then anterior wall; (k) Knot
and check whether there is stenosis or leakage in the anastomotic stoma
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age tube should be left under the anastomosis
via the No. 2 Trocar. After shutting off the gas,
the No. 3 and No. 4 arm should be removed
and the robotic arm should be retrieved, the da
Vinci surgical cart should be removed. After
washing hands, the main surgeon or the second assistant should assist the rst assistant in
completing the transumbilical extraction of
the choledochal cyst and gallbladder and shutting off the abdomen.
12.6 Technical Points andSkills
The da Vinci technique brings great advantages
to the dissection of choledochal cysts, making it
easier to deal with tissue gaps during cyst dissection to reduce side injuries, while the possibility
of complete cyst debridement is greatly improved.
However, we still believe that intraoperative
opening of the anterior cyst wall is necessary
which can clarify the presence of stones in the
distal cyst. Then we can properly ush the distal
end to avoid residual stone obstruction, which
may lead to postoperative pancreatitis.
Although the da Vinci robot has many advantages, it also has some shortcomings, such as the
lack of force feedback and the absence of instruments specically for younger children, so clinicians need to master the following points to
compensate the shortcomings and reduce
injuries:
1. Body position (Non-da Vinci integrated surgi-
cal bed): The body position should be headhigh and foot-low, with the head side elevated
by about 15°–30° to give the robotic arm
enough space to move during surgery. In addition, most da Vinci robotic devices are not
equipped with an integrated surgical bed, and
the bed height cannot be adjusted after docking is completed, so the child’s position must
be adjusted before docking.
2. Position and Trocar depth in the younger
children: Because of the small abdominal
space in young children, the distance between
the right and left abdominal da Vinci Trocar
and the umbilicus should be less than 8cm,
but must be greater than 3 cm, otherwise
there will be a possibility of collision damage
to the instrument. Da Vinci Trocar has a total
of three black marking lines (one thick and
two thin) at the distal end. For older children,
the best position of the middle thick line is
located in the muscular layer, where the traction force of the Trocars on the muscles during the rotation of the robotic arm is almost
zero and the damage is minimal. However, if
the Trocars are placed according to this line
in younger children, it will cause the Trocars
to be stretched too deep into the abdominal
cavity and affect the operation. In this case,
the depth of the Trocar can be adjusted by
using the most distal thin line at as the
boundary of the peritoneum, and the abdominal wall can be elevated by adjusting the
mechanical arm to raise the Trocar, thus
increasing the abdominal cavity space.
Because the abdominal wall muscle layer is
thinner in younger children, and the ability to
resist pulling is stronger than that of older
children and adults, so no abdominal wall
injury will occur.
3. Clamping of intestines and stitches: Because
of the lack of force feedback and the lack of
articial control function of the bite strength
of the dissector, the intraoperative action of
clamping the intestines should be minimized.
If it is necessary to clamp, it is appropriate to
clamp the edge of the intestinal wall, which
can meet the operation purpose. The surgeon
should try not to clamp too much intestinal
wall tissue to avoid excessive mechanical bite
force and damage. When performing biliaryenteric anastomosis, if continuous sutures are
used, the risk of thread breakage is greater
than that of traditional laparoscopic surgery
for the same reasons mentioned above. It will
affect the operation process and requires
attention.
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Z. Gao and D. Cai
12.7 Post-Operative
Complications
The complications after da Vinci-assisted choledochal radical cyst surgery are basically the same
as laparoscopic choledochal cyst radical surgery,
including postoperative bleeding, bile leakage,
leaky gut, anastomotic stricture, pancreatitis,
liver function abnormalities, intestinal adhesions
and intestinal obstruction, and intra-abdominal
hernia.
1. Postoperative bleeding: The da Vinci robot’s
three-dimensional magnication imaging system, jitter-ltering function, and multidegreeof- freedom rotatable manipulator will enable
better vascular handling during surgery and
low incidence of postoperative bleeding.
However, for older children with large cysts,
heavy biliary tract infections, and multiple
vascular growths in the cyst wall, there is a
higher risk of postoperative bleeding from
the peeled surface. For postoperative bleeding, it is necessary to determine whether
there is active bleeding and decide whether
to surgically stop the bleeding. For children
treated conservatively, in addition to transfusion therapy, adequate drainage can avoid
the formation of encapsulated effusion and
abdominal abscess. For children with nonacute but persistent bleeding and ineffective
conservative treatment, reoperation may be
considered, and laparoscopic exploration
may be recommended if abdominal conditions allow.
2. Bile leakage: The da Vinci robotic-assisted
choledochal cyst radical surgery is better than
laparoscopic surgery in the treatment of biliaryenteric anastomoses less than 5 mm in
diameter, but there is still the possibility of
bile leakage, commonly due to poor anastomotic alignment, local ischemia of the anastomosis, and high anastomotic tension. The
clinical manifestation is the bile-like uid
draining from the abdominal cavity. Most
children with bile leakage can heal on their
own if the leakage is well drained. However,
due to excessively large leakage or poor drainage, a few of them will have peritoneal effusion or peritonitis, fever, abdominal pain, and
other symptoms of abdominal infection. For
children with large amount of peritoneal bilelike drainage uid after surgery and ineffective conservative treatment, reoperation is
required. For children with signs of peritonitis, reoperation is required. For children with
encapsulated effusion in the abdominal cavity,
puncture and external drainage of the effusion
can be performed under B-ultrasound localization. Most of the encapsulated effusion can
be improved after external drainage, while a
small number of children with poor effects
after external drainage need reoperation.
3. Leaky gut: Leaky gut is rare clinically, most
of leaky gut are caused by anastomotic needle
leakage during jejunal Roux-Y anastomosis,
while a few are caused by intestinal injury due
to improper instrumentation. For children
with mild pneumoperitoneum after surgery, if
there are no abdominal symptoms, it is necessary to consider that CO2 is not discharged as
much as possible during the surgery, and the
change of the disease should be closely
observed without immediate surgical investigation. However, for those with intestinal contents or fecal uid draining from the abdominal
drainage tube, immediate surgical investigation is required regardless of the presence of
physical signs.
4. Anastomotic stricture: Anastomotic stricture
mostly occurs between four months and
one year after surgery. The earliest clinical
manifestations are mostly liver function
abnormalities, and a small number of children
may present with jaundice and white stools.
Anastomotic stricture can be diagnosed using
B ultrasound and MRCP. For children with
anastomotic stricture, reoperation can be
attempted with da Vinci or laparoscopic techniques. In our hospital, we have completed
four da Vinci- assisted and six laparoscopic
surgeries, and there are no cases of transitioning to open- abdomen surgery. The anastomotic stricture can be disconnected and
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re-anastomosed, or the distal and proximal
lateral anastomosis of the stricture can be performed, and the surgical results are
satisfactory.
5. Pancreatitis: In the clinic, post-surgical pancreatitis is rare, and common causes of pancreatitis include intraoperative pancreatic
injury or residual protein bolus distal to the
cyst. Pancreatic injury is mostly related to the
management of the distal opening of the choledochal cyst. Excessive dissection of the distal opening will inevitably increase the risk of
pancreatic tissue damage. However, inadequate dissection of the distal opening and
excessive residuals will increase the risk of
postoperative bile duct stump carcinogenesis.
The da Vinci has signicant advantages in dissecting the distal opening of the choledochal
cyst. For postsurgical pancreatitis, conservative treatment is the mainstay. Children with
obvious tenderness on the umbilical region
and elevated blood and urine amylase need to
be fasted and treated with Stilamin pumping.
For children with no abdominal signs and
blood amylase below 200 U/L, under the
premise of exclusion of pancreatic gallstones,
there is no need for excessive intervention and
can be followed up regularly.
6. Liver function abnormalities: Liver function
abnormalities within 1–2weeks after surgery
are mostly related to preoperative preexisting
liver injury, which can be improved after conservative liver protection treatment. Four
months after surgery, children with abnormal
liver function (elevated glutamine transferase)
need to be aware of the possibility of anastomotic stenosis.
7. Intestinal adhesions and intestinal obstruction: Intestinal adhesions and intestinal
obstruction are common complications after
conventional abdominal surgery and less
common after da Vinci-assisted choledochal
cyst radical surgery. They are mainly seen in
children with high bile leakage during surgery
or bile-intestinal leakage after surgery.
Intestinal adhesions and intestinal obstruction
have the risk of forming intra-abdominal her-
nia and intestinal strangulation complications.
Thus, clinical differential diagnosis and
parental education should be done at the time
of diagnosis. The serious complications
should be dealt with in time to reduce the risk
of life-threatening intestinal strangulation or
necrosis.
12.8 Comparisons
withConventional
Laparoscopic Surgery
Compared with conventional laparoscopic choledochal cyst radical surgery, the da Vinci roboticassisted surgery has the following advantages:
(1) fewer injuries during biliary dissection; (2)
more reliable management of the distal opening
of the cyst; (3) more suitable for biliary-enteric
anastomosis less than 5mm in diameter; and (4)
faster postoperative recovery and shorter length
of hospital stay.
The dissection of the posterior wall adhesions
of the choledochal cyst and the management of
the proliferating vessels of the cyst wall are the
main factors that inuence whether to transition
to open surgery and the amount of bleeding during the procedure. The da Vinci technique is better than conventional laparoscopic surgery in
dissecting the posterior wall adherent of choledochal cysts and proliferating cystic vessels, with
lower probability of transition to open surgery
and less intraoperative bleeding.
When dealing with the distal opening of the
choledochal cyst, removing as much tissue as
possible from the cystic wall of the choledochus
and closing the stump by ligation or suture can
reduce the risk of distant postoperative carcinogenesis. The da Vinci technique will make it easier to visualize and manage the distal opening of
the common bile duct cyst during the surgery.
In laparoscopic operations, biliary-enteric
anastomosis is extremely challenging in the
diameter less than 5 mm. Even surgeons who
have completed the laparoscopic learning curve
will still be anxious due to unclear vision and
unsatisfactory needle insertion angle.
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Z. Gao and D. Cai
Furthermore, the risk of postoperative anastomotic leakage or stricture will increase. Thanks
to da Vinci’s outstanding magnication imaging
system and precise multi-angle rotating manipulator system, the operating experience and satisfaction with the anastomosis reported by surgeons
are better than that of laparoscopic surgery for
anastomoses less than 5mm in diameter.
The postoperative abdominal drainage and the
length of postoperative hospital stay directly
reect the postoperative recovery of the child,
and also indirectly reect the delicacy of the surgery. The amount of postoperative abdominal
drainage in the da Vinci group was signicantly
less than that in the laparoscopic group, which
may be related to less exudation from the surgical
wound in the da Vinci group. Discomfort complaints, such as mild abdominal pain and wound
pain, were less frequent in children after da Vinci
robotic-assisted choledochal cyst radical surgery
than in laparoscopic surgery, which may be
related to signicant less stretching of the abdominal wall layers by manipulation of the da Vinci
Trocar via a robotic arm. The length of hospital
stay after da Vinci robotic-assisted choledochal
cyst radical surgery is also shorter than that of
laparoscopic surgery.
Compared with laparoscopic surgery, da Vinci
surgery also has disadvantages: (1) the hospitalization cost is signicantly higher than that of
laparoscopy, and (2) the da Vinci surgery takes
longer operative time.
The high cost of da Vinci robotic-assisted surgery is currently the biggest obstacle to the routine clinical implementation of this technology
[10, 11]. The total per capita cost of hospitalization for children undergoing da Vinci roboticassisted choledochal cyst radical surgery is much
higher than that of conventional laparoscopic surgery, and more than half of the cost still needs to
be paid by parents. Therefore, with the current
maturity of laparoscopic surgery, parental acceptance of da Vinci technology is much lower than
that of laparoscopic technology when it was
newly introduced. It can be foreseen that the eld
of da Vinci robotic-assisted surgery is a new technological high ground that pediatric surgeons
need to seize in the next few years. However, how
to screen patients and carry out the corresponding procedure still needs to be in line with medical ethics. First of all, doctors should be familiar
with the characteristics of the disease, while considering the economic situation of the patient’s
family, so as to develop appropriate surgical indications, fully reecting the value of the ne and
precise da Vinci robotic-assisted surgery. Doctors
should neither be afraid to recommend the da
Vinci procedure to suitable patients nor blindly
pursue the numbers of surgery, and only in this
way can they better promote the application of da
Vinci technology in the treatment of choledochal
cyst.
The operative time of da Vinci robotic-assisted
choledochal cyst radical surgery is signicantly
longer than that of conventional laparoscopic surgery. This is mainly because the loading time of
da Vinci is longer than the connection time of
laparoscopic instruments. However, compared
with the previous model, the loading time has
been signicantly optimized (the loading time of
da Vinci Si is about 40–60 minutes, while the
loading time of da Vinci Xi is about 15–20minutes), which greatly shortens the operation time.
With the rapid development of articial intelligence and mechanical engineering, greater
improvements and updates are expected in the
next generation models.
References
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laparoscopic choledochal cyst excision: a report of
205 cases. J Clin Ped Sur. 2017;16:65–9 (in Chinese).
2. Woo R, Le D, Albanese CT, et al. Robot-assisted
laparoscopic resection of a type I choledochal
cyst in a child. J Laparoendosc Adv Surg Tech A.
2006;16:179–83.
3. Pham HD, Okata Y, Vu HM, et al. Robotic-assisted
surgery for choledochal cyst in children: early experience at Vietnam National Children’s Hospital. Pediatr
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