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Hamad et al. Mini-invasive Surg 2023;7:16 https://dx.doi.org/10.20517/2574-1225.2023.03 Page 5 of 10

times (open: 237 min vs. MIS: 301 min) compared with patients who underwent OCCR (all P < 0.05). Both
[30]
patient cohorts had a similar incidence of postoperative morbidity and long-term overall survival . The
overall degree of complications did not differ between the OCCR (Clavien Dindo grades I-II, n = 13; grades
[30]
III-IV, n = 15) and MIS cohorts (Clavien Dindo grades I-II, n = 5; grades III-IV, n = 5) (P = 0.85) . Another
study from a group in China demonstrated similar results with decreased LOS, decreased EBL, and higher
[31]
operative times among patients undergoing LCCR vs. OCCR. Of note, the accumulation of surgeon
experience markedly decreased operative time (290 min in the early cohort vs. 198 min in the late cohort). A
systematic review and meta-analysis that compared LCCR vs. OCCR among 1,408 patients (LCCR, n = 611
vs. OCCR, n = 797) in 7 studies demonstrated that LCCR was associated with shorter hospital LOS, earlier
recovery of bowel function, lower rates of intraoperative blood transfusions, and a decreased relative risk for
[19]
adhesive intestinal obstruction, yet longer operative times . Moreover, the meta-analysis demonstrated no
difference among patients in terms of the total number of postoperative complications, and biliary-specific
complications such as bile leak, intra-abdominal bleeding, and pancreatitis. Overall, LCCR was associated
with improved short-term outcomes; while the main disadvantage was longer operative times, this factor
may be mitigated in the hands of experienced HPB surgeons [Table 1].

Robotic choledochal cyst resection
Background
The robotic platform has been increasingly adopted as the laparoscopic approach has several limitations
including three-dimensional visualization, limited range of instrument motion, and inferior surgeon
ergonomics. With the technical complexity associated with the surgical resection of CC, the robotic
platform may mitigate some of the technical difficulties encountered with rigid laparoscopic instruments
and potentially result in shorter operative times. The robotic platform does, however, come with some
limitations such as requirements to re-dock the robot in case the operation field is shifted or the risk of
instrument collision in small surgical fields. The first robotic CC resection (RCCR) was described in a case
report by Woo and colleagues in 2006 . Several case reports have since been published following Woo and
[32]
colleagues’ initial description, which have demonstrated the widespread feasibility of the robotic approach
based on data from larger case series comparing the robotic approach to LCCR and OCCR
[Figures 3 and 4].

Outcomes
There are only a few published case series in the literature comparing RCCR to LCCR in adult patients. As
noted, the study by Margonis and colleagues is the largest series to date that reported on short-term
outcomes of patients undergoing robotic-assisted resection for CC . More recently, Lee and colleagues
[30]
described their experience utilizing a robotic-hybrid CC excision whereby patients underwent a
laparoscopic dissection before the robotic platform was utilized for the hepaticojejunostomy (HJ)
anastomosis . The authors compared this technique to the laparoscopic-only approach and demonstrated
[33]
that the robotic-assisted approach was associated with no short-term complications (22.4% vs. 0%; P =
0.029) such as bleeding, development of intra-abdominal fluid collections, bile leak, wound infections, and
ileus. However, patients in the robotic cohort had longer operative times (247.94 ± 54.14 vs. 181.31 ± 43.06;
P < 0.05), which the authors attributed to lengthy docking times and staff unfamiliarity with robotic
[33]
instruments . Similar to LCCR, there was a learning curve associated with the implementation of the
robotic platform. The accumulation of surgeon experience resulted in an 80-min decrease in operative time
over the course of the case series. In a similar study, Han and colleagues demonstrated the safety and
feasibility of the robotic platform in adults with comparable short-term outcomes among patients in the
[34]
RCCR and LCCR cohorts . A more recent retrospective analysis by Yoon and colleagues demonstrated
similar perioperative outcomes such as operative time, EBL, and postoperative complications among
[35]
patients undergoing LCCR and RCCR . The authors reported, however, a higher total hospital charge in