Page 41 - Read Online

Page 8 of 10 Hamad et al. Mini-invasive Surg 2023;7:16 https://dx.doi.org/10.20517/2574-1225.2023.03

A systematic review and meta-analysis by Zhang and colleagues compared LCCR and RCCR among
patients with type I through IV CC. Six studies (3 adult studies with a total of 162 patients) were included;
patients treated with the robotic approach had a shorter hospital LOS but longer operative times. Estimated
blood loss, as well as the incidence of bile leak, wound infection, postoperative bleeding, postoperative
cholangitis, anastomotic strictures, adhesive intestinal obstructions, residual cysts, and incidence of biliary
[20]
stones, were the same among patients treated with LCCR vs. RCCR . Collectively, the data strongly suggest
that the robotic platform may offer an advantage in the HJ anastomosis portion of CC resection [Figure 5]
vs. laparoscopy while providing comparable short-term outcomes compared with the LCCR approach, yet
better results than the OCCR approach with decreased EBL and shorter hospital LOS. The longer operative
times associated with the robotic platform will likely be mitigated over time in the hands of experienced
HPB surgeons [Table 2].

Summary
Despite the technical complexity associated with minimally invasive HPB surgery related to CC resection,
an increasing number of surgeons and hospitals have adopted these techniques. A minimally invasive
approach to CC likely has improved perioperative outcomes with shorter LOS, return to baseline function,
as well as improved cosmesis vs. OCCR. Longer operative times with minimally invasive approaches to CC
have been attributed to steep learning curves, which have improved over time as surgeons become more
facile with this technique. RCCR likely provides an additional advantage over LCCR due to more degrees of
freedom with the instruments, providing a greater ability to perform the dissection and HJ reconstruction.
In particular, the robotic platform overcomes some of the shortcomings associated with laparoscopic
surgery and thus decreases operative times when constructing the HJ. It is important to note that there are
several contraindications to the MIS approach including perforated cysts, pneumoperitoneum, inability to
tolerate general anesthesia, hemodynamic instability, coagulopathy, and portal hypertension. It is also
important to note that this study has several limitations including selection bias and a relatively small
sample size.

CONCLUSION
Both LCCR and RCCR have demonstrated similar rates of long-term postoperative complications and
overall survival when compared to OCCR. Overall, a minimally invasive approach to surgical management
of CC should be strongly considered. Future prospective randomized studies should compare both
minimally invasive approaches to the open approach to assess short- and long-term complications
associated with each surgical platform. Selection criteria for patients undergoing MIS for CC resection will
also need to be defined better as experience with this approach expands.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the conception and design of the study and performed data analysis and
interpretation: Hamad A, Nathan JD, Pawlik TM
Performed data acquisition, as well as providing administrative, technical, and material support: Hamad A,
Nathan JD, Pawlik TM

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.