Comparison of surgical results and technical performance between robotic and laparoscopic approaches for Kasai portoenterostomy in biliary atresia: a multicenter retrospective study.

Background: Many variables, including age at surgery, disease type, surgical approaches and perioperative management factors have been demonstrated to influence efficacy in BA infants, however, the effect of surgical performance remains unclear. The objective of this retrospective study was to compare the postoperative efficacy and surgical performance of robotic (RKPE) versus laparoscopic Kasai portoenterostomy (LKPE) for BA.

Methods: Between October 2018 and June 2023, 158 type III BA patients undergoing minimally invasive surgery (RKPE = 66, LKPE = 92) were included in this multicenter retrospective study. All procedures were performed by surgical teams experienced in Kasai portoenterostomy techniques. Technical performance was quantified and analyzed using the Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments (GERT). Postoperative outcomes and surgical performance were compared.

Results: Compared with LKPE group, RKPE group had shorter fibrous cone transection time (48.92 ± 6.98 vs. 61.45 ± 8.98 min; p < 0.001), shorter hepaticojejunostomy time (47.55 ± 6.57 vs. 59.93 ± 7.88 min; p < 0.001) and less estimated intraoperative bleeding [7.00 (5.00-10.00) vs. 13.50 (10.50-16.50) mL; p < 0.001]. More importantly, RKPE group showed a superior OSATS score [30.50 (29.00-31.00) vs. 28.00 (28.00-29.00); p < 0.001], number of errors (46.62 ± 6.32 vs. 56.40 ± 6.82 times/case; p < 0.001), and number of events [9.40 (8.40-10.40) vs. 16.00 (14.00-17.80) times/case; p < 0.001]. On postoperative days 1 and 3, RKPE group had lower C-reactive protein levels (19.87 ± 12.28 vs. 27.05 ± 11.16 mg/L, p < 0.001; 14.88 ± 7.11 vs. 20.73 ± 9.09 mg/L, p < 0.001). During follow-up, RKPE group had higher jaundice clearance rate at 3 (68.18% vs. 51.09%; p = 0.032) and 6 months (78.79% vs. 64.13%; p = 0.047) postoperatively. However, the cholangitis rate within 1 year postoperatively (46.97% vs. 50.00%; p = 0.707), as well as one-year (75.76% vs. 72.83%; p = 0.678) and two-year survival with native liver rates (68.42% vs. 66.67%; p = 0.857), were comparable between two groups.

Conclusions: RKPE provided superior technical skill performance and a higher jaundice clearance rate than LKPE, indicating that it may be a better minimally invasive option for BA. In addition, the survival with native liver rate showed no significant difference between the two cohorts, which needs to be confirmed by further study.