Minimal access portoenterostomy: advantages and disadvantages of standard laparoscopic and robotic techniques

Minimal access portoenterostomy (Kasai procedure) for biliary atresia represents a technically challenging operation. The standard laparoscopic approach yields results comparable to the open technique. After an initial experience with standard laparoscopy, we assessed the potentially superior optics and dexterity of a surgical robotic system for performing portoenterostomy. We reviewed our experience with minimal access portoenterostomy to compare the relative advantages and disadvantages of standard laparoscopic and robotic approaches to biliary atresia.

We reviewed the charts of all patients who underwent either laparoscopic or robotic portoenterostomy at our institution between October 2002 and October 2005. Outcome measures included the need to convert to laparotomy, complications, functional outcome expressed either as the direct bilirubin at most recent follow-up (> or = 3 months) or age at transplant, and density of adhesions at transplant. Surgeons' impressions of the two minimal access modalities were also reviewed.

A total of 10 patients underwent minimal access portoenterostomy (7 standard laparoscopy; 3 robotic-assisted). Mean follow-up was 20 months (range, 1-36 months). There were no conversions to laparotomy and no intraoperative complications. There was one port site infection that resolved with antibiotics. Five patients (4 laparoscopic, 1 robotic) had progressed to transplantation at the time of follow-up. At transplant, one patient had mild adhesions and two had dense adhesions. Adhesions were not noted for 2 patients.

We believe both surgical modalities are feasible from a technical point of view. However, the optical and dexterity advantages of the robotic system were offset by the large instrument size and lack of force feedback.