Technical performance, surgical workload and patient outcomes of robotic and laparoscopic surgery for pediatric choledochal cyst: a multicenter retrospective cohort and propensity score-matched study.

Background: Robotic surgery (RS) and laparoscopic surgery (LS) are increasingly used for pediatric choledochal cysts (CC); however, it remains unclear which technique is superior. We aimed to compare the clinical outcomes, technical performance and surgical workload between RS and LS. Methods: From January 2014 to February 2023, 604 CC patients (RS =302, LS =302) were enrolled in this multicenter retrospective cohort study after propensity score matching. Surgical videos were rated for technical performance using the Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments. Results: During follow-up, overall complication rates were similar between two groups, but RS group had lower anastomotic stricture rate (1.32% vs. 4.30%, P=0.03). Despite longer total operative time, RS group had shorter cyst excision and hepaticojejunostomy time. Moreover, RS group had less estimated intraoperative blood loss, higher left/right hepatic duct exposure rate, higher intrapancreatic bile duct exposure rate, higher OSATS score {31.00 [interquartile range (IQR), 30.00-32.00] vs. 29.00 (IQR, 28.00-30.00), P<0.001}, lower number of errors [46.50 (IQR, 43.33-50.72) vs. 56.00 (IQR, 51.00-61.00) times/patient, P<0.001], lower number of events [4.33 (IQR, 3.51-5.17) vs. 9.33 (IQR, 7.83-11.00) times/patient, P<0.001] and lower National Aeronautics and Space Administration Task Load Index (NASA-TLX) score [61.00 (IQR, 60.00-62.00) vs. 69.00 (IQR, 67.00-72.00), P<0.001]. The total NASA-TLX scores was found to be moderately correlated with total OSATS score (r=-0.420, P<0.001), total number of errors (r=0.502, P<0.001) and events (r=0.614, P<0.001). These improvements in RS were more prominent in patients with aberrant right hepatic artery or small anastomotic diameter. RS had lower fever rate, shorter hospital stays, and lower interleukin-6 and C-reactive protein levels at postoperative days 1 and 3. No cyst malignancy or deaths occurred. Conclusions: RS for selected pediatric CC offers superior technical performance and less surgeon workload, as well as lower anastomotic stricture rate than LS in high-volume children's centers.