IPEG 2024 Round Table Discussion from East Asia - Dr. Hiroki Ishii

So we can move on to the final presentation. OK, Doctor Hiroki Ishi. Talking about a robot assisted surgery. While we finished loading the presentation, we wanna thank the sponsors, Lexion. IPEG and Global cast, um, because I think we're getting, this is gonna be the last presentation, but really thank you everybody for joining, uh, uh, we hope to see you in June, uh, for the meeting and in 2025. This is gonna be, you know, we have to keep this under 2 hours. So this is the last presentation. We're ready. Go any words? Hello everyone. Uh, I'm Shi Hiroki and Nawa University in Japan. This is my topics. Optic-assisted surgery has advantage over laparoscopic surgery for patients with congenital variety dilation weighing 10 kg or less. Introduction and robot-assisted surgery for pediatric patients with congenital via dilatation has become widespread in pediatric surgery. RS induction states that careful consideration of indication for RS in patients weighing 10 kg or less is required. We believe that RS is effective for hepaticodenostomy in these children, and we have been performing RS for pediatric patients with CVD since April 2021 and are now actively performing it for pediatric patients weighing 10 kg or less. When we retrospectively review the medical records of patients with CVD under 16 years of age who are in RS and or laparoscopic surgery for 2013 to 2023. And we compared the two groups. Here, I present one case. Patient is 49 days old girl. Uh, body weight is 3.6 kg. This is uh operative movies. And. Um, could you. You're welcome. Then we move on to robotic manipulation. The da Vinci port is inserted in the umbilicus, right lower abdomen. First, the cyst is opened by laparoscopic manipulation and bile juice from the dilated common bile duct is aspirated. Then we move on to robotic manipulation. The da Vinci port is inserted in the umbilicus, right lower abdomen and left abdomen. The right lower abdominal port is placed slightly lower area. This port position is most important to prevent the art from colliding with the right lower extremity during forceps manipulation. The common bile duct is dissected using the double bipolar method. The open cyst is dissected while checking the lumen. The mucosa of the cyst is necrotic. Dissection of the posterior wall of the cyst is completed. The cystic artery is dissected. The common hepatic duct is temporarily ligated to stop the leakage of bile juice because the arm hits the right thigh when the tips of the left forceps is directed downward and towed ventrally as usual. It was necessary to turn the forceps tip up or to the side and tow the cyst to dissect it. The common bile duct is dissected. The double bipolar method is used to proceed with dissection of the common bile duct and pancreatic tissue. The narrowed segment of the common bile duct is identified on the pancreatic side of the dilated common bile duct right anterior to the pancreas. The narrow segment is present just before it confluence with the pancreatic duct and ligated and dissected. Complete dissection of the cyst. Proceed with dissection around the common hepatic duct and detach the common hepatic duct in the vicinity of the porta hepatis. A membranous stricture is found in the left bile duct and is resected. The left posterior regional branch is a very narrow bile duct. The resected bile duct mucosa is sutured. Hepaticcogygenostomy is started from the left narrow tiny bile duct. These narrow bile ducts can be sutured safely and stably with a robot. The left edge suture can also be sutured stably. Hepaticcogenostomy is completed. And next is, this is, uh, clinical characteristics. The patient included 10 of RS group and 39 of LS group. The median body weight of operation is almost 7 kg. This is surgical outcomes, and post-operative drain removal on hospital stay is significantly different. This is post-operative complications, grade 3 in Colombian dingo clarification, and Rice has 1 case and LS is 3 cases. This is the conclusion, uh RLS group had a significantly shorter post-operative drain removal and hospital stay than the LS groups. RLS could be safe and effective for patients with CBD weighing 10 kg or less. And this is discussion points, and they think that robotic surgery is more effective than laparoscopic surgery. And next is, uh, how many kilograms would you consider safe to perform robotic surgery? Thank you so much, Doctor Ishi. Thank you so much. This is the, uh, we, we got the results of the polls, surgery for cortico cyst. Robot better than map. Well, congratulations. Yes, it's over the 90%. I, I think, OK. Thank you for the presentations. So, do, do we still have time to discuss? Uh, hi. This is. Any comments or questions from the commentators? So I wonder, How The you is show that the length of stay post post-op stay and length of, uh, keep the, the drain in place is longer in. In a laparoscopic group. What do you, how can you explain about this? The reason of significant difference. What is the the reason behind that? Because communication occur more in LS group. And minor complication in laparoscopic surgery has a, uh, meaning. Uh, compared to, uh, robotic surgery. So what about the operating time? How How many minutes less than that, you know, which is shorter or Uh, operator time is almost, uh, uh, 6 hours. Mm. It's similar as the laparoscopic general laparoscopy almost the same time. So you should compare your reason with other other series, other reports in the literature about NS and uh robotic group, and according to our experience, most of our laparoscopic surgery duration is about 3 hour and a half. Only And complication rate is very low, and the length of post-op stay in our series about 6 to 7 days. And nowadays We, I, I don't put any drain after the operation, even in single incision. So how do you think, uh, how do we explain that you compare your robot with 5 parts, including a normal laparoscopic system and our Approach like a single incision, scarlet surgery with uh Laparoscopic. Single incision la lastic surgery. I think they, uh, middle of the, you know, learning curve, you know, stuffs. I think it's a learning curve. Yes, this is in this, yeah, maybe they can reduce the time of the operation, docking time, and, you know, uh, and reduce the complication rate in LS group, yeah, yeah, yeah. I think you can look at at a leak rate or or you know that will be the advantage of the robot is the anastomosis in theory. I agree with you trying. I mean seems long and if you're doing stealing babies, you can probably do it on bigger kids, but probably the anastomosis, you know, complications with anastomosis will be your Um, uh, your upgrade there, so that's what you have to compare. But time is always gonna be longer in the robot, I think. Just for the setting time. But I think with S group you have a 3 instrument. In robot, you are at least 5 and it's very long, uh, jaw. I think this is somewhat very um Not that comfortable for a surgeon to perform in such a tiny baby, I think. But uh, it's according to your preference, yeah. Doctor Maria, Doctor Maria Bayles says that she's, you know, we're still having this discussion. She says, you know, she remembers when, when she started practicing and we're still discussing this. Yeah. OK. Yeah Maybe even after this webinar, we can discuss a lot about, uh, you know, robotic and the laparoscopy and indication or any complication rates or something. So Any, uh, any other comments or questions? I have one comment about the topic. Uh, to date, uh, our center conducted over 300 pediatric robotic surgery. Uh, based on our center experiences, the minimum body weight, uh, was recorded. The body weight was 6.3 kg. That is the minimum. Uh, and, uh, with the location of port site is very critical, critically important, so. Personally, uh, having successfully performed laparoscopic excision of cortical cyst and laparoscopic anastomosis even in patients on body weight 3 kg, I believe, I think that the excision of cortico cysts could be uh faster in la laparoscopic surgery, uh, under 10 kg body weight. But uh the performing the hyperticaljanostomy with a robotic assistance, it can be very excellent choice to minimize the complexity of the port site placement. So, I, I hope to uh adapt to the incision, uh, exchange is laparoscopically and only hepaticostomy is performed by, uh, assistant robotic system or even in Korea, we, some Korean pediatric surgeons start to using uh uh articulating laparoscopic instrument, uh, 5 millimeter. So I also started the training, but it is very useful. For and also the energy devices and, and other rasper and dissector and suture devices is uh developed by uh manually articulating laparoscopic surgery. So many hepatibility surgeons use the, the kinds of devices. So we can choice excigen for laparoscopically and only an anastomosis for robotic. That is my opinion. Yeah, thanks for the comment. Thank you for your comment. I totally agree with you, but we can easily perform the, uh, about the 3 kg children for uh cholo cyst. The robotic surgery, it's easy to remove the, uh, common dilated common bile duct and the anastomosis. We, we all, we all of us can do. The operation by the robotic. The robotic is superior to the lab, I think. You know that there is another issue in Japan that, uh, pyeloplasty and the cortical cyst repair, that's the only two, pathology which was insurance covered for the robotic surgery. So We um We have to improve our skills using So far, these two pathologies, so that's another issue in Japan.