Robotic-assisted and Laparoscopic Splenectomy in Children: A Single Center Comparative Study

Abstract

Background
To explore the safety, efficacy, advantages and disadvantages of robotic-assisted splenectomy (RS) in children by analyzing and comparing the clinical data of RS and traditional laparoscopic splenectomy (LS).

Methods
The clinical data of 35 children who underwent laparoscopic or robotic assisted splenectomy or partial splenectomy from February 2010 to October 2022 were included. A retrospective analysis based on general information, clinical data and prognosis were performed.

Results
Among 35 cases, 14 cases and 21 cases underwent RS and LS, respectively. The average operation time was 167 (120 to 224) minutes in the RS group and 176 (166 to 188) minutes in the LS group, the average intraoperative blood loss was 20 (8.7 to 27.5) ml in the RS group and 51 (23.5 to 75.5) mL in the LS group, the average length of hospital stay was 8 (7 to 9.25) days in the RS group and 10 (9 to 12) days in the LS group; the average hospitalization cost was 69 (67 to 71) thousand RMB in the RS group and 32 (31 to 34) thousand RMB in the LS group. There were no cases of conversion to laparotomy in the RS group, but two cases in the LS group. In terms of postoperative complications, there were one and three cases in the RS and LS group, respectively.

Conclusion
The Robotic Surgical System was safe and feasible in pediatric splenectomy or partial splenectomy which had the advantages of shortening the operation and hospitalization time, reducing intraoperative blood loss, the rate of conversion to laparotomy and the incidence of postoperative complications, but RS had a significantly higher hospitalization cost than LS.

Full text

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Robotic-assisted and Laparoscopic Splenectomy in
Children: A Single Center Comparative Study
Yuebin Zhang
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Shuhao Zhang
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Qingjiang Chen
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Duote Cai
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Wenjuan Luo
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Yi Jin
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Zhigang Gao (  ebwk@zju.edu.cn )
Zhejiang University School of Medicine, National Clinical Research Center for Child Health
Research Article
Keywords: robotic, laparoscopic, splenectomy, children
Posted Date: March 24th, 2023
DOI: https://doi.org/10.21203/rs.3.rs-2716971/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Abstract
Background
To explore the safety, ecacy, advantages and disadvantages of robotic-assisted splenectomy (RS) in
children by analyzing and comparing the clinical data of RS and traditional laparoscopic splenectomy
(LS).
Methods
The clinical data of 35 children who underwent laparoscopic or robotic assisted splenectomy or partial
splenectomy from February 2010 to October 2022 were included. A retrospective analysis based on
general information, clinical data and prognosis were performed.
Results
Among 35 cases, 14 cases and 21 cases underwent RS and LS, respectively. The average operation time
was 167 (120 to 224) minutes in the RS group and 176 (166 to 188) minutes in the LS group, the average
intraoperative blood loss was 20 (8.7 to 27.5) ml in the RS group and 51 (23.5 to 75.5) mL in the LS
group, the average length of hospital stay was 8 (7 to 9.25) days in the RS group and 10 (9 to 12) days in
the LS group; the average hospitalization cost was 69 (67 to 71) thousand RMB in the RS group and 32
(31 to 34) thousand RMB in the LS group. There were no cases of conversion to laparotomy in the RS
group, but two cases in the LS group. In terms of postoperative complications, there were one and three
cases in the RS and LS group, respectively.
Conclusion
The Robotic Surgical System was safe and feasible in pediatric splenectomy or partial splenectomy
which had the advantages of shortening the operation and hospitalization time, reducing intraoperative
blood loss, the rate of conversion to laparotomy and the incidence of postoperative complications, but RS
had a signicantly higher hospitalization cost than LS.
Introduction
Splenectomy is often used to treat splenic tumors, blood diseases and hypersplenism. Before the
application of robot-assisted technology, laparoscopic splenectomy (LS) was the preferred choice in
clinical practice, which has been widely applied clinically. But it is still a complicated and dicult
operation, which has a high requirement for an experienced user with good laparoscopic skills. With the
promotion of robot-assisted technology in clinical applications, many complicated and dicult surgical
operations have become simple and easy. The most widely used surgical robot system currently is the da

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Vinci robotic surgical system. Since its introduction in January 1999[1], the system has been developed to
the fourth-generation and as a result, has become more widely used for pediatric surgery.
Although robotic-assisted splenectomy (RS) has gained wide application in pediatric surgery in recent
years, most studies have small sample size and lack of comparison with LS. This study analyzed and
summarized the clinical data of 35 children who underwent LS or RS in this hospital from February 2010
to October 2022 and compared the safety, effectiveness, advantages and disadvantages of RS with LS.
Materials And Methods
The clinical data of 35 cases of minimally invasive splenectomy and partial splenectomy in this hospital
from February 2010 to October 2022 was analyzed. There were 14 cases and 21 cases in the RS group
and LS group respectively, where the choice of protocol was made voluntarily. All guardians signed the
informed consent documents.
The collected data included: age, sex, weight, diagnosis, surgical approach, operation time, intraoperative
blood loss, conversion to laparotomy, postoperative complications, length of hospital stay (LOS) and
hospitalization cost. The operation was performed by the same general surgical team.
Statistical Analysis
Statistical analysis was made using SPSS 23.0 and GraphPad Prism 6 software. The one-sample
Kolmogorov-Smirnov test was used for normal distribution test of all continuous data and P > 0.05 was
regarded as the data conforming to the normal distribution. If the normal distribution was met, the
continuous data are expressed as mean ± SD, otherwise it was expressed as median with an interquartile
range (IQR). A nonparametric
t
-test was used for continuous variables and P < 0.05 indicated that
difference was statistically signicant.
Results
All 14 cases in the RS group successfully completed da Vinci XI-assisted splenectomy or partial
splenectomy and there was no case of conversion to laparotomy. Eight cases were diagnosed with
splenic tumors and six cases with spherocytosis. There were seven males and seven females in the RS
group, with an average age of 10.1-years-old, ranging from 9.1 to 11.1 years and an average weight of
38.4 kg, ranging from 37.6 to 40.2 kg (Table1). The average operation time was 167 (120 to 224) min, of
which the average installation time of Da Vinci XI system was 12 min, ranging from nine to 15 min. The
average intraoperative blood loss was 20 (8.7 to 27.5) mL and the average LOS was 8 days, ranging from
7 to 9.25 days. The follow-up period ranged from 2 to 28 months. Postoperative complications included
one patient with a splenic cyst that experienced local encapsulation of an effusion after surgery and the
condition improved after four episodes of local puncture and drainage. There was no abdominal
bleeding, incision infection, pancreas injury, thrombosis and other complications. The average
hospitalization cost was 69 (67 to 71) thousand RMB (Table2).

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Table 1
Patient characteristics
LS (n = 21) RS (n = 14) p-Value
Age (years) 8.6 10.1 0.0067
Gender (F:M) 12:9 7:7 0.739
Weight (kg, IQR) 32.4 (29.9–34.1) 38.4 (37.5–40.2) < 0.0001
LS: laparoscopic splenectomy; RS: robotic-assisted splenectomy; IQR: interquartile range.
Table 2
Comparison of outcomes between laparoscopic and robotic splenectomy
LS (n = 21) RS (n = 14) p-Value
Operation time (minutes, IQR) 168 (156–176) 167 (120–224) 0.7968
Intraoperative blood loss (ml, IQR) 51 (23–62) 20 (8–27) 0.0009
Complications   
Intraoperative 3 (14.3%) 0 /
postoperative 3 (14.3%) 1 (7.1%) /
Length of hospital stay (days,
IQR) 8 (7-9.3) 10 (9–12) 0.0015
Hospitalization cost (RMB, IQR) 68511.5 (67454–
71239) 32124 (31233.5-
34212.5) <
0.0001
LS: laparoscopic splenectomy; RS: robotic-assisted splenectomy; IQR: interquartile range.
In the LS group, 18 out of 21 cases underwent laparoscopic splenectomy or partial resection and three
cases were converted to laparotomy due to intraoperative bleeding. Primary diseases included seven
cases of splenic tumors, 11 cases of spherocytosis, one case of thrombocytopenic purpura and two
cases of hypersplenism. There were nine males and 12 females with an average age of 8.6 years, ranging
from 7.9 to 9.2 years, with an average weight of 32.4 kg, ranging from 29.9 to 34.1 kg. The average
operation time was 176 (166 to 188) min. The average intraoperative blood loss was 51 (23.5 to 75.5 mL
and average the LOS was 10 (nine to 12) days. The patients were followed up for three to 12 years. There
were three cases of postoperative complications including one case of residual abdominal infection, one
case of peritoneal encapsulated effusion and one case of abdominal hemorrhage. The average
hospitalization cost was 32 (31 to 34) thousand RMB (Table2).
Discussion

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The use of LS has occurred for more than 30 years since Delaitre et al. reported it in 1991[2] and Tulman
et al. applied LS to pediatric surgery in 1993[3]. Compared with traditional surgery, LS had the advantages
of less surgical trauma and faster postoperative recovery. It has been widely promoted in clinical practice
and is currently the rst choice for splenectomy. However, LS is still a laparoscopic surgery with high risk
and diculty, and it requires high surgical skills and a clinically experienced surgeon.
The da Vinci Robotic Surgery system is an upgraded intelligent laparoscopic system, which can greatly
reduce the diculty of complex operations in minimally invasive surgery and simplify complex
operations through high-denition 3D images, exible robotic arms and advanced control system. In
2003, Talamini[4] et al. rst reported the application of robotic systems in splenectomy. Among the seven
reported cases, two cases were converted to laparotomy, so at that time, it was considered that
splenectomy was not an ideal indication for robotic surgery. In the eld of pediatric surgery, Mbaka[5] et
al. summarized and reported 32 cases of RS in children in 2017, showing that the surgical time of RS was
shorter than that of LS and there was no signicant difference in postoperative complications between
them. This study compared and analyzed 35 cases of splenectomy or partial splenectomy, including 14
cases of RS and 21 cases of LS.
1.Operation time
Previous studies showed that RS was associated with a longer operation time[6], associated with the
cumbersome installation process and long installation time in the third generation or earlier da Vinci SI
system, which led to the prolongation of overall operation time. The fourth generation da Vinci XI system
has simplied the installation process and halved the installation time to around 12 minutes. In this
study, the operation time in the RS group was slightly shorter than that in the LS group and closely related
to the size of the spleen, which reduces operational space for splenomegaly and signicantly increasing
operation time. The operation time of partial splenectomy is also signicantly longer than that of full
splenectomy. Single-center comparative studies by Mbaka[5] et al. and Shelby[7] et al. both found that in
the case of large spleen volume, the operation time of RS was shorter than that of LS. Shelby et al.
reported that the average operation time of RS was 140.5 minutes, which was shorter than 154.9 minutes
for the LS group and in the comparative study by Mbaka et al., the average operation time was
signicantly shortened from 182.4 minutes of LS to 159.6 min for RS. In this study, all 14 children
successfully completed da Vinci XI-assisted full or partial splenectomy. The average operation time was
167 minutes, which was shorter than 176 minutes in the LS group although not signicant (P = 0.79) and
increased spleen volume increased the difference in the operation time between RS and LS.
There are several reasons to explain this difference. The fourth generation da Vinci XI Robotic System is
easier to install than the third-generation or earlier SI system, reducing from more than 30 minutes to 12
minutes in the da Vinci XI system. The da Vinci XI Robotic System signicantly improves the operation
eciency. Anatomical separation, ligation, hemostasis, as well as the overall operation time has been
shortened, particularly in the splenomegaly operation although the small sample number did not allow
statistical signicance analysis. It is hypothesized that with the update of the system to the fourth

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generation, operation time is no longer a factor to hinder the application of robot in splenectomy and the
robot-assisted surgery even has the advantage of reducing operation time in splenomegaly surgery.
2.Intraoperative blood loss
Both the da Vinci XI and laparoscopic systems rely on a lens to provide the surgical eld of view. Their
ability to deal with hemorrhage that inuences the eld of view as well as major abdominal hemorrhage
is inferior to traditional laparotomy, so ne dissection is the most effective way to prevent and control
intraoperative bleeding. The visual eld of the wound and the eciency of electrocoagulation will be
affected by intraoperative bleeding in da Vinci system and it requires washing of the wound to maintain a
clear eld of view and expose the precise location of hemorrhage. Because the suction uid is often a
mixture of ushing uid and blood, coupled with factors such as residual uid in the peritoneal cavity, the
amount of hemorrhage cannot often be accurately estimated and is generally estimated by subtracting
the amount of rinsing uid from the total amount of suction uid. In partial splenectomy, there is often
oozing blood from the wound surface of the residual spleen, and the intraoperative blood loss is often
more than that in full splenectomy. Qureshi[8], Rescorla[9], Hassan[10], Xu[11], Xi[12], et al. reported a
total of 186 cases of LS, with an average bleeding volume of 52 mL. Bhattacharya[13] et al. compared
the data of 202 cases of RS and 258 cases of adult LS through meta-analysis and found that the
intraoperative blood loss in the RS group was signicantly lower than that in the LS group. The data from
this study showed that the average blood loss in the RS group was 20 mL, which was signicantly less
than 51 mL in the LS group, so the da Vinci XI-assisted splenectomy or partial splenectomy procedure
reduced intraoperative bleeding.
3.Intraoperative and postoperative complications
Intraoperative and postoperative complications include major intraoperative bleeding, conversion to
laparotomy, postoperative incision infection and abdominal cavity residual infection, recurrence,
pancreatic injury and postoperative portal vein thrombosis, with complications caused by primary
diseases as well as other internal diseases beyond the scope of this article. Mbaka[5] et al. reported 32
cases of robot-assisted splenectomy and there was no postoperative complication case, while two of 23
cases of laparoscopic splenectomy had major postoperative bleeding and conversion to laparotomy.
Shelby[7] et al. reported 10 RS cases and 14 LS cases and there were no perioperative complications in
either group. The study of Bhattacharya[13] et al. did not nd a signicant difference in intraoperative
and postoperative complications in adult RS and LS patients. Ghidini[14] et al. analyzed the data of 80
pediatric RS cases and their study showed that there was no signicant difference in postoperative
complications and conversion to laparotomy between the RS and LS group. In this cohort, there was one
case of splenic encapsulation effusion in the RS group and each case of abdominal cavity residual
infection, peritoneal encapsulation effusion and peritoneal hemorrhage, as well as three cases of
conversion to laparotomy were all caused by uncontrollable major intraoperative bleeding in the LS
group. The RS and LS groups had no signicant difference in postoperative complications and the RS
group had a signicantly lower rate of major intraoperative bleeding and conversion to laparotomy (P <

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0.05). These results suggest that RS can reduce the risk of conversion to laparotomy by improved control
of intraoperative bleeding.
4.Length of hospital stay (LOS)
There is a difference in LOS reported in domestic and foreign literature. In the study by Mbaka[5] et al.,
LOS in the RS group was 3.93 days, which was longer than that in the LS group at 2.9 days. More severe
primary disease in the RS group may explain the longer LOS in the RS group. Shelby[7] et al. reported the
opposite result where LOS was 2.1 days in the RS group, which was shorter than 3.2 days in the LS group.
In China, Tang Yong[15] et al. reported 31 adult RS cases with 9.4 ± 1.9 days of LOS. Qureshi[8] et al.
reported that the LOS in LS surgery was 1.4 to 4.5 days. In this study, the mean LOS of the RS group was
8 and 10 days for the LS group. There was no statistical signicance between the two groups (P > 0.05),
but the LOS in our cohort was longer than that reported in other literature. It is hypothesized that the
surgical approach may have a limited effect on LOS, while other factors such as variations in medical
environment, concept of rehabilitation and the standard of discharge between China and Western
countries affected LOS more signicantly.
5.Hospitalization cost
The da Vinci XI robotic system operation and instrument cost was higher than the traditional
laparoscope. In our cohort, the average hospitalization cost was 69,000 RMB in the RS group and 32,000
RMB in the LS group. The former was twice as high as the latter and the difference was statistically
signicant (P = 0.0001). In the United States, Shelby[7] et al. reported that the average hospitalization cost
of RS surgery was 44,000 US dollars and 30,000 US dollars for LS surgery, which also showed a
signicant difference. The high cost of robot-assisted surgery mainly results from two aspects. The rst
is the high investment and maintenance cost of robotic equipment, up to 20 times higher than ordinary
laparoscopy. The second is the depreciation of the robotic equipment. Robotic systems have a limited
number of uses and the cost per use is much higher than that of ordinary laparoscopy. The da Vinci XI
robotic surgery will increase the nancial burden of patients, so it is more viable for wealthy patients or
patients with medical insurance.
Conclusion
The da Vinci XI Robotic System was safe and feasible for splenectomy in children and had the
advantages of reducing intraoperative blood loss and lowering the risk of conversion to open surgery. It
was comparable to laparoscopic surgery in terms of surgical complications, operative time, and hospital
stay in spite of a higher hospitalization cost.
Declarations
Acknowledgement:We thank International Science Editing (http://www.internationalscienceediting.com)
for editing this manuscript.

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Author contributions statement
All authors contributed to the study conception and design. Material preparation, data collection and
analysis were performed byYuebin Zhang, Shuhao Zhang, Qingjiang Chen, Duote Cai, Wenjuan Luo, Yi
Jin and Zhigang Gao. The rst draft of the manuscript was written by Yuebin Zhang and all authors
commented on previous versions of the manuscript. All authors read and approved the nal manuscript.
Conicts of Interest: The authors have no relevant nancial or non-nancial interests to disclose.
Funding Information:This work was supported by the Clinical Medical Research of Minimally Invasive
Diagnosis and Treatment of Abdominal Organs in Zhejiang Province [grant number: 01492-02].Health
Science and Technology Plan of Zhejiang Province (2022RC201); Zhejiang Provincial Natural Science
Foundation Project (LY20H030007).
Ethics approval
This study was carried out in accordance with the recommendations of the Ethics Committee of The
Children's Hospital, Zhejiang University School of Medicine [2021-IRBAL-180] with written informed
consent in accordance with Declaration of Helsinki. The protocol was approved by the Ethics Committee
of The Children's Hospital, Zhejiang University School of Medicine and informed consent was obtained all
from their parents.
Consent to participate
Written informed consent was obtained from the parents.
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