Comparison of short-term outcomes of open, laparoscopic, and robotic surgery for Kasai portoenterostomy in biliary atresia: a 10-year single center study

Abstract

Objective:

This study aimed to clarify the comparative clinical efficacy and safety of open (OKPE), laparoscopic (LKPE), and robotic-assisted (RAKPE) approaches for Kasai portoenterostomy in patients with biliary atresia (BA).

Methods:

We retrospectively analyzed 50 patients diagnosed with type III BA who underwent Kasai portoenterostomy between January 2015 and December 2024. Based on the surgical approach, patients were categorized into three groups: OKPE (n = 21), LKPE (n = 18), and RAKPE (n = 11). Clinical characteristics, perioperative indicators, and short-term outcomes, including jaundice clearance (JC) at 6 months and one-year survival with native liver (SNL), were compared among the groups.

Results:

RAKPE was associated with a significantly longer operative time compared to LKPE and OKPE (310 ± 39 vs. 230 ± 34 vs. 200 ± 74 min; P < 0.001). OKPE showed shorter fibrous cone dissection time (47 ± 11 vs. 66 ± 7 vs. 66 ± 9 min; P < 0.001) and less dissection blood loss [2(2–3) vs. 4(3–5) vs. 3(2–4) mL; P < 0.001]. Conversely, minimally invasive approaches achieved faster oral feeding [10 (8–10) vs. 4.5 (4–5) vs. 4 (4–5) days; p < 0.001] and shorter hospital stay [29 (23–36) vs. 19 (15–27) vs. 18 (17–28) days; P = 0.003]. No significant differences were observed across the three groups regarding 6-month JC rates (67% vs. 61% vs. 55%; P = 0.81), postoperative cholangitis incidence (55% vs. 44% vs. 38%; P = 0.66), or one-year SNL rates (71% vs. 72% vs. 64%; P = 0.85).

Conclusions:

OKPE, LKPE, and RAKPE demonstrate comparable short-term efficacy and safety for type III BA. While OKPE offers technical advantages in hilar dissection, minimally invasive approaches significantly optimize postoperative recovery. Surgical technique selection should be individualized based on patient characteristics, surgeon experience, and institutional resources.

Highlights

• RAKPE, LKPE, and OKPE show comparable jaundice clearance and native liver survival.

• Minimally invasive approaches significantly accelerate oral feeding and recovery.

• OKPE maintains technical advantages in reducing hilar dissection time and blood loss.

• Robotic-assisted Kasai is safe but currently involves longer operative durations.

Introduction

Biliary atresia (BA) is a severe neonatal obstructive cholangiopathy characterized by progressive inflammation, fibrosis of intrahepatic and extrahepatic bile ducts (1). Without timely intervention, the patients inevitably progress to end-stage liver cirrhosis and typically die within the first two years of life (2). Since its introduction, the Kasai portoenterostomy (KPE) has remained the cornerstone of surgical management for BA, significantly prolonging survival by reconstructing bile drainage, and transforming the disease from a fatal condition into a manageable chronic disorder (3).

Minimally invasive surgical techniques are expanding the therapeutic landscape for biliary atresia. Laparoscopic Kasai portoenterostomy (LKPE), in particular, has gained increasing acceptance due to its advantages of reduced surgical trauma, faster postoperative recovery, and superior cosmetic outcomes (4, 5). Previous studies have shown that laparoscopic surgery is associated with shorter hospital stays and reduced postoperative pain (6). Robotic-assisted surgery may offer additional technical advantages, including enhanced precision, three-dimensional visualization, and flexible maneuverability (7, 8). However, laparoscopic approaches remain controversial, largely due to the technical challenges of achieving adequate hilar exposure, securing effective hemostasis, and mastering its steep learning curve (9). To date, robotic-assisted Kasai portoenterostomy (RAKPE) remains in an exploratory stage, with limited clinical evidence reported (10, 11). Therefore,this study aims to compare the efficacy and safety of OKPE, LKPE, and RAKPE in the treatment of BA, with the goal of providing evidence-based guidance for optimizing surgical strategies.

Materials and methods

Patient selection

Clinical data were retrospectively collected from children with type III BA who underwent KPE at Children's Hospital of Soochow University between January 2015 and December 2024. Inclusion criteria were as follows (1): a confirmed diagnosis of BA based on clinical presentation and intraoperative cholangiography; (2) surgery performed between 50 and 90 days after birth; (3) a follow-up duration of more than 12 months with complete clinical data available. Exclusion criteria included: (1) the presence of other serious congenital anomalies; (2) failure to undergo KPE; (3) loss to follow-up.

After detailed explanation of advantages and disadvantages of each surgical approach, legal guardians independently selected the surgical approach. All surgeries were performed by experienced hepatobiliary surgeons who had completed at least 20 LKPE and RAKPE procedures. Patients were divided into three groups according to the surgical approach: OKPE, LKPE, and RAKPE. No significant differences in baseline characteristics were observed among the three groups (Table 1). This study was approved by the Medical Ethics Committee (Approval No. 2025CS405). Informed consent was obtained from all guardians.

Surgical techniques

OKPE: Following laparoscopic biliary exploration, the procedure was converted to an open approach through a right subcostal incision. Step 1: following division of the perihepatic ligaments and liver retraction, the fibrous plaque at the porta hepatis was identified. Dissection continued towards the porta hepatis until reaching the superior edge of the bifurcation of the left and right portal vein branches. The fibrous plate was excised flush with the liver surface, extending bilaterally to the points where the vascular sheaths enter the liver parenchyma. Adequate bile drainage was observed, and meticulous hemostasis was achieved using hemostatic gauze packing. Step 2: the jejunum was identified 25 cm distal to the ligament of Treitz and transected. An end-to-side anastomosis was constructed between the proximal limb and distal bowel loop 40 cm from its closed end. The Roux limb was routed anterior to the duodenum and posterior to the transverse colon, and its open end anastomosed to the porta hepatis.

LKPE: After intraoperative cholangiography confirmation (Figure 1A), a 5-mm umbilical trocar and three 3-mm trocars were placed, and pneumoperitoneum was established. The falciform ligament was retracted to expose the porta hepatis. In accordance with OKPE Step 1, blunt and sharp dissection of the fibrous tissue at the porta hepatis was performed exclusively with a laparoscopic Maryland dissector and microscissors, without electrocautery. Construction of the Roux-en-Y limb and portoenterostomy followed the same principles as OKPE Step 2.

Figure 1

RAKPE: Following cholangiography confirmation, OKPE Step 2 was performed initially. After bowel replacement, an 8-mm umbilical trocar, two 8-mm mid-abdominal trocars (5.5 cm from umbilicus), and one 3-mm in the left lower quadrant trocar were inserted (Figure 1B). Following reinsufflation, the falciform ligament was retracted, exposing the porta hepatis and clearly revealing the fibrous plate (Figure 2A). In strict accordance with the principle of “cold dissection”, robotic-assisted dissection of the fibrous tissue at the porta hepatis was meticulously performed from left to right using robotic Maryland bipolar forceps and robotic curved scissors. Following careful transection at the bilateral margins, satisfactory bile drainage was observed, with a thin layer of whitish membranous tissue preserved at the resection site (Figure 2B). The procedure was completed successfully, with adequate exposure of the porta hepatis and patent bile drainage channels achieved (Figure 2C).

Figure 2

Postoperatively, intravenous cefoperazone-sulbactam was administered for 2 weeks, followed by oral cefdinir. Intravenous prednisolone (4 mg·kg⁻¹·d⁻¹) was initiated on postoperative day 5, then switched to oral dosing and tapered over 12 weeks (12).

Data collection

Collected data encompassed: (1) baseline demographics and clinical characteristics: including gender, age, weight, preoperative liver function parameters (total bilirubin [TB], direct bilirubin[DB], aspartate aminotransferase [AST], and alanine aminotransferase [ALT]); (2) perioperative indicators: including operative time, fibrous plate dissection time, intraoperative blood loss, time to oral feeding, and length of hospital stay; (3) postoperative outcomes, including liver function recovery, postoperative complications, incidence of cholangitis incidence, jaundice clearance rates (JCR, defined as TB < 20 μmol/L) at 1 and 6 months, and one-year native liver survival (NLS) rates (13, 14).

Statistical analysis

Categorical variables were compared among the three groups using Fisher's exact test, as appropriate. Continuous variables were assessed for normality and are presented as mean ± standard deviation or median with interquartile range (IQR), as appropriate. Comparisons among the three groups were performed using one-way analysis of variance or the Kruskal–Wallis test. post hoc pairwise comparisons were conducted using the Steel–Dwass test. All statistical analyses were performed using JMP® Pro version 17.0 (JMP, Cary, NC, USA). A two-sided p value < 0.05 was considered statistically significant.

Results

Baseline characteristics

Fifty patients were included: OKPE (n = 21), LKPE (n = 18), RAKPE (n = 11). Baseline characteristics were comparable among the three groups (Table 1). Gender distribution showed no significant difference (p > 0.99), with females comprising 57%, 61%, and 55% in OKPE, LKPE, and RAKPE groups, respectively. Mean age at surgery did not differ significantly between the OKPE, LKPE, and RAKPE groups (61 ± 10 days vs. 57 ± 11 days vs. 60 ± 10; p = 0.46). Body weight averaged 5.1 ± 0.6 kg, 5.0 ± 0.6 kg, and 5.3 ± 0.9 kg for OKPE, LKPE and RAKPE groups, respectively (p = 0.54). Preoperative laboratory parameters (TB, DB, AST, ALT) also showed no significant differences (all p > 0.05), indicating comparable baseline hepatic status.

Operative metrics

Significant differences were observed in operative metrics (Table 2 and Figure 3). Mean operative time was significantly longer in RAKPE group (310 ± 39 min) compared to LKPE (230 ± 34 min) and OKPE (200 ± 74 min) groups (p < 0.001) (9, 10). Fibrous cone dissection time was substantially shorter in OKPE (47 ± 11 min) compared to LKPE (66 ± 7 min) and RAKPE (66 ± 9 min) (p < 0.001). Total blood loss showed no significant difference (p = 0.25), with median values of 20 mL (IQR:15–20), 13 mL (IQR:10–20), and 20 mL (IQR:10–20) for OKPE, LKPE, and RAKPE, respectively. However, blood loss during fibrous cone dissection was significantly lower in OKPE [2 mL (IQR:2–3)] compared to LKPE [4 mL (IQR:3–5)] and RAKPE [3 mL (IQR:2–4)] (p < 0.001).

Figure 3

Postoperative recovery

Time to oral feeding was significantly longer in the OKPE group [10 days (IQR:8–10)] compared to LKPE [4.5 days (IQR:4–5)] and RAKPE groups[4 days (IQR:4–5)] (p < 0.001). Postoperative laboratory values (TB, DB, AST, ALT) showed no significant differences (all p > 0.05), suggesting comparable early hepatic recovery. Hospital stay was significantly longer in OKPE [29 days (IQR:23–36)] compared to LKPE [19 days (IQR:15–27)] and RAKPE [18 days (IQR:17–28)] (p = 0.003) (Table 2).

Complications and outcomes

The overall incidence of postoperative complications was low and comparable among the three groups: 14% (OKPE), 11% (LKPE), and 9% (RAKPE) (p > 0.99). Postoperative complications included 2 cases of wound infection and 1 case of adhesive intestinal obstruction in the OKPE group; 1 case of wound infection and 1 case of biliary leakage in the LKPE group; and 1 case of incisional hernia in the RAKPE group. Postoperative cholangitis rates were 38%, 44%, and 55% in OKPE, LKPE, and RAKPE groups, respectively (p = 0.66). JCR at 1 month were similar between the OKPE, LKPE, and RAKPE groups: 62%, 56%, and 55% (p = 0.87). At 6 months, rates remained comparable: 67%, 61%, and 55% (p = 0.81) (14). One-year NLS rates showed no significant difference: 71%, 72%, and 64% (p = 0.85).

Discussion

BA remains one of the most challenging conditions in pediatric hepatobiliary surgery, necessitating prompt intervention to prevent progression to end-stage liver disease (1, 2). Since Kasai's pioneering hepatoportoenterostomy in 1957, KPE has been established as the primary palliative procedure for restoring bile drainage and delaying liver transplantation (3, 15). This study compares perioperative outcomes and safety profiles of three surgical approaches in treating type III BA.

In this cohort, OKPE and LKPE were associated with significantly shorter operative times compared to RAKPE, but no significant difference was observed between OKPE and LKPE The prolonged operative time observed in the RAKPE group is likely attributable to the well-documented learning curve inherent to robotic surgery in pediatric populations (16, 17), including the technical complexity of hilar dissection and additional time required for robotic system setup. Nevertheless, with accumulated surgical experience, standardized protocols, and simulation-based training, operative time reductions of 30–40 min are achievable, potentially approximating LKPE durations after 15–20 cases (18, 19). OKPE exhibits superior performance in fibrous plate dissection time and intraoperative blood loss during hilar dissection (p < 0.001). This advantage likely reflect the benefits of direct tactile feedback and unrestricted instrument maneuverability, which prove particularly valuable when managing dense fibrotic tissue at the porta hepatis. RAKPE showed less intraoperative blood loss during hilar plate dissection than the LKPE group, benefiting from the enhanced magnification and tremor filtration of the robotic surgical platform. The development of minimally invasive KPE has been characterized by initial controversy and gradual acceptance. Following Esteves et al.'s first LKPE report in 2002 (4), safety concerns prompted opposition from the International Pediatric Endosurgery Group in 2007. However, subsequent studies, including a recent randomized controlled trial and prospective cohort analyses, have since reported comparable long-term outcomes between LKPE and OKPE (5, 6). Robotic assistance, first reported by Dutta and Albanese (2007) and Meehan et al. (16, 17), confers theoretical advantages that address the inherent limitations of conventional laparoscopy. The da Vinci system delivers seven degrees of freedom with wristed instrumentation, tremor filtration, and high-definition three-dimensional visualization, thereby enhancing precision during delicate hilar dissection and Roux-en-Y reconstruction (11, 20). Although challenges persist—including difficulty in adequate porta hepatis exposure, risk of incomplete fibrous plate excision, hemostatic complications with potential thermal injury, and a steep learning curves—minimally invasive approaches consistently yield faster postoperative feeding and shorter hospital stays, attributable to reduced surgical trauma, diminished pain, and accelerated recovery p < 0.001) (6, 21).

Importantly, all three surgical approaches demonstrated comparable short-term outcomes, with no significant differences in JC or 1-year NLS. JC, defined as normalization of serum bilirubin within 6 months post-KPE, represents the most reliable indicator of successful bile drainage and serves as a robust predictor of long-term outcomes (22, 23). Post-KPE cholangitis constitutes the most common serious complication, with reported incidence ranging from 40% to 93% (24). The present study demonstrated comparable rates across all groups (38%–54%), with no significant differences detected. Putative pathophysiologic mechanisms include bacterial translocation, lymphatic dysfunction, portal venous dissemination, and immune-mediated responses. Cholangitis occurring within the first postoperative year adversely impacts outcomes and NLS, serving as a predictor of liver failure and earlier transplantation requirement (25). The RAKPE group exhibited numerically higher cholangitis rates, although this difference did not reach statistical significance, suggesting that achieving technical proficiency requires substantial experience and an extended learning curve. During this developmental phase, RAKPE may not be universally applicable, particularly in patients presenting with severe disease or complex hilar anatomy. For pediatric patients with BA, KPE remains the cornerstone of management, with liver transplantation reserved as salvage therapy. A successful KPE has been shown to confer a significant advantage on subsequent graft survival (26, 27).

This study has several limitations, including a relatively small sample size, single-center design with inherent selection bias, and insufficient long-term follow-up. Future investigations should expand sample sizes through multicenter collaborations, with emphasis on long-term outcome tracking to elucidate differences in cholangitis recurrence, liver fibrosis progression, and transplantation outcomes. Additionally, validating the long-term value of RAKPE and evaluating the cost-effectiveness of robotic technology represent critical research directions. Optimizing surgical techniques, reducing operative times, and minimizing complications through standardized protocols remain ongoing priorities.

Conclusion

OKPE, LKPE and RAKPE demonstrate comparable short-term efficacy and safety profiles. Surgical technique selection should be individualized based on patient characteristics, surgeon experience, institutional resources, and cost considerations, thereby providing a foundation for personalized treatment planning. As surgical expertise evolves and technology advances, minimally invasive approaches may confer additional benefits while maintaining outcomes equivalent to traditional open surgery.

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