Robot-Assisted Resection of Mesenteric Cysts in Pediatric Patients: a single-centered Retrospective study

Robot-Assisted Resection of Mesenteric Cysts in Pediatric Patients: a single-centered Retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robot-Assisted Resection of Mesenteric Cysts in Pediatric Patients: a single-centered Retrospective study Yi Chen, Qingjiang Chen, Duote Cai, Yunzhong Qian, Sai Chen, Shuhao Zhang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4093184/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Mesenteric cysts (MCs) are rare intra-abdominal masses in childhood. Laparoscopic-assisted surgery has become the main procedure for their resection, but robot-assisted surgery has rarely been reported. The purpose of this study was to retrospectively analyze and present our experience with robot-assisted resection of MCs using the da Vinci Xi surgical system and to discuss the technical points. Methods Children diagnosed with abdominal MCs who underwent surgical treatment at the Children's Hospital of Zhejiang University School of Medicine between January 2020 and November 2023 were retrospectively analyzed, and clinical data, surgical details, and prognosis of the patients were systematically collected. Results Among 40 patients, a total of 18 underwent robot-assisted surgery and 22 underwent laparoscopic-assisted surgery. In the robot-assisted surgery group, the entire procedure was performed endoscopically, whereas in the laparoscopic surgery group, eight procedures were converted to laparotomy. The operation time of 134.5 minutes for the robot-assisted group was not significantly longer than the 104 minutes for the laparoscopic-assisted surgery group ( P > 0.05), but the average length of postoperative hospital stay was significantly shorter ( P < 0.05). Conclusions Robotic-assisted resection of MCs is safe and feasible and the refinement of the Da Vinci Xi surgical system was much better than that of the conventional laparoscopic equipment, resulting in significantly improved intraoperative and postoperative outcomes. Mesenteric cysts Robotic-assisted Laparoscopic-assisted Children Figures Figure 1 Figure 2 1. Introduction Mesenteric cysts (MCs) are relatively rare intra-abdominal anomalies with a reported incidence of 1/100,000 in adults and 1/20,000 in infants[ 1 , 2 ]. They can occur anywhere in the gastrointestinal tract and mesentery and may extend into the retroperitoneum. The mesentery of the small intestine, is the most common site for MCs[ 1 , 3 ]. Most MCs present as asymptomatic abdominal masses[ 4 ], but sometimes give rise to manifestations such as abdominal pain, vomiting, fever and other discomforts, which are often caused by bleeding, infection, or intestinal torsion[ 5 ]. Once diagnosed, surgical resection is usually recommended[ 6 – 8 ]. Although laparoscopic surgery has become the main surgical modality for this disorder, there is still a high rate of conversion to laparotomy because most MCs are multiple and adherent to peripheral organ vessels[ 9 ]. With the development of minimally-invasive techniques, the invention and application of the da Vinci robotic surgical system has ushered in a new era of surgical procedures. Compared with traditional laparoscopic surgery, the stability and refinement of the da Vinci robotic surgical system are greatly superior[ 9 ]. The da Vinci robotic surgical system has been widely used in the treatment of various diseases, but treatment of MCs has rarely been reported, therefore in this study we report its use in robot-assisted MC resection in pediatric patients. 2. Materials and Methods 2.1 Patients and clinical data Forty patients with MCs who underwent surgical resection between January 2020 and November 2023 at the Children's Hospital of Zhejiang University School of Medicine were retrospectively studied. The study was approved by the Institute's Ethics Committee and patients underwent robot-assisted surgery or conventional laparoscopic-assisted surgery according to the surgeon's clinical decision and the preference of the patients' parents. Children with direct choice of laparotomy or known comorbidities were excluded. 2.2 Sugical procedure 2.2.1 Robot-assisted surgery. The Da Vinci Xi Surgical System was used to perform the surgery. Each patient was placed in the supine position with a slight Trendelenburg position or head-up tilt position depending on the location of the cysts. The cystic lesion was considered the "target" organ for robot-assisted surgery. The camera port was placed in the middle of the umbilical cord with an 8 mm da Vinci trocar. Another two 8 mm trocars were placed in the vertical line between the lesion and the umbilicus, 5–8 cm from the camera port, and an auxiliary port was considered behind when necessary (Fig. 1 ). Intraoperative exploration was first performed to assess the location and extent of the cyst and its relationship to the bowel and mesenteric vessels. When the cyst was too large for surgical manipulation, the cystic fluid was aspirated before resection. Cystectomy was performed for simple cysts. Segmental enterotomy was required for complex MCs that had a close relationship with the adjacent intestine. For MCs located in the root of the mesentery and involving large blood vessels, the wall of the cyst was first peeled off to skeletonize the mesenteric vessels. A 4 − 0 absorbable thread was used to close the mesenteric defect and suture the remaining intestine intra-abdominally. The resected cyst/attached bowel was placed into a sturdy surgical bag and removed through a slightly-enlarged umbilical incision (Fig. 2 ). 2.2.2 Laparoscopic-assisted surgery. The patient was placed in the supine position and two 5 mm trocars were placed, one each at the left and right sides of the abdomen, which were used as ports for operating devices. After finding the lesion, the cyst was isolated and resected, and when the cyst was difficult to isolate, the cyst fluid was aspirated, and the diseased bowel was removed from the abdominal cavity through the enlarged umbilical incision and resected together with the cyst. If no significant bleeding was seen, the bowel was placed back into the abdominal cavity and the incision was sutured. 2.3 Statistical Analysis All statistical analyses were conducted using SPSS 27.0 software (IBM SPSS Statistics for Windows, Armonk, NY, USA). Categorical variables were analyzed using the Pearson’s chi-square test and Fisher’s exact test, with frequencies presented as percentages of the respective groups. Continuous variables were assessed using the Mann-Whitney U test, and the frequencies were reported as medians and interquartile ranges (IQRs). Two-tailed P values < 0.05 were considered statistically significant for all analyses. 3. Results 3.1 Robot-assisted surgery Eighteen patients (12 males and six females) underwent robot-assisted surgery, all the cysts were removed under complete endoscopic treatment, and no cases were converted to laparotomy. The median age of these patients was 57 months (range: 43–84 months) with a median weight of 17.2 kg (range: 14.15–21.15 kg). The median surgical time was 134.5 minutes (range: 72.25–210 minutes), and none of the patients required blood transfusion. The median length of postoperative hospital stay was 8 days (range: 6–11 days). 3.2 Laparoscopic-assisted surgery Twenty-two patients (13 males and nine females) underwent conventional laparoscopic-assisted surgery. The median age was 53.6 months (range: 22.5–77.5) and the median weight was 16.6 kg (range: 12–21.45 kg). The median surgical time was 104 minutes (range: 72.5–121.5 minutes). The median length of postoperative hospital stay was 10.5 days (range: 8.75–13.5 days). 3.3 Treatment outcomes No blood transfusion was performed in 40 patients. In the robotic assisted surgery group, 7 patients underwent cyst stripping, while 11 patients underwent cyst removal and enterectomy. 13 children located in the small bowel, while 5 in the colon and all children were treated endoscopically without the need for external bowel placement. In the laparoscopic-assisted surgery group, 8 children underwent cyst excision, 14 children underwent cyst excision and bowl resection. 13 children located in the small bowel, while 5 in the colon, and 9 children were difficult to complete, with Conversion to laparotomy. In the laparoscopic group, one case of ureteral injury occurred during the operation, and a double "J" tube was placed after repair during the operation, which was removed and recovered 2 months later. The remaining patients recovered well after surgery, the abdominal incision had healed well 2 months after the operation, and no obvious abnormality was found by ultrasound. There were no statistically-significant differences in age or weight between the two groups ( P > 0.05), but the postoperative hospitalization time in the robot-assisted surgery group was significantly shorter than that in the laparoscopic-assisted surgery group ( P < 0.05) (Table 1 ). Table 1 Clinical parameters of the patients Group RAS LAS P -value n 18 22 - Gender (male/ female) 12/6 13/9 - Age (Months) 57 (43–84) 53.6 (22.5–77.5) 0.35 Weight (kg) 17.2 (14.15–21.15) 16.6 (12–21.45) 0.53 Symptomatic 14 15 - Abdominal pain 12 12 - Vomiting 5 8 - Fever 4 5 - Surgical time (minutes) 134.50 (72.25–210) 104 (72.5–121.5) 0.26 Blood loss (mL) 5 (2–5) 5 (2–10) 0.62 Cyst resection /Bowel resection 7/11 8/14 - Location (ileum/colon) 13/5 17/5 - Conversion to laparotomy 0 9 - Postoperative hospital stay (days) 8 (6–11) 10.5 (8.75–13.5) 0.02 Cost (CNY) 67872 (59152–72062) 18128 (15715–22407) < 0.01 Complications 0 1 - Data are shown as the medians ± inter-quartile ranges (IQRs) RAS, Robotic-assisted surgery; LAS, Laparoscopic-assisted surgery 4. Discussion Compared with traditional laparoscopic surgery, the robot-assisted hand has the following features. First, the 3D high-definition vision and higher magnification up to 10 times allow for more accurate visualization and more precise dissection, allowing clear identification of the boundaries between the cyst and the surrounding tissues. Second, the robotic surgical system maintains lens clarity for a long period of time without being affected by smoke, which ensures smooth, uninterrupted, and time-saving operation throughout the entire surgical procedure. Third, the da Vinci Xi surgical system features hand tremor elimination, motion scaling, and motion indexing. The EndoWrist surgical instruments with seven degrees of motion mimic the dexterity of the human body and improve control of fine motions, which helps to remove cysts from the intestinal tract or mesenteric blood vessels[ 10 , 11 ]. Therefore, Da Vinci robot-assisted surgery is becoming more popular as the feasibility of the system has been recognized[ 12 – 14 ]. MCs are often closely associated with surrounding organs. It is difficult to distinguish their boundaries by the naked eye using ordinary laparoscopic instruments, and complete resection is difficult, especially in those patients it is located in the root of the mesentery. Therefore, it is difficult to perform traditional laparoscopic surgery under total laparoscopy in some patients, making it necessary to enlarge the umbilical incision or even to transfer to laparotomy to resect the diseased cysts and the bowels and perform intestinal anastomosis[ 15 ]. Although surgical trauma is still reduced compared with laparotomy, when cysts are removed for intestinal anastomosis, some bowel loops still need to be exposed outside the body, thus increasing the risk of postoperative intestinal adhesions and intestinal fistula. The greater clarity and resolution of the Da Vinci surgical system can help the surgeons distinguish the cyst wall from the normal intestinal wall and other surrounding adhesive tissue, thus making it possible to remove the cysts under full endoscopic guidance and reduce cyst residue. In this way, the external placement of the intestine is avoided, intestinal resection and anastomosis are not required, and the occurrence of intestinal adhesion, intestinal obstruction and intestinal fistula can be further reduced, leading to faster postoperative recovery. We successfully treated 18 cases of MCs with robot-assisted surgery, including four cases of MCs located at the root of the mesentery, all of which were performed laparoscopically without conversion to laparotomy. We used an ultrasonic scalpel or electrocoagulation to dissect the cysts. The mesenteric vessels, which do not affect the intestinal blood supply, were cut directly, while they were always separated by blunt tips, which peeled the thin cyst wall away from the blood vessels. Vascular skeletonization of the involved mesenteric vessels may significantly reduce postoperative recurrence. If a residual envelope is suspected, the epithelium can be destroyed using an electrocautery. When the cyst infiltrates the intestinal wall, or it is difficult to separate or the intestinal circulation is impaired, intestinal resection and anastomosis should be performed. No anastomotic leakage or intraperitoneal infection occurred after operation, and no recurrence of cysts was found during short- and medium-term follow-up. Using laparoscopic surgery it was difficult to achieve such a fine degree of resection, resulting in a conversion rate of 40.9%, and one case of ureter injury during the operation. The Da Vinci system also has shortcomings. First, the total hospitalization cost is high which causes the difficulty of widespread implementation. This can be partly overcome through the corresponding fund, and with the localization of the machine, the cost will not be a problem. Second, compared to laparoscopic surgery, the operation time is slightly longer, but the difference is not significant. Installation is time-consuming, but replacing the Da Vinci Si system with the Da Vinci Xi system greatly reduces installation time. Our average installation time has been reduced to 15–20 minutes[ 9 , 16 ]. With the rapid development of artificial intelligence and mechanical engineering, these problems will be solved in the future. The limitations of this study are its retrospective nature and small sample size, and the follow-up time is not long enough, so larger multicenter prospective clinical trials and long-term follow-up are required to verify the advantages of this technique. 5. Conclusions Robot-assisted MC resection is safe and feasible, and effectively reduces the difficulty of surgery and reduces the length of hospital stay. Furthermore the procedure does not increase the operation time and results in fewer surgical complications. This study shows that due to its stability and refinement, it is suitable for robot-assisted MC excision in pediatric patients. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of The Children's Hospital, Zhejiang University School of Medicine [2024-IRB-0036-P-01]. Written informed consent was obtained from all the study participants and their parents involved in the study. All procedures were performed in accordance with the declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Key R&D Program of Zhejiang (2023C03029); Zhejiang Provincial Natural Science Foundation Project (LY20H030007) and Central Guiding Fund for Local Science and Technology Development Projects (NO.2023ZY1058). Authors' contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by YC, QJC and DTC. The first draft of the manuscript was written by YC and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements We thank International Science Editing (http://www.internationalscienceediting.com) for editing this manuscript. References Tripathy PK, Jena PK, Pattnaik K: Management outcomes of mesenteric cysts in paediatric age group . Afr J Paediatr Surg 2022, 19 (1):32-35. Leung BC, Sankey R, Fronza M, Maatouk M: Conservative approach to the acute management of a large mesenteric cyst . WORLD J CLIN CASES 2017, 5 (9):360-363. Prakash A, Agrawal A, Gupta RK, Sanghvi B, Parelkar S: Early management of mesenteric cyst prevents catastrophes: a single centre analysis of 17 cases . Afr J Paediatr Surg 2010, 7 (3):140-143. Karim T, Topno M, Kate M: Simple mesenteric cyst in a child: presentation and management . ARAB J GASTROENTEROL 2011, 12 (2):90-91. de Perrot M, Brundler M, Totsch M, Mentha G, Morel P: Mesenteric cysts. Toward less confusion? Dig Surg 2000, 17 (4):323-328. Iyer CP, Mahour GH: Duplications of the alimentary tract in infants and children . J PEDIATR SURG 1995, 30 (9):1267-1270. Autorino R, Zargar H, Kaouk JH: Robotic-assisted laparoscopic surgery: recent advances in urology . FERTIL STERIL 2014, 102 (4):939-949. Maza G, Sharma A: Past, Present, and Future of Robotic Surgery . Otolaryngol Clin North Am 2020, 53 (6):935-941. Jin Y, Zhang Y, Cai D, Huang Z, Zhang S, Mao J, Gao Z: Robot-Assisted Resection of Intestinal Duplication in Children . J Laparoendosc Adv Surg Tech A 2022, 32 (12):1288-1292. Herron DM, Marohn M: A consensus document on robotic surgery . SURG ENDOSC 2008, 22 (2):313-325, 311-312. Klein MD, Langenburg SE, Kabeer M, Lorincz A, Knight CG: Pediatric robotic surgery: lessons from a clinical experience . J Laparoendosc Adv Surg Tech A 2007, 17 (2):265-271. Han JH, Lee JH, Hwang DW, Song KB, Shin SH, Kwon JW, Lee YJ, Kim SC, Park KM: Robot resection of a choledochal cyst with Roux-en-y hepaticojejunostomy in adults: Initial experiences with 22 cases and a comparison with laparoscopic approaches . Ann Hepatobiliary Pancreat Surg 2018, 22 (4):359-366. Esposito C, Blanc T, Patkowski D, Lopez PJ, Masieri L, Spinoit AF, Escolino M: Laparoscopic and robot-assisted ureterocalicostomy for treatment of primary and recurrent pelvi-ureteric junction obstruction in children: a multicenter comparative study with laparoscopic and robot-assisted Anderson-Hynes pyeloplasty . INT UROL NEPHROL 2022, 54 (10):2503-2509. Delgado-Miguel C, Camps JI: Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes . PEDIATR SURG INT 2022, 38 (1):51-57. Chen Q, Zhang S, Luo W, Cai D, Zhang Y, Huang Z, Xuan X, Xiong Q, Gao Z: Robotic-assisted laparoscopic management of mesenteric cysts in children . FRONT PEDIATR 2022, 10 :1089168. Yu DY, Chang YW, Lee HY, Kim WY, Kim HY, Lee JB, Son GS: Detailed comparison of the da Vinci Xi and S surgical systems for transaxillary thyroidectomy . MEDICINE 2021, 100 (3):e24370. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4093184","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280910682,"identity":"819f7059-8f0a-4e52-b029-31603d2a17d0","order_by":0,"name":"Yi Chen","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Chen","suffix":""},{"id":280910683,"identity":"322eced3-ff92-4330-a22b-b569fe2ec2e4","order_by":1,"name":"Qingjiang Chen","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Qingjiang","middleName":"","lastName":"Chen","suffix":""},{"id":280910684,"identity":"e063b687-d9cd-43d2-8b0f-9bd8d2421912","order_by":2,"name":"Duote Cai","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Duote","middleName":"","lastName":"Cai","suffix":""},{"id":280910685,"identity":"466a8ba7-ce03-4a1c-bc76-e3609d7c71e6","order_by":3,"name":"Yunzhong Qian","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Yunzhong","middleName":"","lastName":"Qian","suffix":""},{"id":280910686,"identity":"faa0caba-a0bb-42a8-8cf2-6ee99a9a09e4","order_by":4,"name":"Sai Chen","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Sai","middleName":"","lastName":"Chen","suffix":""},{"id":280910687,"identity":"24a3f47f-71c1-4e04-9e95-c8882c6a1926","order_by":5,"name":"Shuhao Zhang","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Shuhao","middleName":"","lastName":"Zhang","suffix":""},{"id":280910688,"identity":"ca470cab-6a3d-4a83-a2f4-cad0be4cf00e","order_by":6,"name":"Yi Jin","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Jin","suffix":""},{"id":280910689,"identity":"344b735d-428c-4716-8280-edca93c58248","order_by":7,"name":"Linyan Wang","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Linyan","middleName":"","lastName":"Wang","suffix":""},{"id":280910690,"identity":"6a41a5a2-7f8d-4e58-9e63-469c4b881dec","order_by":8,"name":"Qiang Shu","email":"","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Shu","suffix":""},{"id":280910691,"identity":"666e8a4e-ddd6-44e4-a683-57b2bf525096","order_by":9,"name":"Zhigang Gao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYDACCQZmhg8MbCCmAfFaGGeQrIWZB8IkUgu/dI+xsc0fvsQG9uZtEgw1dwhrkZxzxjg5h4ctsYHnWJkEw7FnhLUY3MjdfDhHAqhFIsdMgrHhMGEt9iAtFgZALfJviNRiIJG7OZkhAWQLD5FaJO6c/2zYc4DNuI0nrdgi4RgRWvhntyVL/PhzTLaf/fDGGx9qiNACBccgkZlAtAYGhhoS1I6CUTAKRsGIAwC/ZzRII49kcgAAAABJRU5ErkJggg==","orcid":"","institution":"Children's Hospital of Zhejiang University","correspondingAuthor":true,"prefix":"","firstName":"Zhigang","middleName":"","lastName":"Gao","suffix":""}],"badges":[],"createdAt":"2024-03-13 13:16:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4093184/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4093184/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53118085,"identity":"6d59933c-61dd-44b2-afa0-340bb21e936e","added_by":"auto","created_at":"2024-03-20 19:53:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1085774,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A) Trocar position of robot-assisted MCs resection.\u003c/strong\u003eThe umbilicus and the lower abdomen with MCs were taken as two points to make line a, then line b was drawn perpendicular to line a through the umbilicus (point 2). Two points (1 and 3) were marked on line b about 5-8 cm away from the umbilicus. Points 1, 2, and 3 were the positions of the Da Vinci 8-mm trocar, and the point 4 was the position of the 5-mm laparoscopic port for the assistant surgeon, when necessary. (B) Completed the placement of Da Vinci trocar.\u003c/p\u003e","description":"","filename":"Figure1Trocarposition.png","url":"https://assets-eu.researchsquare.com/files/rs-4093184/v1/2cda9908285f527452443a6e.png"},{"id":53118084,"identity":"91ed911d-4e7c-4b74-99e4-121b598f1f32","added_by":"auto","created_at":"2024-03-20 19:53:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":684316,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRobot-assisted laparoscopic resection of mesenteric cysts.\u003c/strong\u003e (A) Female, age nine (1) The cyst penetrated the ileum mesentery. (2) The cyst was completely removed without excising the intestine, and the mesenteric blood vessels were protected. (3) The mesenteric defect was repaired. (4) The cyst was removed using a retrieval bag. (B) Male, age eight (1) The cyst penetrated the ileal mesentery and adhered to the surrounding intestine. (2) The cyst was removed with segmental bowel resection. (3) Intraperitoneal enterostomy assisted by intestinal suspension traction was performed and (4) the mesangial hiatus was closed.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4093184/v1/f4e1a72c1ee763e6cc03e692.png"},{"id":76877766,"identity":"3fd36a5d-45a8-4012-9d00-ff5216834ca3","added_by":"auto","created_at":"2025-02-21 16:24:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3852319,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4093184/v1/f597ed31-16df-4a2d-a6c6-982c6b14c103.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robot-Assisted Resection of Mesenteric Cysts in Pediatric Patients: a single-centered Retrospective study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMesenteric cysts (MCs) are relatively rare intra-abdominal anomalies with a reported incidence of 1/100,000 in adults and 1/20,000 in infants[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. They can occur anywhere in the gastrointestinal tract and mesentery and may extend into the retroperitoneum. The mesentery of the small intestine, is the most common site for MCs[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Most MCs present as asymptomatic abdominal masses[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], but sometimes give rise to manifestations such as abdominal pain, vomiting, fever and other discomforts, which are often caused by bleeding, infection, or intestinal torsion[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Once diagnosed, surgical resection is usually recommended[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although laparoscopic surgery has become the main surgical modality for this disorder, there is still a high rate of conversion to laparotomy because most MCs are multiple and adherent to peripheral organ vessels[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. With the development of minimally-invasive techniques, the invention and application of the da Vinci robotic surgical system has ushered in a new era of surgical procedures. Compared with traditional laparoscopic surgery, the stability and refinement of the da Vinci robotic surgical system are greatly superior[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The da Vinci robotic surgical system has been widely used in the treatment of various diseases, but treatment of MCs has rarely been reported, therefore in this study we report its use in robot-assisted MC resection in pediatric patients.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patients and clinical data\u003c/h2\u003e \u003cp\u003eForty patients with MCs who underwent surgical resection between January 2020 and November 2023 at the Children's Hospital of Zhejiang University School of Medicine were retrospectively studied. The study was approved by the Institute's Ethics Committee and patients underwent robot-assisted surgery or conventional laparoscopic-assisted surgery according to the surgeon's clinical decision and the preference of the patients' parents. Children with direct choice of laparotomy or known comorbidities were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Sugical procedure\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Robot-assisted surgery.\u003c/h2\u003e \u003cp\u003eThe Da Vinci Xi Surgical System was used to perform the surgery. Each patient was placed in the supine position with a slight Trendelenburg position or head-up tilt position depending on the location of the cysts. The cystic lesion was considered the \"target\" organ for robot-assisted surgery. The camera port was placed in the middle of the umbilical cord with an 8 mm da Vinci trocar. Another two 8 mm trocars were placed in the vertical line between the lesion and the umbilicus, 5\u0026ndash;8 cm from the camera port, and an auxiliary port was considered behind when necessary (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIntraoperative exploration was first performed to assess the location and extent of the cyst and its relationship to the bowel and mesenteric vessels. When the cyst was too large for surgical manipulation, the cystic fluid was aspirated before resection. Cystectomy was performed for simple cysts. Segmental enterotomy was required for complex MCs that had a close relationship with the adjacent intestine. For MCs located in the root of the mesentery and involving large blood vessels, the wall of the cyst was first peeled off to skeletonize the mesenteric vessels. A 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable thread was used to close the mesenteric defect and suture the remaining intestine intra-abdominally. The resected cyst/attached bowel was placed into a sturdy surgical bag and removed through a slightly-enlarged umbilical incision (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Laparoscopic-assisted surgery.\u003c/h2\u003e \u003cp\u003eThe patient was placed in the supine position and two 5 mm trocars were placed, one each at the left and right sides of the abdomen, which were used as ports for operating devices. After finding the lesion, the cyst was isolated and resected, and when the cyst was difficult to isolate, the cyst fluid was aspirated, and the diseased bowel was removed from the abdominal cavity through the enlarged umbilical incision and resected together with the cyst. If no significant bleeding was seen, the bowel was placed back into the abdominal cavity and the incision was sutured.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using SPSS 27.0 software (IBM SPSS Statistics for Windows, Armonk, NY, USA). Categorical variables were analyzed using the Pearson\u0026rsquo;s chi-square test and Fisher\u0026rsquo;s exact test, with frequencies presented as percentages of the respective groups. Continuous variables were assessed using the Mann-Whitney U test, and the frequencies were reported as medians and interquartile ranges (IQRs). Two-tailed \u003cem\u003eP\u003c/em\u003e values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Robot-assisted surgery\u003c/h2\u003e \u003cp\u003eEighteen patients (12 males and six females) underwent robot-assisted surgery, all the cysts were removed under complete endoscopic treatment, and no cases were converted to laparotomy. The median age of these patients was 57 months (range: 43\u0026ndash;84 months) with a median weight of 17.2 kg (range: 14.15\u0026ndash;21.15 kg). The median surgical time was 134.5 minutes (range: 72.25\u0026ndash;210 minutes), and none of the patients required blood transfusion. The median length of postoperative hospital stay was 8 days (range: 6\u0026ndash;11 days).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Laparoscopic-assisted surgery\u003c/h2\u003e \u003cp\u003eTwenty-two patients (13 males and nine females) underwent conventional laparoscopic-assisted surgery. The median age was 53.6 months (range: 22.5\u0026ndash;77.5) and the median weight was 16.6 kg (range: 12\u0026ndash;21.45 kg). The median surgical time was 104 minutes (range: 72.5\u0026ndash;121.5 minutes). The median length of postoperative hospital stay was 10.5 days (range: 8.75\u0026ndash;13.5 days).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Treatment outcomes\u003c/h2\u003e \u003cp\u003eNo blood transfusion was performed in 40 patients. In the robotic assisted surgery group, 7 patients underwent cyst stripping, while 11 patients underwent cyst removal and enterectomy. 13 children located in the small bowel, while 5 in the colon and all children were treated endoscopically without the need for external bowel placement. In the laparoscopic-assisted surgery group, 8 children underwent cyst excision, 14 children underwent cyst excision and bowl resection. 13 children located in the small bowel, while 5 in the colon, and 9 children were difficult to complete, with Conversion to laparotomy.\u003c/p\u003e \u003cp\u003eIn the laparoscopic group, one case of ureteral injury occurred during the operation, and a double \"J\" tube was placed after repair during the operation, which was removed and recovered 2 months later. The remaining patients recovered well after surgery, the abdominal incision had healed well 2 months after the operation, and no obvious abnormality was found by ultrasound. There were no statistically-significant differences in age or weight between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but the postoperative hospitalization time in the robot-assisted surgery group was significantly shorter than that in the laparoscopic-assisted surgery group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical parameters of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRAS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLAS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (male/ female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (43\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.6 (22.5\u0026ndash;77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.2 (14.15\u0026ndash;21.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.6 (12\u0026ndash;21.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134.50 (72.25\u0026ndash;210)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (72.5\u0026ndash;121.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (2\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCyst resection /Bowel resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation (ileum/colon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to laparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6\u0026ndash;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5 (8.75\u0026ndash;13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost (CNY)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67872 (59152\u0026ndash;72062)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18128 (15715\u0026ndash;22407)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are shown as the medians\u0026thinsp;\u0026plusmn;\u0026thinsp;inter-quartile ranges (IQRs)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eRAS, Robotic-assisted surgery; LAS, Laparoscopic-assisted surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eCompared with traditional laparoscopic surgery, the robot-assisted hand has the following features. First, the 3D high-definition vision and higher magnification up to 10 times allow for more accurate visualization and more precise dissection, allowing clear identification of the boundaries between the cyst and the surrounding tissues. Second, the robotic surgical system maintains lens clarity for a long period of time without being affected by smoke, which ensures smooth, uninterrupted, and time-saving operation throughout the entire surgical procedure. Third, the da Vinci Xi surgical system features hand tremor elimination, motion scaling, and motion indexing. The EndoWrist surgical instruments with seven degrees of motion mimic the dexterity of the human body and improve control of fine motions, which helps to remove cysts from the intestinal tract or mesenteric blood vessels[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, Da Vinci robot-assisted surgery is becoming more popular as the feasibility of the system has been recognized[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMCs are often closely associated with surrounding organs. It is difficult to distinguish their boundaries by the naked eye using ordinary laparoscopic instruments, and complete resection is difficult, especially in those patients it is located in the root of the mesentery. Therefore, it is difficult to perform traditional laparoscopic surgery under total laparoscopy in some patients, making it necessary to enlarge the umbilical incision or even to transfer to laparotomy to resect the diseased cysts and the bowels and perform intestinal anastomosis[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although surgical trauma is still reduced compared with laparotomy, when cysts are removed for intestinal anastomosis, some bowel loops still need to be exposed outside the body, thus increasing the risk of postoperative intestinal adhesions and intestinal fistula.\u003c/p\u003e \u003cp\u003eThe greater clarity and resolution of the Da Vinci surgical system can help the surgeons distinguish the cyst wall from the normal intestinal wall and other surrounding adhesive tissue, thus making it possible to remove the cysts under full endoscopic guidance and reduce cyst residue. In this way, the external placement of the intestine is avoided, intestinal resection and anastomosis are not required, and the occurrence of intestinal adhesion, intestinal obstruction and intestinal fistula can be further reduced, leading to faster postoperative recovery.\u003c/p\u003e \u003cp\u003eWe successfully treated 18 cases of MCs with robot-assisted surgery, including four cases of MCs located at the root of the mesentery, all of which were performed laparoscopically without conversion to laparotomy. We used an ultrasonic scalpel or electrocoagulation to dissect the cysts. The mesenteric vessels, which do not affect the intestinal blood supply, were cut directly, while they were always separated by blunt tips, which peeled the thin cyst wall away from the blood vessels. Vascular skeletonization of the involved mesenteric vessels may significantly reduce postoperative recurrence. If a residual envelope is suspected, the epithelium can be destroyed using an electrocautery. When the cyst infiltrates the intestinal wall, or it is difficult to separate or the intestinal circulation is impaired, intestinal resection and anastomosis should be performed. No anastomotic leakage or intraperitoneal infection occurred after operation, and no recurrence of cysts was found during short- and medium-term follow-up. Using laparoscopic surgery it was difficult to achieve such a fine degree of resection, resulting in a conversion rate of 40.9%, and one case of ureter injury during the operation.\u003c/p\u003e \u003cp\u003eThe Da Vinci system also has shortcomings. First, the total hospitalization cost is high which causes the difficulty of widespread implementation. This can be partly overcome through the corresponding fund, and with the localization of the machine, the cost will not be a problem. Second, compared to laparoscopic surgery, the operation time is slightly longer, but the difference is not significant. Installation is time-consuming, but replacing the Da Vinci Si system with the Da Vinci Xi system greatly reduces installation time. Our average installation time has been reduced to 15\u0026ndash;20 minutes[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. With the rapid development of artificial intelligence and mechanical engineering, these problems will be solved in the future.\u003c/p\u003e \u003cp\u003eThe limitations of this study are its retrospective nature and small sample size, and the follow-up time is not long enough, so larger multicenter prospective clinical trials and long-term follow-up are required to verify the advantages of this technique.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eRobot-assisted MC resection is safe and feasible, and effectively reduces the difficulty of surgery and reduces the length of hospital stay. Furthermore the procedure does not increase the operation time and results in fewer surgical complications. This study shows that due to its stability and refinement, it is suitable for robot-assisted MC excision in pediatric patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of The Children's Hospital, Zhejiang University School of Medicine [2024-IRB-0036-P-01]. Written informed consent was obtained from all the study participants and their parents involved in the study. All procedures were performed in accordance with the declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Key R\u0026amp;D Program of Zhejiang (2023C03029); Zhejiang Provincial Natural Science Foundation Project (LY20H030007) and Central Guiding Fund for Local Science and Technology Development Projects (NO.2023ZY1058).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by YC, QJC and DTC. The first draft of the manuscript was written by YC and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank International Science Editing (http://www.internationalscienceediting.com) for editing this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTripathy PK, Jena PK, Pattnaik K: \u003cstrong\u003eManagement outcomes of mesenteric cysts in paediatric age group\u003c/strong\u003e. \u003cem\u003eAfr J Paediatr Surg\u003c/em\u003e 2022, \u003cstrong\u003e19\u003c/strong\u003e(1):32-35.\u003c/li\u003e\n\u003cli\u003eLeung BC, Sankey R, Fronza M, Maatouk M: \u003cstrong\u003eConservative approach to the acute management of a large mesenteric cyst\u003c/strong\u003e. \u003cem\u003eWORLD J CLIN CASES\u003c/em\u003e 2017, \u003cstrong\u003e5\u003c/strong\u003e(9):360-363.\u003c/li\u003e\n\u003cli\u003ePrakash A, Agrawal A, Gupta RK, Sanghvi B, Parelkar S: \u003cstrong\u003eEarly management of mesenteric cyst prevents catastrophes: a single centre analysis of 17 cases\u003c/strong\u003e. \u003cem\u003eAfr J Paediatr Surg\u003c/em\u003e 2010, \u003cstrong\u003e7\u003c/strong\u003e(3):140-143.\u003c/li\u003e\n\u003cli\u003eKarim T, Topno M, Kate M: \u003cstrong\u003eSimple mesenteric cyst in a child: presentation and management\u003c/strong\u003e. \u003cem\u003eARAB J GASTROENTEROL\u003c/em\u003e 2011, \u003cstrong\u003e12\u003c/strong\u003e(2):90-91.\u003c/li\u003e\n\u003cli\u003ede Perrot M, Brundler M, Totsch M, Mentha G, Morel P: \u003cstrong\u003eMesenteric cysts. Toward less confusion?\u003c/strong\u003e \u003cem\u003eDig Surg\u003c/em\u003e 2000, \u003cstrong\u003e17\u003c/strong\u003e(4):323-328.\u003c/li\u003e\n\u003cli\u003eIyer CP, Mahour GH: \u003cstrong\u003eDuplications of the alimentary tract in infants and children\u003c/strong\u003e. \u003cem\u003eJ PEDIATR SURG\u003c/em\u003e 1995, \u003cstrong\u003e30\u003c/strong\u003e(9):1267-1270.\u003c/li\u003e\n\u003cli\u003eAutorino R, Zargar H, Kaouk JH: \u003cstrong\u003eRobotic-assisted laparoscopic surgery: recent advances in urology\u003c/strong\u003e. \u003cem\u003eFERTIL STERIL\u003c/em\u003e 2014, \u003cstrong\u003e102\u003c/strong\u003e(4):939-949.\u003c/li\u003e\n\u003cli\u003eMaza G, Sharma A: \u003cstrong\u003ePast, Present, and Future of Robotic Surgery\u003c/strong\u003e. \u003cem\u003eOtolaryngol Clin North Am\u003c/em\u003e 2020, \u003cstrong\u003e53\u003c/strong\u003e(6):935-941.\u003c/li\u003e\n\u003cli\u003eJin Y, Zhang Y, Cai D, Huang Z, Zhang S, Mao J, Gao Z: \u003cstrong\u003eRobot-Assisted Resection of Intestinal Duplication in Children\u003c/strong\u003e. \u003cem\u003eJ Laparoendosc Adv Surg Tech A\u003c/em\u003e 2022, \u003cstrong\u003e32\u003c/strong\u003e(12):1288-1292.\u003c/li\u003e\n\u003cli\u003eHerron DM, Marohn M: \u003cstrong\u003eA consensus document on robotic surgery\u003c/strong\u003e. \u003cem\u003eSURG ENDOSC\u003c/em\u003e 2008, \u003cstrong\u003e22\u003c/strong\u003e(2):313-325, 311-312.\u003c/li\u003e\n\u003cli\u003eKlein MD, Langenburg SE, Kabeer M, Lorincz A, Knight CG: \u003cstrong\u003ePediatric robotic surgery: lessons from a clinical experience\u003c/strong\u003e. \u003cem\u003eJ Laparoendosc Adv Surg Tech A\u003c/em\u003e 2007, \u003cstrong\u003e17\u003c/strong\u003e(2):265-271.\u003c/li\u003e\n\u003cli\u003eHan JH, Lee JH, Hwang DW, Song KB, Shin SH, Kwon JW, Lee YJ, Kim SC, Park KM: \u003cstrong\u003eRobot resection of a choledochal cyst with Roux-en-y hepaticojejunostomy in adults: Initial experiences with 22 cases and a comparison with laparoscopic approaches\u003c/strong\u003e. \u003cem\u003eAnn Hepatobiliary Pancreat Surg\u003c/em\u003e 2018, \u003cstrong\u003e22\u003c/strong\u003e(4):359-366.\u003c/li\u003e\n\u003cli\u003eEsposito C, Blanc T, Patkowski D, Lopez PJ, Masieri L, Spinoit AF, Escolino M: \u003cstrong\u003eLaparoscopic and robot-assisted ureterocalicostomy for treatment of primary and recurrent pelvi-ureteric junction obstruction in children: a multicenter comparative study with laparoscopic and robot-assisted Anderson-Hynes pyeloplasty\u003c/strong\u003e. \u003cem\u003eINT UROL NEPHROL\u003c/em\u003e 2022, \u003cstrong\u003e54\u003c/strong\u003e(10):2503-2509.\u003c/li\u003e\n\u003cli\u003eDelgado-Miguel C, Camps JI: \u003cstrong\u003eRobotic Soave pull-through procedure for Hirschsprung\u0026apos;s disease in children under 12-months: long-term outcomes\u003c/strong\u003e. \u003cem\u003ePEDIATR SURG INT\u003c/em\u003e 2022, \u003cstrong\u003e38\u003c/strong\u003e(1):51-57.\u003c/li\u003e\n\u003cli\u003eChen Q, Zhang S, Luo W, Cai D, Zhang Y, Huang Z, Xuan X, Xiong Q, Gao Z: \u003cstrong\u003eRobotic-assisted laparoscopic management of mesenteric cysts in children\u003c/strong\u003e. \u003cem\u003eFRONT PEDIATR\u003c/em\u003e 2022, \u003cstrong\u003e10\u003c/strong\u003e:1089168.\u003c/li\u003e\n\u003cli\u003eYu DY, Chang YW, Lee HY, Kim WY, Kim HY, Lee JB, Son GS: \u003cstrong\u003eDetailed comparison of the da Vinci Xi and S surgical systems for transaxillary thyroidectomy\u003c/strong\u003e. \u003cem\u003eMEDICINE\u003c/em\u003e 2021, \u003cstrong\u003e100\u003c/strong\u003e(3):e24370.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mesenteric cysts, Robotic-assisted, Laparoscopic-assisted, Children","lastPublishedDoi":"10.21203/rs.3.rs-4093184/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4093184/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMesenteric cysts (MCs) are rare intra-abdominal masses in childhood. Laparoscopic-assisted surgery has become the main procedure for their resection, but robot-assisted surgery has rarely been reported. The purpose of this study was to retrospectively analyze and present our experience with robot-assisted resection of MCs using the da Vinci Xi surgical system and to discuss the technical points.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eChildren diagnosed with abdominal MCs who underwent surgical treatment at the Children's Hospital of Zhejiang University School of Medicine between January 2020 and November 2023 were retrospectively analyzed, and clinical data, surgical details, and prognosis of the patients were systematically collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 40 patients, a total of 18 underwent robot-assisted surgery and 22 underwent laparoscopic-assisted surgery. In the robot-assisted surgery group, the entire procedure was performed endoscopically, whereas in the laparoscopic surgery group, eight procedures were converted to laparotomy. The operation time of 134.5 minutes for the robot-assisted group was not significantly longer than the 104 minutes for the laparoscopic-assisted surgery group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but the average length of postoperative hospital stay was significantly shorter (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRobotic-assisted resection of MCs is safe and feasible and the refinement of the Da Vinci Xi surgical system was much better than that of the conventional laparoscopic equipment, resulting in significantly improved intraoperative and postoperative outcomes.\u003c/p\u003e","manuscriptTitle":"Robot-Assisted Resection of Mesenteric Cysts in Pediatric Patients: a single-centered Retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-20 19:53:46","doi":"10.21203/rs.3.rs-4093184/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4bde4b43-b24a-462f-8ddb-d9c7f9afbe84","owner":[],"postedDate":"March 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-21T16:23:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-20 19:53:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4093184","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4093184","identity":"rs-4093184","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}