Robotic-assisted vs. open and laparoscopic Kasai portoenterostomy for biliary atresia: a systematic review and meta-analysis.

BACKGROUND

Biliary atresia is a progressive neonatal cholangiopathy that requires timely Kasai portoenterostomy to restore bile drainage and improve native liver survival. Robotic-assisted Kasai portoenterostomy (RAKPE) has recently emerged as a potential minimally invasive alternative to open Kasai portoenterostomy (OKPE) and laparoscopic Kasai portoenterostomy (LKPE). However, its comparative efficacy and safety remain uncertain.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library for comparative studies published from January 1, 2000, to May 20, 2026. Eligible studies included children with biliary atresia who underwent RAKPE and were compared with patients treated by OKPE and/or LKPE. The primary outcomes were 6-month jaundice clearance and 1-year native liver survival. Odds ratios (ORs) were calculated for dichotomous outcomes, and mean differences (MDs) were calculated for continuous outcomes. RAKPE was analyzed separately against OKPE and LKPE.

RESULTS

Five retrospective comparative studies were included. RAKPE showed short-term clinical outcomes that were generally comparable to those of OKPE and LKPE. The pooled estimates suggested a possible tendency toward higher jaundice clearance after RAKPE, but the differences were not statistically significant. Sensitivity analyses indicated that RAKPE might be associated with less intraoperative blood loss and shorter hospital stay in selected comparisons. These perioperative findings were influenced by individual studies and should therefore be interpreted as preliminary.

CONCLUSION

Current comparative evidence suggests that RAKPE can achieve jaundice clearance, native liver survival, and postoperative cholangitis outcomes similar to those of OKPE and LKPE in children with biliary atresia. The robotic approach may have advantages in selected perioperative outcomes, but longer operative time remains a consistent drawback. Because the available evidence is based on a small number of retrospective studies, multicenter prospective studies with standardized outcome definitions and longer follow-up are needed before the role of RAKPE can be defined more firmly.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261401089, PROSPERO CRD420261401089.