Outcomes of laparoscopic versus open excision of choledochal cyst in preschool-aged children: analysis from a nationally representative database.

BACKGROUND: Laparoscopic surgery for choledochal cysts (CC) in young children is a technically demanding procedure, and comparative outcomes with open surgery remain incompletely defined. This study aims to compare outcomes of laparoscopic surgery (LS) and open surgery (OS) in children ≤ 5 years. METHODS: A retrospective cohort study was conducted using the Pediatric Health Information System (PHIS) database to identify children with CC who underwent definitive surgical excision between 2015 and 2025. Patients were grouped by operative approach (LS vs. OS). Demographic characteristics, operative techniques, and postoperative outcomes were compared. RESULTS: A total of 533 children were included (LS: 251, 47.1%; OS: 282, 52.9%). LS was more often performed during elective admissions (p < 0.001) and in older children (p < 0.001). Preoperative malnutrition (p = 0.032), cholangitis (p = 0.029), and the need for drainage procedures prior to definitive surgery (p = 0.050) were more common in OS. Hepaticoduodenostomy predominated in LS, while hepaticojejunostomy was more common with OS (p < 0.001). There were no differences in overall 90-day postoperative complications (p = 0.618). LS was associated with fewer blood transfusions (p = 0.049), total parenteral nutrition (p = 0.005), and mechanical ventilation (p = 0.001), decreased odds of intensive care unit admission (p < 0.001), and shorter length of stay (p < 0.001). At 90-day follow-up, biliary calculi were more common after LS (2.8% vs. 0.4%, p = 0.029), while hepatic fibrosis was observed only after OS (3.5%, p = 0.002). CONCLUSION: In preschool-aged children with choledochal cysts, laparoscopic and open approaches demonstrate similar short-term complication rates. Laparoscopy is associated with improved perioperative recovery and reduced resource utilization. When patient and disease factors permit, LS represents a reasonable primary operative approach, although careful patient selection remains essential.