Robotic assisted completion cholecystectomy. the utility of a robot in a difficult opeartion

Imran Siddiqui, MD, FACS, Russell Kirks, MD, Erin Baker, MD, Allyson Cochran, MSPH, Ryan Swan, MD, David Iannitt, MD, Dionisios Vrochides, MD, John Martinie, MD. Carolinas Medical Center

Background: We retrospectively analyzed six cases of robotic-assisted completion cholecystectomy to evaluate the safety and efficacy of the robotic platform for this treatment indication.  Partial cholecystectomy may be performed in the setting of gangrenous cholecystitis when inflammation obscures visualization of critical structures.  As a result, the gallbladder is transected at the infundibulum or distal body without attempting dissection of the triangle of Calot to prevent bile duct injury.  Leaving a remnant gallbladder can result in symptomatic retained stones, biliary fistulae, and abscesses requiring surgical intervention. Reoperation is also required for incidental gall bladder carcinoma.  The robotic platform offers improved visualization and dexterity in settings of complex anatomy.  We describe an early safety and feasibility case series of robotic-assisted completion cholecystectomy.

Methods: Patients undergoing robotic completion cholecystectomy from 2010 to 2015 at a quaternary HPB referral center were identified. Patient demographics, prior surgical and endoscopic interventions, intraoperative findings, and postoperative complications were analyzed retrospectively. 90-day morbidity and mortality, reoperation, hospital length of stay, and readmission were tracked.

Results: Six patients were identified and included in this review.  All six were initially found to have gangrenous cholecystitis and received subtotal cholecystectomy (3 laparoscopic, 2 open, 1 laparoscopic to open conversion).  After initial surgery, two patients presented with a symptomatic gallbladder remnant, one developed biliary fistula, and three patients (50%) had incidental diagnosis of adenocarcinoma of the gallbladder (two with T2 disease and one tumor in situ). All procedures were completed robotically.  Median age was 59.5 years (range 42-65y), median BMI was 30.9 (range 23-33.25), and the American Society of Anesthesiologists (ASA) classification was 3 in all patients.  Median EBL was 72.5 mL (range 50-150mL) while median operative time was 181.5 min (range 176-206min).  The operative times for two patients could not be located, excluding them from analysis of this variable.  All gallbladder malignancies were staged with portal lymphadenectomy at the time of completion cholecystectomy.  No immediate complications or bile leaks occurred and no postoperative intervention was required.  Median hospital length of stay was 2 days (range 1-4 d).  At median follow-up of 22 months, all patients were free of symptoms and port site recurrence.

Conclusion: This early case series supports the safety and feasibility of completion cholecystectomy performed with the surgical robot.  Further studies are needed to identify if the robotic approach can be extended to all patients in this cohort.

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