Sean Degmetich, MD1, Manuel Garcia, MD2, Esther Wu, MD2, Stephanie Keeth, DNP2, Aarthy Kannappan, MD2, Daniel Sirkureja, MD2, Jeffrey Quigley, MD2, Keith Scharf, DO, FACS, FASMBS2, Marcos Michelotti, MD, FACS2. 1University of California, Riverside/ Riverside University Health System, 2Loma Linda University
Summary of Surgical Case: The so-called “post-cholecystectomy syndrome” can occur in 10 – 40% of the patients who underwent partial cholecystectomy (PC). A systematic review has shown an incidence of symptomatic cholelithiasis after PC of 2.2% to 5 %. Completion cholecystectomy is generally advised for any residual gallbladder with post-cholecystectomy syndrome, and it can be done via a minimally invasive approach. Our case study is a 43 year old male who was seen in clinic for post-cholecystectomy syndrome. He had an open partial cholecystectomy several years prior but subsequently developed an episode of gallstone pancreatitis afterwards. Endoscopic retrograde cholangiopancreatography revealed a stone in the remnant gallbladder, also confirmed with CT imaging. Robotic remnant cholecystectomy using indocyanine green (ICG) fluorescence guidance was performed. Using ICG, the cystic duct was clearly identified from the common bile duct and the remnant gallbladder safely removed from a hostile environment. ICG fluorescence cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree in complex re-do hepatobiliary surgeries.
Educational/Technical Points: When encountering a difficult gallbladder, PC may be performed in order to avoid biliary injury. Retained gallbladder however is not without risks, including further gallstone formation and possible fistulization. In addition, there is a need for completion cholecystectomy in the presence of post-cholecystectomy syndrome. The real advantage of robotic technology compared to laparoscopy is seen in complex cases, where wrist dexterity and use of ICG fluorescence is of an essence (by allowing real-time identification of the bile structures). The use of both technologies has the potential to improve the success of completion cholecystectomy and reduce complications related to misidentified structures.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87933
Program Number: V171
Presentation Session: Biliary Videos Session
Presentation Type: Video
sages_adbutler_leaderboard