May Fluorescent Cholangiography Make Cholecystectomy Safer? Personal Experience of More Than 150 Cases of Single Site(tm) Robotic Cholecystectomy

Giuseppe Spinoglio, MD¹, Alessandra Marano¹, Fabio Priora², Luca M Lenti², Ferruccio Ravazzoni², Giampaolo Formisano³. ¹Humanitas Clinical and Research Center, Rozzano, Italy, ²SS Antonio and Biagio Hospital, Alessandria, Italy, ³Misericordia Hospital, Grosseto, Italy

Objective

Bile duct injury (BDI) rate increased from 0.2% in the era of open surgery to 0.4-0.5% during standard laparoscopy and 0.7% in case of single-incision approach. Single Site™ robotic system overcomes technical limitations of single-incision cholecystectomy by restoring the linchpins of standard laparoscopy, such as triangulation and optimal working angles. The aim of our study is to analyse the adding value of fluorescent cholangiography (FC) combined to Single Site™ platform in reducing bile duct injuries.

Description

From July 2011 to December 2014, 154 patients underwent Single Site™ robotic cholecystectomy (SSRC) with FC for symptomatic cholelithiasis and gallbladder polyposis. Twelve out of 154 patients suffered from acute cholecystitis (7.8%).Patients characteristics, intra and postoperative findings and data about extrahepatic biliary ducts visualization were retrospectively analysed. A dose of 2.5mg of Indocyanine Green (ICG) is injected intravenously about 30-45 minutes before surgery.

Preliminary results

Mean BMI was 24.7 kg/m2. Mean operative time and mean console time were 71 and 30 minutes, respectively. There were no conversions, BDIs, intra- or postoperative complications or adverse events; mean hospital stay was 1.2 days. At a medium follow up of 23.6 months, any patients presented incisional hernia. The rates of visualization of the cystic duct, the common hepatic duct and the common bile duct were 94.6 %, 76.1 %, 78.7 % prior to Calot’s dissection, respectively, and 99.1%, 92%, 96.4% after Calot’s dissection, respectively. At least one biliary structure was visualized in 148 out of 154 patients (96.1%) before Calot’s dissection, and in 100% of cases after Calot’s dissection.

Conclusions

Our consistent experience validates that FC is a simple, fast and effective tool to visualize the biliary tree, especially in case of aberrant ducts and anatomical variations. Its routinary use improves the safety of SSRC and should be applied also in laparoscopic and single-incision cholecystectomy.