Robot-Assisted Choledochotomy and Common Bile Duct Exploration As an Option for Complex Choledocholithiasis

Ahmed Almamar, MD, MSc, FRCSC, Heather Emmerton-Coughlin, MD, FRCSC, Nawar Alkhamesi, MD, PhD, FRCS, Gen, Surg, FRCS, FRCSEd, Christopher M Schlachta, BSc, MDCM, FRCSC, FACS. Department of Surgery, Western University and Canadian Surgical Technologies and Advanced Robotics (CSTAR), London, Canada

Background: The aim of this study is to evaluate the safety and feasibility of elective, robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) as compared to the open technique for ERCP refractory choledocholithiasis.

Method: A prospective database of all RCD/CBDE has been maintained since our first procedure in 2006. With ethics board approval, this database was compared with a detailed chart-review of all contemporaneous elective open procedures (OCD/CBDE) performed from 2005 until present.  Emergency procedures were excluded from analysis. Outcomes were analyzed on the basis of intent-to-treat.

Results: In the past decade, a total of 67 cases of elective CD/CBDE were performed in our institution, comprising 40 consecutive, unselected RCD/CBDE performed by one surgeon and 27 OCD/CBDE performed by others. Comparing RCD/CBDE to OCD/CBDE there were no significant differences between groups with respect to age (65±20 vs. 67±18, p= 0.05), gender (M12:F28 vs. M16:F25, p= 0.05), ASA class, co-morbidities or reason for failed ERCP. Patients had prior cholecystectomy in 38% of those undergoing RCD/CBDE compared to 33% having OCD/CBDE. The mean duration of surgery for RCD/CBDE was 31 minutes longer than OCD/CBDE (205 ±70 min vs. 174±73 min, p= 0.02), while the median hospital stay was six days less (4 vs 10 days, p= 0.02). Four had outpatient RCD/CBDE. Postoperative complications, mainly wound complications (54%), occurred in 9 (22%) RCD/CBDE and in 15 (56%) OCD/CBDE (p=0.39). Conversion to laparotomy was performed in 6 (15%) patients, mainly due to adhesions, and was associated with a higher complication rate than non-converted cases (67% vs. 15%, p=0.02). There was one mortality in the RCD/CBDE group and two in the OCD/CBDE group. External biliary drainage (t-tube) was used in 52% of patients of robotic-assisted group compared to 77% in the open group (p= 0.37).

Conclusion: The use of robotic-assisted CD/CBDE trades longer operating time for a significant reduction in hospital stay. A trend toward reduced postoperative complications was not statistically significant. A cost-effectiveness analysis is in progress.