Robotic Assisted Cholecystectomy in the complex, comorbid population: Safer?

Wanda M Good, DO, Jason Cundiff, MD, Sherri L Finn, Alainna Simpson. Pacific Northwest University of Health Sciences

Introduction: The routine utilization of robotics in general surgery remains controversial, but may represent a better approach for safer, cost effective cholecystectomy in complex patient populations.  Laparoscopic cholecystectomy has been the standard of care for biliary disease with well-established outcomes, but patients with morbid obesity, multiple co-morbidities, complex abdominal surgical history and acute cholecystitis remain challenging populations with potentially higher complication rates.  The emergence of daVinci robotic technology with enhanced optics and wristed instrumentation provides improved technical capability and may result in lower intraoperative complication rates and conversion to open cholecystectomy.

Methods: From March 1, 2012 to August 30, 2015, a total of 503 patients underwent robotic assisted laparoscopic cholecystectomy by two surgeons at a single institution.  Most patients were identified as being morbidly obese (BMI > 35), with a history of major abdominal surgery, or suffering from acute cholecystitis.  A retrospective review was performed for these patients, noting the outcomes and complications of the procedure.

Results: Over 500 patients with a mean age of 54.9 ± 10.0 years (range, 19-87).  All patients were identified as having at least one of the inclusion criteria delineated above.  Mean preoperative body mass index (BMI) of 38.4 ± 7.9 kg/m2 (range, 24.8-80.4).  53% of patients were categorized as having acute cholecystitis.  28% of patients had prior history of major abdominal surgery.  The incidence of common duct injury was 0.0%.  One patient had a bile leak (0.15%) which was predicted after removal of a necrotic gallbladder extending to the cystic duct, requiring postop ERCP with stent placement.  Two patients required interventional drainage of an intraabdominal abscess (0.39%). Two patients required conversion to open cholecystectomy (0.39%)

Conclusion: Robotic assisted cholecystectomy in a difficult patient population results in improved, cost-effective patient outcomes.  Laparoscopic cholecystectomy is the most common abdominal surgical procedure in the U.S. with approximately 750,000 performed annually.  Seemingly low statistical complication rates for bile leak, common bile duct injury and conversion to open cholecystectomy still adversely affect thousands of individual patients annually.  The technical advantages conferred by the 3D Hi-definition visual system and endowrist instrumentation may allow for better visualization, and therefore more precise means of performing cholecystectomy in challenging patients due to morbid obesity, acute inflammatory state or dense intraabdominal adhesions.