Eugenia Kang, MD, Diane Kwan, MD. John Muir Medical Center
Introduction: Laparoscopic cholecystectomy has become the standard of care for removing the gallbladder. This standard confers the well-known benefits of minimally invasive surgery including less pain, faster recovery, and better cosmetic results. Traditional technique uses four port sites. By utilizing the technology afforded by robotic cholecystectomy, one small incision hidden in the umbilicus is all that is needed to remove the gallbladder as safely and effectively as laparoscopic cholecystectomy, with improved cosmesis.
Technique: A 2.5 cm incision is made through the umbilicus to accommodate the single-site port. Curved robotic instruments are inserted through the port and docked under direct visualization of the robotic camera. The flexible, curved instruments allow triangulation in the area of dissection, and achievement of the critical view of safety without requiring multiple ports. The same techniques of dissection are utilized as in laparoscopic cholecystectomy, allowing dissection of the gallbladder off the liver bed, and removal through the umbilical incision without any need to dilate or extend the port site.
Methods: We performed a retrospective analysis of a two-surgeon experience between March 2014 and September 2015. The goal of the study was to evaluate operative times over the learning curve of the robotic procedure, review complications, and validate this technique as an alternative to the traditional laparoscopic procedure.
Results: 111 consecutive patients were studied. Four patients had conversion to multiport robotic, laparoscopic or open cholecystectomy. Ten patients required additional time to perform an intraoperative cholangiogram. A total of 14 patients were subsequently excluded. Ages ranged from 17 to 84. 76 (78%) were female; 21 (22%) were male. Average length of operation was 83 minutes (44-140), which decreased with increasing experience. Average length of hospital stay was 1.2 days (all outpatients were discharged the day of surgery or after 23 hrs observation). 4/97 (4%) had postoperative wound infections that resolved with antibiotic treatment. Two patients (2%) experienced port site hernias.
Conclusion: Robotic-assisted single-incision cholecystectomy can be performed safely and effectively with good outcomes and improved operative times. No patients were readmitted with bile leak. Hernia formation risk is low. Infection risk is low. Trends in operative time correlate with BMI and were increased in male patients and inpatient cases. There is no difference in operative time with ASA. Operative times improve over time. Additional prospective studies are needed to compare results between laparoscopic and robotic techniques.