Robotic Single Site Cholecystectomy: MIS Fellowship Program Experience with the First 135 Cases in a New York City Community Medical Center

Thomas J Shaknovsky, DO, Frederick Sabido, MD, FACS. Richmond University Medical Center, Affiliate of Downstate Medical Center, Department of Minimally Invasive Surgery

INTRODUCTION: In our practice and as part of our MIS fellowship program, we used the da Vinci robotic single site platform for all patients needing a laparoscopic cholecystectomy for 15 consecutive months.  The purpose of this study is to document the experience, results and conclusions after performing the first 135 robotic single site cholecystectomies as part of an Advanced GI MIS fellowship teaching curriculum.

METHODS AND PROCEDURES: From March 2014 to July 2015, all robotic single site cholecytectomies performed by the MIS fellowship program director with active participation by the MIS Fellow and general surgical residents were retrospectively reviewed.  All patients were randomized to a single group, regardless of BMI, diagnosis, co-morbidities, age or ASA class.  No exclusion criterion was employed.  Age, ASA (American Society of Anethesiologists), diagnosis, BMI, total operative time (docking and console time) and complications (death, cystic duct leak, bleeding, incisional hernia, wound infection, conversion to open procedure and common bile duct injury) were retrospectively analyzed.  All cases performed with fluorescence firefly cholangiogram.  The umbilical fascial incision was closed with 0-maxon suture in a ratio of 4:1 to the defect in running fashion.  Patient follow up was at 1 week and 3 months from surgery.      

RESULTS: A total of 135 robotic single site cholecystectomies were performed at our institution over the 15 month time frame.  Mean age was 53.1 years (range 21-80) and mean BMI was 30 (range 19-53).  Mean ASA was 2 (range 1-4) and mean total operative time was 69.75 minutes (range 40-105 minutes). The patient cohort diagnosis breakdown was 22 (16.3%) with cholelithiasis, 19 (14.1%) with acute cholecystitis, 88 (65.2%) with chronic cholecystitis, 2 (1.4%) with biliary dyskinesia and 4 (3%) with gallbladder polyps.  Three (2%) patients developed an incisional hernia which was successfully treated with interval repair with mesh. There were no deaths, no conversions to an open procedure, no cystic duct leaks, no bleeding complications, no wound infections, no re-admissions for urinary retention and most importantly no common bile duct injuries.  All patients were discharged as an ambulatory procedure.

CONCLUSION: Robotic single site cholecystectomy is cosmetically superior and safe to perform on any patient regardless of diagnosis, BMI, age and ASA at a teaching community medical center.  Routine use of fluorescence firefly cholangiogram virtually eliminates the risk of CBD injury.  Closure technique of the fascial defect with 0-maxon in a ratio of 4:1 in running fashion minimizes the risk of incisional hernia.    

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