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  • 1. Introduction
  • 2. Surgical Approach and Placement of Ports
  • 3. Robot Docking
  • 4. Exposure
  • 5. Critical View of Safety Dissection
  • 6. Clipping and Division of Cystic Duct and Artery
  • 7. Removal of the Gallbladder from the Bed of the Liver
  • 8. Hemostasis, Cleanup, and Robot Undocking
  • 9. Closure
  • 10. Post-op Remarks
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Robotic-Assisted Laparoscopic Interval Cholecystectomy

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Chloe A. Warehall, MD1; Divyansh Agarwal, MD, PhD1; Charu Paranjape, MD, FACS1,2
1Massachusetts General Hospital
2Newton-Wellesley Hospital

Main Text

Acute cholecystitis occurs when gallstones become impacted in the neck of the gallbladder or cystic duct in approximately 90–95% of cases. Symptoms may include acute right upper quadrant pain, fever, nausea, and emesis often associated with eating. Acute cholecystitis generally has imaging findings of gallbladder wall thickening, edema, gallbladder distension, pericholecystic fluid, and positive sonographic Murphy sign. However, acute cholecystitis is largely a clinical diagnosis of persistent right upper quadrant (RUQ) pain and associated tenderness on palpation of the RUQ in the setting of gallstones. The standard treatment is a cholecystectomy to prevent recurrent cholecystitis or sequelae of gallstones. Timing of the cholecystectomy is dependent on length of symptoms, which reflect the degree of inflammation.  Here we present the case of a 74-year-old male who presented with six days of acute cholecystitis symptoms who was initially managed with antibiotics. After improvement of his pain and no systemic symptoms of infection, he underwent an interval robotic cholecystectomy. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

Acute cholecystitis; interval robotic cholecystectomy.

Approximately 200,000 patients in the United States are affected by acute cholecystitis each year, with about 90–95% being caused by a gallstone being impacted in the neck of the gallbladder or cystic duct. Symptoms may include acute right upper quadrant (RUQ) pain, fever, nausea, and emesis often associated with eating.1 Pain can also be produced due to temporary obstruction of gallstones, which is termed biliary colic. This discomfort is waxing and waning in nature, and usually resolves with time. Once a patient has had persistent pain for greater than six hours, acute cholecystitis is suspected.2 

Acute cholecystitis generally has imaging findings of gallbladder wall thickening, edema, gallbladder distension, pericholecystic fluid, and positive sonographic Murphy sign. However, acute cholecystitis is largely a clinical diagnosis of persistent RUQ pain and associated tenderness on palpation of the RUQ, usually in the presence of gallstones. There is significant morbidity and mortality, particularly in the elderly, associated with cholecystitis, and it can lead to severe complications such as gallbladder gangrene, perforation, and empyema.3 Therefore, early cholecystectomy following diagnosis remains the gold standard management of cholecystitis in the appropriate patient population. 

Research has demonstrated that early laparoscopic cholecystectomy, within 1–3 days of symptom onset, is associated with improved patient outcomes, less postoperative complications, shorter hospital stay, and lower hospital costs compared to late surgical intervention, greater than 3 days after onset.1 However, it is not uncommon for patients to present multiple days after symptom onset, commonly due to lack of health insurance, difficulty accessing health care, or initial attempt at home remedies. While there is some data demonstrating that a cholecystectomy after 72 hours of symptoms can be performed in the subacute period without added risk of conversion or complications, if more than 5–7 days have passed since the onset of symptoms, the institutional practice at our center tends to favor waiting 4–6 weeks for interval cholecystectomy to allow the inflammation to subside.4

Over the last several decades, laparoscopic cholecystectomy has become the standard operation for patients with cholecystitis, even being deemed safe in those with moderate or severe cholecystitis.5 Recent publications have shown similar outcomes between robotic-assisted and laparoscopic cholecystectomies in terms of safety and efficacy; however, robotic-assisted cholecystectomies have demonstrated reduced length of hospital stay and fewer unexpected overnight admissions.6 

The patient in this case was a 74-year-old male who presented to the emergency department with six days of RUQ abdominal pain. The pain first came with a sharp, stabbing pain that began an hour after dinner and prevented the patient from sleeping. The following day, the pain had improved somewhat, but recurred after eating. This pain was associated with nausea and non-bloody, non-bilious emesis. Over the following week, the patient endorsed anorexia but had slight improvement in RUQ pain. After measuring a fever of 102.3 °F at home, he visited his primary care physician (PCP) who ordered labs and a RUQ ultrasound (RUQUS) given concern for gallbladder pathology. The patient denied any history of gallbladder issues or the experience of similar right upper quadrant pain. Labs were largely unremarkable except for a total bilirubin of 1.4. The RUQUS demonstrated an impacted stone at the gallbladder neck with upstream gallbladder distension and diffuse wall thickening. Sonographic Murphy’s sign was negative, and there was no ductal dilatation. Given the concern for acute cholecystitis, he was subsequently referred to the emergency department for further evaluation. 

Surgery was consulted for further management of the patient’s acute cholecystitis. The patient was admitted and started on IV fluids and IV antibiotics. Although a laparoscopic cholecystectomy was originally planned for the following day, given the patient’s prolonged symptoms for nearly one week, after discussing the risks and benefits with the patient, a collective decision was made to pursue nonoperative management with antibiotics. Over the next 24–48 hours, the patient’s pain was controlled, and his diet was advanced as tolerated. The remainder of the hospital course was uncomplicated, and ultimately the patient was deemed appropriate for discharge in stable condition. He was transitioned from IV to oral antibiotics to complete a 7-day course. The patient presented to the acute care surgery clinic approximately three weeks later to discuss an interval cholecystectomy. He reported that since his hospital admission, he was following a strict low-fat diet and had not had any recurrent symptoms. He denied abdominal pain, nausea, vomiting, fever, chills, or jaundice. 

The patient’s past medical history was notable for hyperlipidemia, hypothyroidism, glaucoma, bilateral cataracts, and benign prostatic hyperplasia. He had no previous surgical history. Although the patient had improved symptoms following treatment of cholecystitis with antibiotics, given the risk of recurrent cholecystitis or other sequelae of gallstones, he expressed his desire to undergo an interval robotic cholecystectomy, understanding the risks of surgery including bleeding, infection, common bile duct injury, bile leak, retained stones, injury to nearby structures, need for future procedures, or conversion to an open procedure. 

The focused physical examination was performed with the patient in supine position with particular focus in the RUQ. The patient was afebrile with normal vital signs. Neurologically the patient was alert and oriented to person, place, and time. His breathing was unlabored on room air with normal respiratory effort. 

The abdomen was soft with only mild tenderness to deep palpation in the RUQ. Bowel sounds were normoactive, and there was no rebound tenderness appreciated. 

The patient’s complete blood count, electrolytes, and liver function tests were within normal limits. No additional imaging studies were necessary or obtained in this case aside from the aforementioned RUQUS. 

The patient was brought to the operating room and placed in supine positioning. Midazolam was administered for sedation, and induction of general anesthesia with fentanyl, propofol, and rocuronium was performed. One-time dose of 2 g Cefazolin was given for perioperative microbial coverage. The abdomen was then prepped and draped in the standard fashion, and a hard stop timeout was performed. 

A 12-mm transumbilical incision was made, and pneumoperitoneum was obtained through an open Hassan technique with insertion of a 12-mm robotic port under direct vision. After insufflating the abdomen, camera inspection revealed that no iatrogenic injury was made upon trocar placement. Three 8-mm ports were then introduced into the abdomen under direct vision—two in the right hemiabdomen, and one in the left upper quadrant. Next, the robot was docked in the standard fashion after identifying and zeroing the operative target area.

The gallbladder was identified and was appreciated to have ongoing inflammation with a thickened wall and omental adhesions. The omental adhesions were dissected, and the gallbladder was retracted cephalad with two graspers—one at the fundus, and the other at the infundibulum. 

Careful dissection was then done at the Calot's triangle to identify the lymph node of Lund as well as the junction of the gallbladder with the cystic duct and the cystic artery. After obtaining the critical view of safety, the cystic duct was clipped and transected with two clips on the remaining cystic duct stump and one clip on the gallbladder side. The same technique was used to clip and transect the cystic artery, along with a small suspected posterior branch of the cystic artery.

The gallbladder was removed off of the liver fossa bed with electrocautery dissection with minimal spillage from a small hole on the gallbladder wall. The gallbladder was then placed in an Endo Catch bag, which was secured extra-abdominally. The liver bed was then inspected for any bleeding, and hemostasis was confirmed with electrocautery, along with application of hemostatic powder spray. The operative area was irrigated and suctioned, and laparoscopic TAP blocks were performed for pain control.

The robot was undocked, and the laparoscopic ports were removed under direct visualization. The gallbladder was then removed through the umbilical port and palpated to have small gallstones. It was then sent for pathological analysis. Local anesthetic was administered at all the port sites. The fascia at the umbilical port was closed with a figure-of-eight 0 Vicryl suture. Skin at all port sites were closed with 4-0 Monocryl sutures. All surgical sites were washed, dried, and dressed. Patient’s anesthetics were then reversed. He was extubated and transported to the PACU in stable condition having tolerated the procedure well. 

Regarding cholecystitis, there are multiple options for treatment including nonoperative management with antibiotics, percutaneous cholecystostomy tube (PCT) placement, and cholecystectomy. 

For patients with mild acute calculous cholecystitis and significant comorbidities, antibiotic treatment is an option for nonoperative management. However, this puts patients at risk for recurrent cholecystitis and other sequelae of cholelithiasis. Approximately 33% of patients greater than 65 will develop a recurrence of symptoms following nonoperative management.7 Additionally, there is higher morality (29.3%) at two-year follow-up associated with nonoperative management in individuals over 65, compared to that associated with a laparoscopic cholecystectomy (15.2%).1

For individuals that have a high perioperative risk but require gallbladder decompression secondary to biliary sepsis, a PCT can be placed. There is some evidence that demonstrates higher rates of postprocedural complications associated with a PCT compared to a laparoscopic cholecystectomy (65% vs 12%).1 However, retrospective analysis has shown evidence that in patients with acute cholecystitis who are managed with a PCT, approximately 90% will recover without complication or recurrent biliary sepsis following PCT removal even if they do not undergo an interval cholecystectomy. This makes PCT alone a viable option, particularly in patients who are unfit for surgical intervention.8

In patients who are surgical candidates, the most appropriate management of cholecystitis is a cholecystectomy. For decades, laparoscopic cholecystectomy has been the gold standard in comparison to open cholecystectomy. Factors such as obesity and multiple comorbidities increase a patient’s risk of conversion to open.9 Although robotic-assistance offers several advantages over laparoscopic surgery including three-dimensional vision, six degrees of motion and improved surgeon ergonomics, the literature thus far has shown comparable outcomes between robotic-assisted and laparoscopic cholecystectomies in terms of perioperative outcomes, safety, and efficacy.10 Robotic cholecystectomies are noted to have increased operating time and subsequent cost associated with them, but they may reduce the risk of open conversion and bile leakage, particularly in patients with advanced liver or complex gallbladder disease.11 In a recent study, robotic-assisted cholecystectomy was deemed superior over laparoscopic techniques in terms of hospital length of stay, estimated blood loss, and lower likelihood of conversion to open surgery.12

It has been estimated that it takes a surgical team about 16–32 robotic cholecystectomies to significantly decrease the setup time and total operating time.11 Notably, as surgeons overcame the learning curve of laparoscopic surgery when it was first introduced, superior perioperative benefits resulted in it becoming the new standard of care with time.13

Cholecystectomy is a common procedure for patients presenting with cholecystitis or other biliary pathology. Here we described a robotic-assisted interval cholecystectomy, which was primarily driven by a combination of the length of his symptoms at presentation, patient preference, and surgeon experience. The patient tolerated the procedure well without any intraoperative complications and minimal blood loss.

Postoperatively, the patient was able to be discharged home the same day with a prescription of 5 tablets of 5 mg oxycodone for pain management. During his clinic visit two weeks postoperatively, he reported that his pain had been well controlled. Anatomic pathology was reviewed as chronic cholecystitis with cholelithiasis.

A robotic-assisted cholecystectomy should be considered as an elective option for both acute and chronic cholecystitis. It has excellent perioperative outcomes, safety, and efficacy, and may reduce the risk of open conversion and bile leakage, particularly in patients with advanced liver or complex gallbladder disease.11,12

No special equipment, tools, or implants were used in this procedure.

No relevant disclosures of conflicts of interest.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

We thank the patient for giving us the permission to present this case in JOMI.

Citations

  1. Gallaher JR, Charles A. Acute cholecystitis: a review. JAMA. 2022 Mar 8;327(10):965-975. doi:10.1001/jama.2022.2350.
  2. Jones MW, Genova R, O'Rourke MC. Acute Cholecystitis. 2023 May 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–.
  3. Koti RS, Davidson CJ, Davidson BR. Surgical management of acute cholecystitis. Langenbecks Arch Surg. 2015 May;400(4):403-19. doi:10.1007/s00423-015-1306-y.
  4. Lee AY, Carter JJ, Hochberg MS, Stone AM, Cohen SL, Pachter HL. The timing of surgery for cholecystitis: a review of 202 consecutive patients at a large municipal hospital. Am J Surg. 2008;195(4):467-470. doi:10.1016/j.amjsurg.2007.04.015.
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  7. Bergman S, Al-Bader M, Sourial N, et al. Recurrence of biliary disease following non-operative management in elderly patients. Surg Endosc. 2015 Dec;29(12):3485-90. doi:10.1007/s00464-015-4098-9.
  8. Fleming CA, Ismail M, Kavanagh RG, et al. Clinical and survival outcomes using percutaneous cholecystostomy tube alone or subsequent interval cholecystectomy to treat acute cholecystitis. J Gastrointest Surg. 2020 Mar;24(3):627-632. doi:10.1007/s11605-019-04194-0.
  9. Rosen M, Brody F, Ponsky J. Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg. 2002 Sep;184(3):254-8. doi:10.1016/s0002-9610(02)00934-0.
  10. Main WPL, Mitko JM, Hussain LR, Meister KM, Kerlakian GM. Robotic versus laparoscopic cholecystectomy in the obese patient. Am Surg. 2017;83(11):447-449. doi:10.1177/000313481708301111.
  11. Chandhok S, Chao P, Koea J, Srinivasa S. Robotic-assisted cholecystectomy: current status and future application. Lap Endosc Robot Surg. 2022;5(3):85-91. doi:10.1016/j.lers.2022.06.002.
  12. Tao Z, Emuakhagbon VS, Pham T, Augustine MM, Guzzetta A, Huerta S. Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in veteran patients. J Robot Surg. 2021 Dec;15(6):849-857. doi:10.1007/s11701-020-01183-3.
  13. Huang Y, Chua TC, Maddern GJ, Samra JS. Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: a meta-analysis. Surgery. 2017 Mar;161(3):628-636. doi:10.1016/j.surg.2016.08.061.

Cite this article

Warehall CA, Agarwal D, Paranjape C. Robotic-assisted laparoscopic interval cholecystectomy. J Med Insight. 2023;2023(408). doi:10.24296/jomi/408.