Robotic Cholecystectomy for Porcelain Gallbladder and a 6.8-cm Stone

The incidence of porcelain gallbladder is low but carries a potential risk of malignancy. Large gallstones pose technical obstacles for minimally invasive surgical procedures. In this case, a 72-year-old woman undergoes a robotic cholecystectomy because of her porcelain gallbladder and a 6.8-cm gallstone. The surgical procedure involved appropriately addressing two major concerns: obtaining sufficient gallbladder retraction because of the large size of the stone, and the presence of hepatic steatosis. Key modifications included strategic port placement, utilizing stone position for retraction, and early cystic artery division. The procedure finished without any issues. The frozen section analysis results showed benign pathology. The patient recovered from surgery without any complications. Key takeaways are that robotic cholecystectomy can be safely performed for a porcelain gallbladder with large gallstones using appropriate technical modifications, and that flexibility in the operating room is crucial in cases where standard methods become impractical.

Porcelain gallbladder (PG) is a rare condition that causes calcification of the gallbladder wall, with an incidence of 0.06–0.8% in cholecystectomy specimens.¹ The condition was first described in 1929, characterized by the distinctive bluish discoloration of the gallbladder wall resulting from calcium deposition. Chronic inflammation leads to calcium carbonate and calcium phosphate deposition within the gallbladder wall, accompanied by significant fibrosis development.^2,3

The clinical relevance of PG is due to its potential to develop into gallbladder adenocarcinoma, with malignancy rates varying between 4–22%.^4,5

In this case, a 72-year-old female patient presented with epigastric discomfort—commonly seen in similar cases, though some patients may remain asymptomatic.⁶ Ultrasound demonstrated a gallbladder with a curvilinear echogenic appearance and acoustic shadowing, containing a 6.8-cm gallstone. Subsequent magnetic resonance imaging was performed to complete the preoperative evaluation and rule out malignancy. It confirmed the presence of the large gallstone within a calcified gallbladder and excluded other biliary pathology.

Surgical intervention was required, and a robotic procedure was chosen over laparoscopy because robotic surgery provided superior surgeon ergonomics and more degrees of freedom.^7,8

The main operative challenges expected in this case were the large 6.8-centimeter stone, which made gallbladder retraction difficult, and the patient's hepatic steatosis, which made liver retraction harder and increased the risk of hepatic injury during the dissection.

The initial laparoscopic access was performed using standard techniques with initial port placement based on future specimen retrieval. Small bowel, diaphragmatic surfaces, and falciform ligament showed no abnormalities during the diagnostic laparoscopy examination. The liver exhibited a nodular appearance with yellow speckles, which indicated steatotic changes, so gentle retraction techniques were needed to avoid hepatic injury.

The gallbladder displayed no signs of inflammation, while its wall showed characteristic calcification, which matches the PG appearance. The examination revealed no peritoneal carcinomatosis or suspicious lesions that allowed the surgical team to move forward with their planned cholecystectomy.

The robotic system was docked following the diagnostic laparoscopy. The operating ports received placement under direct visual monitoring while the patient rested in reverse Trendelenburg position. The air seal systems maintained their function, while the robotic system tracked insufflation pressure measurements throughout the docking procedure.

Fundal retraction became very challenging because of the stone's large dimensions. A gentle upward pressure on the stone enabled fundal retraction, while multiple instruments worked together for cephalad retraction.
The hepatocystic triangle became accessible through peritoneal dissection. The cirrhotic liver presented stiff nodular tissue, which needed extensive retraction to gain surgical access. Rouviere's sulcus served as a landmark to guide the safe segment IVb peritoneal reflection dissection. The use of electrocautery for peritoneal layer dissection better enabled the attempted achievement of a critical view of safety. The enlarged gallbladder made it possible to identify the cystic artery because it stretched the vessel. To minimize unnecessary retraction and reduce the risk of liver injury, while facilitating cystic duct identification and mobilization, the decision was made to clip and transect the cystic artery prior to achieving a complete critical view of safety. Although this approach deviated from standard CVS protocol, the surgical team proceeded with confidence in the accurate identification of the vessel. The artery was ligated with two proximal clips and one distal clip, and then transected. The cystic duct became visible after progressive dissection of the infundibulum. ICG fluorescence imaging showed the expected posterior insertion into the common bile duct. The challenging duct anatomy required infundibular retraction to achieve optimal ligation. Two clips were placed on the patient's side, followed by another two clips on the specimen, and the cystic duct was transected.

A second ICG imaging session after duct division revealed that the common bile duct remained intact with normal bile flow and no signs of leakage or blockage.

The gallbladder dissection process started after the division of vascular and ductal structures while maintaining correct anatomical planes along the cystic plate. A modified retraction technique utilized precise grasp tools instead of handling large gallbladder portions to decrease the risk of perforation while enabling focused retraction.

The robotic system's high degree of movement flexibility allowed surgeons to execute delicate operations within tight areas while maintaining precise control of their instruments. The liver bed received a thorough inspection after gallbladder dissection to confirm that all remaining bleeding sources were addressed. The right upper quadrant, along with the infrahepatic space, received thorough attention. The inspection of clip placement sites confirmed both secure positions and sufficient hemostasis.

Transversus abdominis plane blocks were performed under direct visualization. The extraction bag containing the gallbladder needed an enlarged site for removal because the stone measured 6.8 cm. The pathologists received the entire gallbladder specimen for examination while preserving its integrity without contaminating the peritoneal cavity.

The closure followed a layered approach with appropriate fascial reapproximation through suitable suturing methods. Port sites measuring larger than 10 mm received fascial closure to prevent herniation. The complete evacuation of pneumoperitoneum and final visual inspection revealed that no instruments or foreign objects remained in the abdomen.

The frozen section analysis of the gallbladder specimen revealed no malignancy, which established the benign status of the PG in this particular case. The pathology results allowed standard postoperative care without any need for further oncological procedures.

The postoperative management of this patient included the possibility of immediate release from the hospital or overnight hospitalization based on her recovery status and comfort level. The decision to release the patient was made considering the size of the extraction incision because larger wounds typically cause greater postoperative pain.

The successful robotic cholecystectomy of a patient with a PG, a 6.8-cm stone, and steatotic liver tissue is presented in this video. The surgical procedure included purposeful port placement for specimen extraction, together with stone retraction and non-standard critical view of safety protocols when required. The case required altering standard retraction methods and proceeding with cystic artery division at an early stage since a standard critical view could not be performed safely. Surgical decision-making needs to be guided by judgment because standardized protocols should not replace assessment of anatomical variations that create unsafe or impractical standard procedures. This case demonstrates how surgeons should learn to safely deviate from standard procedures while developing problem-solving approaches for complex gallbladder conditions through surgical flexibility and real-time adaptation during challenging minimally invasive surgeries.

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.

Nothing to disclose.