Robotic Cholecystectomy for Recurrent Gallstone Pancreatitis in a Patient with Prior Distal Pancreatectomy and Splenectomy for Acinar Cell Carcinoma

Recurrent gallstone pancreatitis is a common and potentially morbid condition for which definitive cholecystectomy is recommended to prevent recurrent biliary complications and reduce hospital readmissions. Surgical management may be technically challenging in patients with prior pancreatic resection because of altered anatomy, adhesions, and concern for malignancy recurrence. This video demonstrates a robotic-assisted cholecystectomy performed in a 78-year-old man with recurrent gallstone pancreatitis and a history of distal pancreatectomy for pancreatic acinar cell carcinoma. Preoperative imaging demonstrated cholelithiasis without evidence of recurrent malignancy. Diagnostic laparoscopy was performed to exclude occult intra-abdominal disease before proceeding with cholecystectomy. Operative findings included chronic cholecystitis and cholelithiasis. Robotic dissection facilitated meticulous clearance of fibrofatty tissue within the hepatocystic triangle and safe dissection around the cystic structures prior to cystic duct division, consistent with established principles for preventing bile duct injury. The procedure was completed without complication. This case highlights the role of robotic-assisted cholecystectomy in patients with recurrent gallstone pancreatitis and prior pancreatic surgery, where enhanced visualization and instrument dexterity may improve operative safety in complex inflammatory and reoperative settings.

Robotic cholecystectomy; gallstone pancreatitis; critical view of safety; prior pancreatic resection; cholelithiasis.

Gallstone disease remains the leading cause of acute and recurrent pancreatitis worldwide, accounting for up to 40–50% of cases.^1,2 Current guidelines strongly recommend cholecystectomy following an episode of gallstone pancreatitis to prevent recurrence, as nonoperative management is associated with high rates of repeat biliary events and increased mortality.^3,4 While laparoscopic cholecystectomy is the standard approach, prior upper abdominal surgery—particularly pancreatic resection—introduces technical challenges due to adhesions, distorted anatomy, and chronic inflammatory changes.⁵

The robotic surgical platform has emerged as a valuable adjunct in complex biliary surgery. Enhanced three-dimensional visualization, tremor filtration, and wristed instrumentation may facilitate precise dissection in hostile operative fields, potentially improving the ability to achieve the critical view of safety (CVS) and reducing the risk of bile duct injury.^6–8 This case demonstrates the application of robotic-assisted cholecystectomy in a patient with recurrent gallstone pancreatitis and prior distal pancreatectomy.

The patient is a 78-year-old man with a history of pancreatic acinar cell carcinoma treated with distal pancreatectomy, splenectomy, and partial left adrenal resection in 2021. His medical comorbidities included atrial flutter on apixaban, insulin-dependent type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and coronary artery disease. He experienced two documented hospitalizations for acute pancreatitis within a five-month period, with an additional self-limited episode of epigastric pain consistent with pancreatitis. Cross-sectional imaging demonstrated cholelithiasis without biliary ductal dilation or evidence of malignancy recurrence. Given recurrent gallstone pancreatitis, definitive surgical management was recommended in accordance with established guidelines.^3,4

On examination, the patient was well appearing and in no acute distress. The abdomen was soft and nondistended, with well-healed port site scars and a vertical midline scar from prior pancreatic surgery. There was no abdominal tenderness or evidence of peritonitis. Cardiopulmonary examination was unremarkable.

Preoperative computed tomography of the abdomen demonstrated gallstones within the gallbladder without evidence of acute cholecystitis, biliary obstruction, or recurrent pancreatic malignancy. Imaging findings were consistent with gallstone-mediated pancreatitis as the most likely etiology of recurrent symptoms.²

Natural History

Without cholecystectomy, patients with gallstone pancreatitis face recurrence rates approaching 30–50%, with increasing risk of severe pancreatitis, cholangitis, and mortality.^1,3 The risk persists even after mild episodes and is not mitigated by endoscopic sphincterotomy alone.⁴ Prior pancreatic surgery does not alter this natural history and may increase operative complexity if definitive management is delayed.⁵

Treatment options include continued nonoperative management, endoscopic biliary sphincterotomy, or cholecystectomy. Nonoperative strategies are associated with unacceptably high recurrence rates and are not considered definitive therapy.³ Endoscopic sphincterotomy alone may reduce biliary colic but does not reliably prevent recurrent pancreatitis.⁴ Cholecystectomy remains the standard of care and was recommended for this patient.

The primary goals of treatment were to prevent recurrent pancreatitis, reduce future hospitalizations, and definitively address the underlying biliary pathology. A robotic-assisted approach was selected to facilitate precise dissection in the setting of prior upper abdominal surgery and chronic inflammation, with the aim of safely achieving the critical view of safety.^6–8

Patients with prior pancreatic resection, chronic inflammation, or malignancy history represent a high-risk subgroup in biliary surgery. Robotic-assisted cholecystectomy may be particularly beneficial in these patients by improving visualization and dexterity during dissection.^7,8 Contraindications include hemodynamic instability, inability to tolerate pneumoperitoneum, or extensive metastatic disease.

Surgical Technique

After induction of general anesthesia and completion of a surgical time-out, abdominal access was obtained at Palmer’s point using an optical trocar, and pneumoperitoneum was established. Diagnostic laparoscopy demonstrated no evidence of malignancy recurrence. Three additional robotic ports were placed under direct visualization, and the robot was docked.

The gallbladder fundus was retracted cephalad, and the infundibulum was retracted medially and laterally. The peritoneum overlying the lateral gallbladder and hepatocystic triangle was widely opened using hook electrocautery. Fibrofatty tissue was meticulously cleared from the hepatocystic triangle. The gallbladder was dissected off the cystic plate approximately one-third of the way to facilitate visualization.

The cystic duct was identified entering the gallbladder. No discrete cystic artery was visualized, consistent with chronic inflammatory obliteration. A critical view of safety was therefore not definitively achieved prior to clipping and division of the cystic duct. The gallbladder was then removed from the cystic plate. An inadvertent cholecystostomy was created while removing the gallbladder off the cystic place, and stones were evacuated. The gallbladder was then extracted in an endoscopic retrieval bag. Hemostasis was confirmed, bilateral transversus abdominis plane (TAP) blocks were performed, and all ports were removed.

Cholecystectomy following gallstone pancreatitis is a cornerstone of definitive management and is supported by robust clinical evidence and international guidelines.^1,3,4 However, prior pancreatic surgery significantly alters the operative landscape. Adhesions, distorted anatomy, and inflammatory obliteration of key structures—such as the cystic artery—are common and increase the risk of bile duct injury.^5,9

The critical view of safety, as originally described by Strasberg, remains the most effective strategy for preventing bile duct injury during cholecystectomy.³ Achieving the CVS requires clearance of fibrofatty tissue from the hepatocystic triangle and partial mobilization of the gallbladder off the cystic plate. The robotic platform may enhance the surgeon’s ability to meet these criteria through improved visualization and instrument articulation.^7,8

In this case, diagnostic laparoscopy was performed first to exclude occult malignancy recurrence, a prudent step in patients with prior pancreatic cancer.¹⁰ Robotic dissection allowed careful clearance of the hepatocystic triangle despite chronic inflammation and obliteration of the cystic artery. The cystic duct was clearly identified entering the gallbladder prior to division.

Emerging data suggest that robotic cholecystectomy may reduce conversion rates and facilitate safer dissection in complex cases, though definitive outcome advantages over laparoscopy remain an area of active investigation.^8,9 This case supports the selective use of robotic assistance in patients with recurrent gallstone pancreatitis and prior upper abdominal surgery.

Nothing to disclose.

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