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

CHAPTER 1

Hi there, my name's Charles Vining, I am a surgical oncologist here at Penn State Hershey Medical Center, and today, we are gonna be taking care of a patient with recurrent gallstone pancreatitis, and a history of a distal pancreatectomy and splenectomy for acinar cell carcinoma. So this is a 73-year-old gentleman. Approximately three years ago, he had a robotic distal pancreatectomy and splenectomy and has done very well since then. He has no evidence of recurrence; however, earlier in 2024, he developed his first episode of gallstone pancreatitis, which was managed conservatively, and at that time, no additional workup was performed. However, he had a second episode of gallstone pancreatitis, at which time he had a workup, and it included a right upper quadrant ultrasound that demonstrated evidence of cholelithiasis, and it was thought that his episodes of pancreatitis were related to his gallstones. Therefore, he was discharged from the hospital, but sent to me electively to consider a cholecystectomy on this patient. So after a very detailed discussion with the patient, we elected to proceed to the operating room for a robotic, possible open, cholecystectomy due to the history of recurrent gallstone pancreatitis. During this operation, the mainstay is safety, and so we are looking to try to obtain a critical view of safety that's identifying two and only two structures going into the gallbladder, clearing all of the fatty tissue around the hepatocystic triangle, and taking the gallbladder approximately a third of the way off of the cystic plate. So that's what we'll be trying to do today. I'll take a Schnidt. Incision.

CHAPTER 2

Can we get the gas on, please? 15 high flow. And Colin, are you able to bring down that monitor just a touch? That's perfect. We should be insufflating. All eights, Dr. Vining? All eights, please. Yes. Do a quick look around, make sure everything looks okay. History of pancreatic acinar cell carcinoma with a resection approximately three years ago. I do not see anything sinister going on here. This all looks very, very good. Okay. Let's see. One, two, and three, those are all gonna be perfect, okay. Danielle, can we trade sides and look at these three spots? One. Two,and - three. We're gonna start with this one. Great. Okay, very good. Can we get a little bit of right side up? Let's trade spots again. Thank you. Going to switch this guy out for this one. Great, can we have the robot in, please?

CHAPTER 3

We will do a ProGrasp in one, fen-bi in two, and then a hook in four. Okay. Can we get the lights down, please?

CHAPTER 4

I'm gonna start by just taking down this omentum from the liver edge here.

CHAPTER 5

We've got the duodenum stuck right up here to the gallbladder, so we're gonna start by opening up the peritoneum here overlying the gallbladder. Danielle, do you have the hooks? Sorry, the clips ready when we need them? I do. You got large clips? I do. Excellent. Can we just have a fault? It's not working again. Okay. If you notice it again, I'll like restart the cautery portion of it. Okay. Okay, Danielle. Can I get three clips in four, please? Yeah, hold on.

CHAPTER 6

I'll take another one, please. Okay, I'll take the scissors, please. They don't need to be hot. And then I'll take the hook back hot. Thank you. Okay, I'll take the hook.

CHAPTER 7

I wonder if I can grab that instead... Hmm. This right here? Now that's leaking. Um, do we have the robotic suction irrigator? Yeah. You want it open? Yeah. Gonna need it. Ready. Thank you. Yes, please. Five? Yeah, five will be good. Hmm. Can I get the suction irrigator in four, please? Yes. Thank you. Okay, can I get the hook back, please? All right, Danielle, I'm gonna take some clips again. I'm ready for them when you are. All right, I'll take one more. Okay. Can we get number four out? Awesome.

CHAPTER 8

Push in a little bit more. Push in, push in, push in. Is it not going in any further? Yeah. Okay. Could I get a suction irrigator in two, please? All right, I'll take that suction irrigator. Let's take out one and two. You can close the bag. I wouldn't take it, I'd just close it, yeah. You can take the hand piece off of it. We can take the robot out. And I think if Danielle, you could put the camera in here, I'll take the suction irrigator, and maybe I'll start with that bullet, and see if we can clean things up a little bit here. Can we get like a Ray-Tec just right here? Can you flatten the patient out, and can I get a little squeeze on the bag? You could just turn the camera towards me just a little bit. Right there. Yep. Can we get...? Are we losing gas? It is because the gas is on on that one, I think? So I'm gonna take that out, put it all over here, that should help, I'm hoping. See how it's right in the middle of the smudge? Can you just ... All right, I think I'm gonna take another bag. Want another five? Another five-millimeter bag. Yeah. Nuisance stones. Mm. And do we have... Camera? TAP block stuff? Yeah, we can clean the camera. We got another bag behind you. I can grab that. I don't think we're gonna get any more. I think we're about done here. Let's do our TAP blocks. If you could look, swing over here with the camera, like that. How much does he weigh? 71.8. Perfect. Danielle, if you could hold that right there. If you can scoot down towards me just ... Right there. A little bit more towards me, yeah. Okay.

CHAPTER 9

I usually can just ... Yeah. There we are, okay. It seems to have stopped the bleeding. Can I get a Kelly? Let's watch this guy here. Great. That was the gas one. It all looks good.

CHAPTER 10

So we're all done with the case. The case went well. It was challenging, and there was a significant amount of inflammation, as we had expected. We were able to take down all of the adhesions safely. Now, we didn't identify clearly a cystic artery, it was either diminutive, or it was obliterated from his episodes of recurrent cholecystitis and gallstone pancreatitis; however, we were able to identify the cystic duct, removed all the fibrofatty tissue from the hepatocystic triangle, and removed the gallbladder approximately a third of the way up the cystic plate, basically demonstrating a safe critical view, we were able to clip the cystic duct, and then remove the gallbladder off of the cystic plate. During the procedure, we did make a hole in the gallbladder and leak some bile and some gallstones, and that's not a major issue, it's just important to collect the stones as best you can at the end of the case, 'cause the stones can potentially form an abscess in the future. We are able to remove all of the stones, take the gallbladder out safely, and performed this in a robotic fashion.