Robotic Cholecystectomy for Chronic Cholecystitis for a Patient with Recurrent Gallstone Pancreatitis and a Percutaneous Cholecystostomy Tube

A 66-year-old man with chronic pancreatitis and prior exploratory laparotomy and appendectomy for perforated appendicitis presented with persistent right upper quadrant pain, nausea, and weight loss after placement of a percutaneous cholecystostomy (PC) tube for gallstone pancreatitis and chronic cholecystitis. Imaging confirmed gallbladder distension with equivocal wall thickening. He underwent robotic cholecystectomy with removal of the PC tube. The procedure was notable for extensive intra-abdominal adhesions requiring prolonged adhesiolysis. A critical view of safety was achieved, and the gallbladder was removed without complication. This case illustrates the technical considerations and challenges of delayed cholecystectomy following PC tube drainage.

Robotic cholecystectomy; percutaneous cholecystostomy; chronic cholecystitis; bile duct injury; adhesiolysis.

Cholecystectomy remains the definitive treatment for symptomatic cholelithiasis and cholecystitis. In high-risk or acutely ill patients, percutaneous cholecystostomy (PC) is often employed as a temporizing measure. Many of these patients later require interval cholecystectomy once stabilized. However, prior PC tube placement and recurrent inflammation often result in dense adhesions, distorted anatomy, and an increased risk of bile duct injury at the time of definitive surgery.

This video demonstrates a robotic cholecystectomy performed in a patient with chronic cholecystitis and a PC tube in place.

The patient is a 66-year-old man with chronic pancreatitis, prior exploratory laparotomy for perforated appendicitis (2024), and small cell lung cancer in remission. He was hospitalized in June 2024 with abdominal pain, a phlegmon, and an intra-abdominal abscess requiring drainage and eventual appendectomy. In the months following, he developed recurrent right upper quadrant pain and underwent PC tube placement for gallstone pancreatitis and chronic cholecystitis.

Despite drainage, he continued to experience significant pain at the tube site, nausea, weight loss, and poor quality of life. He was referred for definitive surgical management.

The patient was thin and chronically ill-appearing. Abdomen was soft and nondistended but tender around the cholecystostomy tube site and epigastrium. The tube was draining bilious fluid. Cardiopulmonary examination was normal.

A CT scan of the abdomen and pelvis demonstrated a distended gallbladder with a PC tube in place. Additionally, there were stable pancreatic calcifications with a pancreatic stent, as well as a decrease in perigastric fluid collections previously noted likely secondary to pancreatitis. There was no evidence of intra-abdominal abscess.

Without cholecystectomy, patients managed with PC tube remain at risk of recurrent biliary events, including recurrent cholecystitis, cholangitis, and gallstone pancreatitis. Reported recurrence rates range from 22–47% within one year if the gallbladder is left in situ.¹ Definitive surgery eliminates this risk but is technically challenging due to chronic inflammation and adhesions.

Options for treatment are:

• Conservative management with PC tube maintenance—avoids immediate operative risk but is associated with recurrent symptoms and decreased quality of life.
• Open cholecystectomy—reliable but associated with longer recovery and greater morbidity.
• Robotic-assisted laparoscopic cholecystectomy—offers improved visualization and dexterity in difficult dissections, with potential to reduce bile duct injury in high-risk cases.

Given persistent symptoms, poor quality of life, and stabilization of comorbidities, a robotic cholecystectomy was chosen as the modality for definitive treatment. The robotic platform was expected to aid in adhesiolysis and safe dissection of the hepatocystic triangle.

The patient was placed supine under general anesthesia with bilateral TAP blocks for analgesia. After sterile preparation, an optical trocar was placed at Palmer’s point for diagnostic laparoscopy. Extensive adhesions between the omentum, colon, duodenum, liver, and gallbladder were encountered and lysed.

The PC tube was identified, cut, and removed; the tract was ablated and divided. After docking the robot, the gallbladder was retracted to expose Calot’s triangle. The peritoneum was incised, fibrofatty tissue was cleared, and the cystic duct and artery were identified. A critical view of safety was obtained, confirming only two structures entering the gallbladder.

Both cystic duct and artery were clipped and divided. The gallbladder was dissected off the cystic plate using electrocautery and retrieved in an Endo Catch bag. The abdomen was irrigated and inspected, showing no bleeding or bile leak. All ports were removed under direct visualization, and skin was closed with absorbable sutures and Dermabond. Estimated blood loss was < 30 mL. The patient was extubated, transferred to recovery in stable condition and discharged the same day.

This case highlights the feasibility of robotic cholecystectomy following PC tube placement. PC tube is often used in elderly or critically ill patients as a bridge to surgery, but a significant proportion ultimately undergo delayed cholecystectomy.¹ Reported recurrence of biliary events in patients managed only with PC tube ranges from 22–47% at one year, making interval surgery advisable in suitable candidates.

The optimal timing of cholecystectomy after PC tube remains debated. Some studies suggest that early interval cholecystectomy (within 6–8 weeks) is associated with fewer complications and shorter operative times, whereas delayed surgery may allow maturation of adhesions and increased technical difficulty.²

Prior PC tube and chronic inflammation distort anatomy in Calot’s triangle, increasing the risk of bile duct injury, which carries significant morbidity and mortality. Nationwide data suggest a higher incidence of bile duct injury after PC tube compared to primary cholecystectomy.³ In standard laparoscopic cholecystectomy, bile duct injury occurs in ~0.3–0.5% of cases, but the rate may be higher following PC tube.

The robotic approach provides three-dimensional visualization, tremor filtration, and wristed instruments that may facilitate careful adhesiolysis and precise dissection in distorted anatomy. While high-quality randomized data are limited, several series suggest that robotic cholecystectomy may decrease conversion rates to open surgery and aid in achieving the critical view of safety.

To minimize bile duct injury, surgeons should adhere to the critical view of safety, consider intraoperative cholangiography or indocyanine green fluorescence imaging, and perform subtotal cholecystectomy when anatomy is unclear.⁴

In summary, robotic cholecystectomy after PC tube placement is feasible and safe in experienced hands. However, these cases remain technically demanding, with an increased risk of bile duct injury compared to routine cholecystectomy. Careful patient selection, adherence to safety principles, and liberal use of bailout techniques are essential.

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.