Robotic-Assisted Cholecystectomy for Porcelain Gallbladder and Cholelithiasis

Abstract

This video demonstrates a successful robotic-assisted cholecystectomy for a patient with a large, mobile gallstone and imaging findings consistent with porcelain gallbladder. Resection of the specimen allowed for prevention of complications secondary to the gallstone and possibly reduced the risk of malignancy. Minimally invasive methods allow for a safe alternative to open cholecystectomy with reduced perioperative morbidity. This video demonstrates how to obtain the critical view of safety as well as how to use Firefly to verify identified anatomy. The specimen was successfully removed, and the patient tolerated the procedure well. The specimen was sent to pathology for evaluation of potential underlying malignancy. This resection method may be utilized for any form of biliary pathology, including symptomatic cholelithiasis and cholecystitis, which are among the most frequent procedures performed by general surgeons.

Keywords

Gallstone; cholangiography; intraoperative fluorescent cholangiography; critical view of safety; cholangiocarcinoma.

Case Overview

Background

Gallbladder and biliary tree disease is a frequent reason for evaluation by surgical specialists, both in the outpatient setting and the emergency department. Prevalence of biliary pathology is projected to be possibly greater than 20% of the population.¹

Gallbladder wall calcifications represent an often asymptomatic abnormality of the gallbladder. The location of these calcifications can be mucosal or intramural, with the latter referred to as porcelain gallbladder. Porcelain gallbladder has been shown to have increased rates of malignancy in historical data.² Rates of bile duct cancer in association with porcelain gallbladder have been reported between 6 and 62%.^3–5 Additionally, the pattern of calcification can modify the associated risk of malignancy such that selective mucosal calcification is associated with a significant risk of cancer and intramucosal calcification may not.⁴ However, no definitive characteristics have been established to link malignancy rates. As a result, patients who are otherwise healthy and have minimal comorbidities are often recommended early cholecystectomy.

Although gallbladder adenocarcinoma is rare, the incidence is increasing,⁶ and outcomes are poor, especially if not surgically resectable.⁷ Gallbladder adenocarcinoma is most commonly sporadic but also occurs secondary to chronic inflammation, such as primary sclerosing cholangitis (PSC) or hepatobiliary flukes.^8,9 Additionally, large gallstones greater than 3 centimeters are associated with increased risk.¹⁰

Cholecystectomies are most often performed in a minimally invasive fashion. Frequency of robotic-assisted cholecystectomies are increasing, with reported rates as high as 37-fold from 2010 to 2019.¹¹ In the era of laparoscopy, elements of operative technique and anatomic characterization such as the critical view of safety and dissection ventral to the line of safety from Rouviere’s sulcus to the peritoneal reflection at the base of segment 4b allowed mitigation of the risk of devastating biliovascular injury.^12,13

The robotic platform offers a number of benefits compared to laparoscopy, including improved degrees of freedom of instruments and a magnified 3-dimensional view. One of the most important advantages is the use of intraoperative fluorescent cholangiography by intravenous injection of indocyanine green, which can also help identify structures and create a faster, safer surgery.¹⁴

Focused History of the Patient

This patient is a 72-year-old female who was found to have porcelain gallbladder seven years prior to this procedure incidentally during screening hepatic ultrasound. She also had a large gallstone, approximately 6.8 cm, which was symptomatic. Additionally, she was found to have a pericholecystic hypoechoic lesion, which did not have malignant features on subsequent MRI. Her past medical history is significant for metabolic dysfunction-associated fatty liver disease (MAFLD), hypertension, hyperlipidemia, type II diabetes mellitus, chronic kidney disease stage 3a, hypothyroidism, and morbid obesity. Liver biochemistries demonstrated mild transaminase elevation but were otherwise within normal limits and the patient was deemed an appropriate and safe candidate for gallbladder resection. After discussion regarding risks, benefits, and monitoring options, the patient elected to proceed with surgical intervention.

Physical Exam

Patients with porcelain gallbladder are typically asymptomatic and these radiographic findings are identified incidentally. Patients with cholelithiasis often endorse right upper quadrant pain, most typically following fatty meals. These pain episodes often last minutes to hours before subsiding. 

Discussion

Gallbladder disease is an extensive pathology that ranges from benign disease to aggressive malignancies. General surgeons are frequently tasked with evaluation and treatment of these diseases. When the patient’s disease or comorbidities increase complexity or there is an increased concern for malignancy, surgical oncologists and hepatopancreatobiliary surgeons are available to assist in care. 

Here, a successful robotic-assisted cholecystectomy is demonstrated in an asymptomatic patient with underlying liver disease, porcelain gallbladder, and large cholelithiasis. Creation of the critical view of safety is performed through the assistance of fluorescent cholangiography to minimize the risk of complications associated with common bile duct injury. The operation was performed at a training hospital and demonstrated the nature of surgical operative education including graded autonomy, use of the robotic platform for instruction and technical guidance, as well as classical points in surgical education of the operation of cholecystectomy. The patient was kept overnight, due to operational logistics that resulted in a late in the day start time for this robotic operation, and was discharged on postoperative day 1 with pain controlled and tolerating a diet.

Pathologic evaluation of the resected specimen demonstrated adenomyomatosis, chronic cholecystitis with reactive changes, and cholelithiasis. 

Minimally invasive techniques are safe and effective for cholecystectomy. Advances in robotic technology and increased surgeon familiarity may allow for shorter operative times and further improved patient outcomes. Further research into improved radiographic characterization of biliary lesions may decrease need for prophylactic resection in high-risk patients.

Disclosures

Nothing to disclose.

Statement of Consent

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.