Perforated gallbladder managed by robotic approach

Abstract

Presenter: Michael Caparelli MD | The Jewish Hospital Background: The rate of gallbladder perforation in the setting of acute cholecystitis is 2-11% with the fundus, the most distal location with regard to blood supply being the most common site of perforation. The mortality rate of gallbladder perforation is alarmingly high at 12-16% and attributed to delayed diagnosis due to limitations of modern imaging. A high suspicion of gallbladder perforation and early operative intervention are key to reducing morbidity and mortality. Gallbladder perforation may be managed with laparoscopic cholecystectomy, although there is a high conversion rate due to unclear anatomy. We describe a case of robotic cholecystectomy for gallbladder perforation and discuss the advantages of this operative modality. Methods: The patient is a 62 year-old male with history of hypertension, type 2 diabetes, pulmonary embolism (on apixaban) and schizoaffective disorder who presented with 3 days of right upper quadrant pain. Computed tomography showed acute cholecystitis and a 6.5 cm subscapsular hepatic fluid collection. Due to current use of anticoagulation he underwent percutaneous drainage the subhepatic fluid collection, which was bilious and suggestive of gallbladder perforation. Magnetic resonance cholangiopancreatography revealed fundal gallbladder perforation with leakage of bile into the subcapsular hepatic space. He subsequently spiked fevers and went into atrial fibrillation with rapid ventricular rate. Collaboration with hepatobiliary surgery was had and it was determined that the benefits of early cholecystectomy outweigh the risks of long-term percutaneous drainage. The patient underwent indocyanine green (ICG) aided robotic cholecystectomy with intraoperative cholangiogram (IOC). IOC showed free flow into the duodenum with normal intra and extra hepatic ducts. Subcapsular hepatic (segments 4a & 5) and subdiaphragmatic abscesses were evacuated. Results: The subhepatic drain was removed on postoperative day (POD) 3. The patient was transitioned to oral antibiotics and discharged to his group home on POD 5. Pathology showed chronic cholecysitis with transmural fistula. He is doing well two months from surgery. Conclusion: Acute cholecystitis with gallbladder perforation carries a high mortality rate secondary to delayed diagnosis. Early diagnosis and surgical intervention is key. Management of gallbladder perforation may be performed open or laparoscopically with a high risk of conversion. To our knowledge this is the first video documented case of a robotic cholecystectomy for gallbladder perforation. Robotic cholecystectomy offers unique advantages when compared to laparoscopic or open techniques. The robotic camera allows for 3D images, which enhance the visual field when compared to laparoscopic imaging. This allows for better visualization of anatomy during dissection, which may lead to decreased conversion rates. Additionally, instrument articulation reproduces that of the human wrist, allowing for dissection in more difficult angles. ICG fluorescence helps to define biliary anatomy in real time and reduces the need for radiation exposure from traditional cholangiopancreatography. In this case ICG-cholangiography allowed for visualization of the common bile and cystic ducts, and differentiation of hepatic and gallbladder tissue for safe dissection. Robotic cholecystectomy should not be considered standard, but a valuable tool in experienced hands for management of difficult cholecystectomies.