Robotic-assisted Cholecystectomy Research Articles

IDEAL–compliant implementation of the Dexter® surgical robot in cholecystectomy: a comprehensive framework and clinical outcomes

Abstract Objectives The integration of advanced technologies is transforming surgical practice, particularly through robotic systems. This study presents the early clinical implementation of the Dexter® surgical robot for cholecystectomy and evaluates clinical outcomes using the IDEAL framework. Methods Twenty patients underwent elective robotic-assisted cholecystectomy using the Dexter® robot. A thorough implementation process, including rigorous surgeon and nurse training and standardized care protocols, was established. Data on operative metrics, complications, and patient outcomes were analyzed, and patient well-being was assessed via a postoperative phone survey. Results Six surgeons and thirty nurses were trained, with surgeons completing a minimum of 20 h of simulation. Preoperative and operative times were significantly reduced through this process. Comparing the first 10 operations to the second, docking time decreased from 11.4 ± 4.1 min to 7.1 ± 2.1 min (p=0.0144) and operative time improved from 130.5 ± 25.7 min to 99.7 ± 21.8 min (p=0.0134). Mean intraoperative blood loss was minimal, averaging 19.5 ± 31.4 mL, and the average length of hospital stay was 3.1 ± 1.4 days. Postoperative pain levels were low, and patient satisfaction was high, as assessed by telephone survey. Conclusions Our findings highlight the value of the IDEAL framework in guiding the systematic evaluation and implementation of new surgical technologies such as the Dexter® robot. A structured approach is essential to improve patient outcomes and safety in the coming digital transformation of surgery.

Robotic-Assisted Versus Laparoscopic Approach for Treatment of Acute Cholecystitis in Children.

Introduction: Laparoscopic cholecystectomy (Lap-C) is the standard of care for patients requiring cholecystectomy in the acute setting. Although robotic-assisted cholecystectomy (RA-C) performance has increased, utilization in the acute setting has not been widely reported. We describe the feasibility of RA-C for pediatric patients undergoing acute inpatient cholecystectomy. Methods: A single institutional retrospective review of patients receiving RA-C while admitted for acute cholecystitis and/or choledocholithiasis (June 2017-June 2022) was compared with a matched cohort who underwent traditional multiport Lap-C (June 2021-June 2022). Demographic, perioperative, and postoperative data were analyzed. Results: Fifty patients were included: 25 each in the RA-C and Lap-C groups. Fifty-four percent were female; 66% were non-Hispanic white. Median age (15.7 years [interquartile range, IQR 14.7, 17.3] versus 15.3 years [IQR 14.5, 16.9], P = .91) and preoperative weight (92.6 kg [IQR 60, 105.9] versus 72.3 kg [IQR 61.6, 85.6], P = .15) were similar between the RA-C and Lap-C groups, respectively. No differences were observed in median operating time (89 minutes [IQR 76, 103] versus 88 minutes [IQR 77, 137], P = .70), postoperative length of stay (22.5 hours [21.4, 24.9] versus 20.6 hours [18.0, 25.1], P = .06), or 30-day complications (12% versus 16%, P = .69). Although opioid utilization (.23 milliequivalents/kilogram [MME/kg] [IQR .03, .30] versus .03 MME/kg [0, .09], P = .02) was higher in the RA-C cohort overall, no differences were detected during an analysis of the most recent 2 years (P = .96). Conclusion: RA-C in the acute setting can be performed safely in the pediatric population with comparable procedural times as well as perioperative and 30-day outcomes.

BN SO57 - Transversus Abdominis Plane (TAP) Block in Laparoscopic and Robot-Assisted Cholecystectomy: Is it worth the effort?

Abstract Background Minimal access cholecystectomy is a common procedure undertaken worldwide. These are usually performed on an ambulatory basis and given the short timeline, strategies to optimize pain control and reduce nausea or vomiting are key factors to facilitate early hospital discharge. There has been studies showing that both TAP block and wound infiltration deliver superior pain relief after laparoscopic cholecystectomy, but TAP blocks are not used routinely after cholecystectomy in the U.K. This study aims to assess the efficacy of post-operative subcostal TAP block in laparoscopic and robot-assisted cholecystectomy in reducing post-operative opioid requirements and facilitating same day discharge. Method A retrospective cohort analysis was performed at a single centre (January 2022 – July 2023). Patients undergoing laparoscopic or robot assisted cholecystectomy under a single surgeon who performs cholecystectomy with additional use of postoperative TAP block were included. The primary outcome of post-operative opioid requirements was assessed. Secondary outcomes included length of post-operative stay and individual morphine/fentanyl requirements. Results Among 87 patients, 22(25.3%) underwent TAP block and 65(74.7%) had local anaesthetic infiltration of the port sites. Of the two cohorts, there were no significant differences in the age, M:F ratio or ASA grade. There were more obese patients (BMI > 30kg/m2) in the TAP block cohort (63.6% vs 47.7%; p= 0.012). Of the patients in the TAP block, 88.2% were discharged the same day. 95.5% of these patients had no post-operative morphine or fentanyl requirements.The difference in outcomes were not statistically significant. There were no post-procedural complications from use of the TAP block in any patient. Conclusion These results demonstrate that use of TAP block can provide a safe alternative approach for post-operative analgesia, with low post-operative opioid requirements and facilitation of same-day discharge.

BN SO59 - Learning Curve for Robotic-Assisted Cholecystectomy

Abstract Background Assessment of learning curves following the introduction of robotic-assisted technology has shown that improvement in surgical outcomes can be seen with increasing robotic experience. Method All robotic-assisted cholecystectomies performed by a single consultant upper gastrointestinal surgeon as primary operator were analysed between 6/8/21 - 6/6/24 at a UK specialist centre using the Versius robotic system (CMR surgical). We recorded set up time during cases over this period. Results 38 robotic-assisted cholecystectomies were performed within the study period. In the first 10 cases, average set up time was 8 minutes and 18 seconds. In the second 10 cases this reduced to 5 minutes and 36 seconds. No further improvement was seen after case 20. Conclusion Our results demonstrate that set up time for robotic-assisted cholecystectomy improves over the first 20 cases. This data suggests 20 cases are adequate for acquiring the skillset required to set up the Versius robotic system efficiently in real life practice.

Online videos of robotic-assisted cholecystectomies: more harm than good?

BackgroundMany surgeons use online videos to learn. However, these videos vary in content, quality, and educational value. In the setting of recent work questioning the safety of robotic-assisted cholecystectomies, we aimed (1) to identify highly watched online videos of robotic-assisted cholecystectomies, (2) to determine whether these videos demonstrate suboptimal techniques, and (3) to compare videos based on platform.MethodsTwo authors searched YouTube and a members-only Facebook group to identify highly watched videos of robotic-assisted cholecystectomies. Three members of the Society of American Gastrointestinal and Endoscopic Surgeons Safe Cholecystectomy Task Force then reviewed videos in random order. These three members rated each video using Sanford and Strasberg’s six-point criteria for critical view of safety (CVS) scoring and the Parkland grading scale for cholecystitis. We performed regression to determine any association between Parkland grade and CVS score. We also compared scores between the YouTube and Facebook videos using a t test.ResultsWe identified 50 videos of robotic-assisted cholecystectomies, including 25 from YouTube and 25 from Facebook. Of the 50 videos, six demonstrated a top-down approach. The remaining 44 videos received a mean of 2.4 of 6 points for the CVS score (SD = 1.8). Overall, 4 of the 50 videos (8%) received a passing CVS score of 5 or 6. Videos received a mean of 2.4 of 5 points for the Parkland grade (SD = 0.9). Videos on YouTube had lower CVS scores than videos on Facebook (1.9 vs. 2.8, respectively), though this difference was not significant (p = 0.09). By regression, there was no association between Parkland grade and CVS score (p = 0.13).ConclusionPublicly available and closed-group online videos of robotic-assisted cholecystectomy demonstrated inadequate dissection and may be of limited educational value. Future work should center on introducing measures to identify and feature videos with high-quality techniques most useful to surgeons.Graphical abstract

Robotic assisted common bile duct exploration for management of complex gallstone disease.

Minimally invasive cholecystectomy and common bile duct exploration offers single-stage management for complex gallstone disease (cholelithiasis and choledocholithiasis). The Robotic platform presents benefits in improving operative precision, which has not been extensively evaluated in the acute setting of managing complex gallstone disease, as well as in performing transcholedochal or postcholecystectomy common bile duct exploration. The authors report an early series of emergent and expedited robotic-assisted cholecystectomy with common bile duct exploration (RC-CBDE) or robotic common bile duct exploration (R-CBDE) alone. A retrospective analysis from a specialist unit in the United Kingdom was undertaken from April 2022 to September 2023, inclusive. All patients who underwent RC-CBDE or R-CBDE were included. Data was collated on patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. Twenty-three consecutive patients were identified. The median (IQR) age was 51 (33-66) years. Median (IQR) Charlson Comorbidity Index (CCI) was 1 (0-4). Five patients underwent operative intervention as an emergency and 18 on an expedited basis. Two patients underwent postcholecystectomy R-CBDE. Fourteen (61%) were transcholedochal and nine were transcystic (39%) CBDE. Median (IQR) bilirubin was 51 (34-253). Median (IQR) operative time was 176 (124-222) minutes. Median (IQR) postoperative length of stay was 2 (0-4) days. There were no bile leaks requiring intervention. The clearance rate of CBDS was 100%. No patients developed postoperative pancreatitis. One patient required intervention for port site hernia following RC-CBDE. One patient developed subhepatic collection postoperatively and required laparoscopic washout and placement of drains. No patients had retained stones after a 3-month follow-up. Early experience confirms that RC-CBDE and R-CBDE in feasible, safe, and effective treatment for complex gallstone disease. Integrated adjuncts (intraoperative robotic ultrasound - IORUS and Firefly - fluorescence guided surgery - FGS) and superior ergonomics of the robotic platform may assist in reducing the learning curve and increase wider uptake of this complex procedure.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Learning Curve for Robotic-Assisted Cholecystectomy

This cohort study evaluates the learning curve for robotic-assisted cholecystectomy among US surgeons from 2010 through 2019.

Three-arm robotic cholecystectomy: a novel, cost-effective method of delivering and learning robotic surgery in upper GI surgery.

Cholecystectomy is one of the commonest performed surgeries worldwide. With the introduction of robotic surgery, the numbers of robot-assisted cholecystectomies has risen over the past decade. Despite the proven use of this procedure as a training operation for those surgeons adopting robotics, the consumable cost of routine robotic cholecystectomy can be difficult to justify in the absence of evidence favouring or disputing this approach.Here, we describe a novel method for performing a robot-assisted cholecystectomyusing a "three-arm" techniqueon the newer, 4th generation, da Vinci system. Whilst maintaining the ability to perform precision dissection, this method reduces the consumable cost by 46%. The initial series of 109 procedures proves this procedure to be safe, feasible, trainable and time efficient.

Initial experience of a single surgeon for safety and feasibility of the Versius Robotic System in robot-assisted cholecystectomy and hernia repair.

This study aimed to evaluate the feasibility, safety, and perioperative outcomes of cholecystectomy and hernia repair performed with the Versius Robotic System by a surgeon with no prior robotic surgery experience. A retrospective analysis was conducted on adult patients who underwent cholecystectomy, inguinal, or umbilical hernia repair using the Versius Robotic System between August 2021 and June 2023 et al. Zahra Hospital, Dubai, UAE. A total of 105 patients (mean age 38.9 ± 9.2years) were included. Significant correlations existed between the number of robot-assisted cholecystectomies and the operative metrics. As the number increased, the duration of the total operative (r = -0.755, p < 0.001), docking (r = -0.683, p < 0.001), and console (r = -0.711, p < 0.001) times decreased, indicating improved efficiency with experience. This study demonstrates the safety and feasibility of the Versius Robotic System for cholecystectomy and hernia repair, even for surgeons lacking prior robotic surgery experience.

Robotic-assisted cholecystectomy in the third trimester of pregnancy

Acute and chronic cholecystitis commonly occur during pregnancy. Hormonal changes during pregnancy put women at a higher risk of forming gallstones and biliary dyskinesia leading to disease. The standard of care for acute cholecystitis is to have an elective cholecystectomy within 48 hours. Extensive research exists on the current practice of performing a laparoscopic cholecystectomy in pregnancy. Based on our review of the current literature, there is only one report that details a robotic cholecystectomy performed on a pregnant patient. This report will detail the methods used to perform the surgery and steps taken to ensure the safety of mother and fetus. It will describe the unique circumstances surrounding the robotic technique used in this case and include the demographics and background of this patient, in an effort to promote this technique in future cases.&#x0D; &#x0D; Key words: obstetrics, acute cholecystitis, symptomatic cholelithiasis, pregnancy, laparoscopic cholecystectomy, robotic-assisted cholecystectomy

Initial experience of robotic-assisted cholecystectomy in a tertiary care teaching hospital

Abstract Background: Robotic surgery was designed to overcome some of the major limitations of laparoscopy in terms of visibility, dexterity and precision. However, its potential limitations include high costs and low tactile feedback. at a tertiary care teaching hospital. Methods: In this retrospective study, we assessed the safety and feasibility of robotic-assisted cholecystectomy using the Versius Surgical Robot System® at our tertiary care teaching hospital between 2 September 2021 and 22 August 2022. Results: Of the 30 patients studied, 11 were males. The mean body mass index of the patients was 25.7. Intraoperative complications were noted in one case (haemorrhage from the liver bed) and conversion to laparoscopic surgery was noted in the same case. The median docking time was 16 min and the median console time was 72 min. No post-operative complications were noted. Both docking time and console time significantly decreased throughout this study. Conclusions: This study shows that the robotic-assisted cholecystectomy is a promising, safe and feasible alternative to traditional laparoscopic cholecystectomy.

Robot assisted Laparoscopic Cholecystectomy- A Comparative study

Background- Robotic surgery has recently grown in acceptance and usefulness in general surgery, and it may offer superior results to laparoscopic surgery in some gastrointestinal operations. Objectives- To assess if the use of robot assistance during laparoscopic cholecystectomy is warranted when compared to traditional laparoscopic cholecystectomy. Methods- It was a retrospective record based study. All patients undergoing robotic or laparoscopic cholecystectomy between 2019 and 2022 at a single academic medical center were captured using institutional data. A total of 110 robotic surgeries were done and 1200 Laparoscopic cholecystectomies was done during the study period. The bulk of cases were primarily handled by two acute care general surgeons, who also conducted robotic and laparoscopic cholecystectomies. The institutional Clinical Data Repository provided the financial information. The study was approved by Institutional Ethics Committee. Age, sex, race, body mass index (BMI), and comorbid conditions of the patient were examined prior to surgery. SPSS was used for analysis. Results- A total of 1310 patients were identified who underwent robotic or laparoscopic cholecystectomy between 2019 and 2022 among them Robotic-assisted approach was used in 9.1% (n = 110) of cases. There were no demographic differences in age, sex, race, and body mass index (BMI). Type II diabetes mellitus, hypertension, and CHF disease were statistically significantly different between groups. Mean age (Robotic: 41 [29-56] vs. Laparoscopic: 43 [30-54] years, p = 0.11) and BMI (Robotic: 28.4 [26.6-32.4] vs. Laparoscopic: 29.2 [27.5-33.4]) were similar between groups. both operative duration was greater and hospital cost were greater in robotic-assisted cholecystectomy and it was statistically significant (p&lt;0.05), but hospital duration of stay and 90-day related readmission rates were less in robotic-assisted cholecystectomy which was significant; 30-day readmission rates were similar between both groups. Conclusion- When compared to laparoscopic cholecystectomy, robotic cholecystectomy has longer operating times and higher hospital costs, but it is also related with shorter hospital stays and a lower readmission rate within 90 days after the index procedure. Before exploring robotic cholecystectomy, hospitals and surgeons must weigh the enhanced clinical outcomes against the time and money necessary.

A retrospective study of laparoscopic, robotic-assisted, and open emergent/urgent cholecystectomy based on the PINC AI Healthcare Database 2017–2020

BackgroundRobotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied.MethodsThe PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2).ResultsRAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging.ConclusionsA comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.

A Medium-Term Comparison of Quality of Life and Pain After Robotic or Laparoscopic Cholecystectomy

IntroductionWe sought to compare medium-term outcomes between robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC) using validated quality of life (QoL) and pain assessments. Materials and MethodsPatients who underwent RC or LC between 2012 and 2017 at a single academic institution were examined. Cases converted to open were excluded. Patients were contacted by telephone in 2019 and completed two standardized surveys to rate their QoL and pain. ResultsOf those screened, 122 (35.8%) completed both surveys. Ninety three (76.2%) underwent RC and 29 (23.8%) underwent LC. The groups (RC versus LC) were similar based on mean age (47.9 versus 45.5 y, P = 0.48), gender (66.7% versus 72.4% female, P = 0.56), race (86.0% White/5.4% Black versus 72.4% White/13.8% Black, P = 0.2), insurance status (98.9% versus 100.0% insured, P = 0.58), median body mass index (31.8 versus 31.3, P = 0.43), and median Charlson Comorbidity Index (1 versus 0, P = 0.14). Fewer RC patients had a history of steroid use compared to LC (16.1% versus 34.5%, P = 0.03). No overall significant difference in QoL was demonstrated. LC group had higher severity of “tiring-exhausting pain” (P = 0.04), “electric-shock pain” (P = 0.003), and “shooting pain” (P = 0.05). The “overall intensity” of pain in the “gallbladder region” between the groups was similar at the time of follow-up (P = 0.31). ConclusionsQoL over 2-7 y following time of surgery is comparable for robotic-assisted versus conventional laparoscopic cholecystectomies. The laparoscopic approach may be associated with a higher severity of subset categories of pain, but overall pain between the two approaches is comparable.

A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy.

The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases. Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables. Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively. This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.

Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy

Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear. To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy. This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023. Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches. The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups. A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]). This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.

407 Robotic Assisted Cholecystectomy and Common Bile Duct Exploration for Single Stage Management of Complex Gallstone Disease

Abstract Aim Laparoscopic cholecystectomy and common bile duct exploration (LC-CBDE) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for treatment of choledocholithiasis. The ‘Achilles heel’ of LC-CBDE is the choledochotomy incision and closure following duct clearance. Robotic assisted surgery (RAS) aspires to overcome these technical challenges by providing improved views (3D enhancement) and articulated instruments potentially improving surgical precision. We aim to scrutinise the outcomes of an early series of robotic assisted cholecystectomy and common bile duct exploration (RC-CBDE) cases performed at our institution. Method Retrospective analysis from a specialist benign pancreatico-biliary unit in the United Kingdom was undertaken from April 2022 – December 2022 inclusive. All patients who underwent RC-CBDE for complicated gallstone disease were included. Collated data included patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. Results 10 patients were identified. Median (IQR) age was 51 (33 – 66) years. Median (IQR) BMI was 26 (21 – 32) kg/m2. Median (IQR) Charlson Co-morbidity Index (CCI) was 1 (0 – 4). 4 patients were operated on during the acute presentation, with median (IQR) bilirubin 51 (34 – 252.5). Median (IQR) operative time was 176 (124 – 222) minutes. Median (IQR) post-operative length of stay was 4 (1 – 5) days. One patient required reintervention for port site hernia repair from drain site. Conclusions RC-CBDE is a safe and effective treatment for choledocholithiasis with equivocal outcomes to LC-CBDE. Benefits of RAS include enhanced views and ergonomics aiding precise closure of choledochotomy, which may both reduce complications and promote wider uptake of common bile duct exploration – a previously underutilised, technically-challenging operative procedure.

Short-term outcomes and costs analysis of robotic-assisted versus laparoscopic cholecystectomy—a retrospective single-center analysis

PurposeRobotic-assisted surgery is an alternative technique for patients undergoing minimal invasive cholecystectomy (CHE). The aim of this study is to compare the outcomes and costs of laparoscopic versus robotic CHE, previously described as the major disadvantage of the robotic system, in a single Austrian tertiary center.MethodsA retrospective single-center analysis was carried out of all patients who underwent an elective minimally invasive cholecystectomy between January 2010 and August 2020 at our tertiary referral institution. Patients were divided into two groups: robotic-assisted CHE (RC) and laparoscopic CHE (LC) and compared according to demographic data, short-term postoperative outcomes and costs.ResultsIn the study period, 2088 elective minimal invasive cholecystectomies were performed. Of these, 220 patients met the inclusion criteria and were analyzed. One hundred ten (50%) patients underwent LC, and 110 patients RC. There was no significant difference in the mean operation time between both groups (RC: 60.2 min vs LC: 62.0 min; p = 0.58). Postoperative length of stay was the same in both groups (RC: 2.65 days vs LC: 2.65 days, p = 1). Overall hospital costs were slightly higher in the robotic group with a total of €2088 for RC versus €1726 for LC.ConclusionsRobotic-assisted cholecystectomy is a safe and feasible alternative to laparoscopic cholecystectomy. Since there are no significant clinical and cost differences between the two procedures, RC is a justified operation for training the whole operation team in handling the system as a first step procedure. Prospective randomized trials are necessary to confirm these conclusions.

Safety and Feasibility of Cholecystectomy with the HugoTM RAS: Proof of Setup Guides and First-In-Human German Experience

Introduction: The Hugo RAS robotic platform by Medtronic was recently certified for human use in Europe. Several centers have gained initial experience with this system in urology and gynecology. However, few data about its feasibility and safety in general surgery have been published. Methods: The first-in-human surgical procedures with the Hugo RAS in Germany were performed at our hospital in February 2023. We report our early experience with robotic cholecystectomy using this new platform. The primary aim was to test the setup guides of the manufacturer and to evaluate the safety and feasibility of Hugo RAS for this procedure. Results: A modified setup with two 11-mm ports and two 8-mm ports without an assistant port was used in 14 consecutive cases. A 30° or a 0° camera, a bipolar grasper or a Maryland on the left arm, a monopolar scissors on the right arm, and a double-fenestrated grasper on the additional arm were mounted. Clip application and gallbladder extraction were performed by the bedside assistant through the right arm 11-mm port. There were no complications, no adverse events, and no conversions. Arm collisions were reduced through slight corrections in trocar positions. Conclusion: Robotic-assisted cholecystectomy with the Hugo RAS was safe and feasible. The modularity of robotic arms allows individual setup modifications which may be of advantage for patients and surgeons.