Robotic-assisted Cholecystectomy Research Articles

Robot-assisted cholecystectomy with the new HUGO™ robotic-assisted system: first worldwide report with system description, docking settings, and video.

Robotic surgery has gained worldwide acceptance in the past decade, and several studies have shown that this technique is safe and feasible. The innovation of this system is the open surgical console with an HD-3D display, a system tower, and four independent arm carts. We describe the first robot-assisted cholecystectomy performed with the new Hugo RAS (robotic-assisted surgery) system (Medtronic, Minneapolis, MN, USA) in Spain. The procedure was completed without conversion. No intraoperative complication or technical failure of the system was recorded. The operative time was 70min. The docking time was 3min. Hospital length of stay was 1days. This case report shows the safety and feasibility of cholecystectomy with the Hugo RAS system and provides relevant data that may be of help to early adopters of this surgical platform.

Effects of extremely low-pressure pneumoperitoneum on postoperative recovery after single site robot-assisted cholecystectomy: a randomized controlled trial.

A robotic platform has enabled extremely low-pressure pneumoperitoneum (ELPP, 4 mmHg) to reduce surgical insults to human physiology during a minimally invasive surgery. The objective of this study was to investigate the effect of ELPP in single-site robotic cholecystectomy (SSRC) on postoperative pain, shoulder pain, and physiological changes during surgery compared to a standard pressure pneumoperitoneum (SPP, 12-14 mmHg). A total of 182 patients who underwent an elective cholecystectomy were randomized into an ELPP SSRC group (n = 91) and an SPP SSRC group (n = 91). Postoperative pain was assessed at 6, 12, 24, and 48 h after surgery. The number of patients complaining of shoulder pain was observed. Intraoperative changes of ventilatory parameters were also measured. Postoperative pain scores (p = 0.038, p < 0.001, p < 0.001, and p = 0.015 at 6, 12, 24, and 48 h after surgery, respectively) and the number of patients with shoulder pain (p <0.001) were significantly lower in the ELPP SSRC group than in the SPP SSRC group. Intraoperative changes in peak inspiratory pressure (p < 0.001), plateau pressure (p < 0.001), EtCO2 (p < 0.001), and lung compliance (p < 0.001) were also less in the ELPP SSRC group. The ELPP during robotic cholecystectomy could significantly relieve postoperative pain and shoulder pain. In addition, the ELPP can reduce changes in lung compliance during surgery and the demand for postoperative analgesics, thereby improving the quality of life of patients during early stages of postoperative rehabilitation.

Retrospective analysis of operative time and time to discharge for laparoscopic vs robotic approaches to appendectomy and cholecystectomy.

Robotic-assisted appendectomies and cholecystectomies are believed to increase cost compared to the gold standard laparoscopic approach. Two equally qualified surgeons performed both approaches over 2 years to evaluate intraoperative duration, time to discharge, conversion to open procedure, and readmission within 30days. 110 laparoscopic, 81 robotic-assisted appendectomies; and 105 laparoscopic and 165 robotic-assisted cholecystectomies were performed. Intraoperative time; laparoscopic appendectomy was 1.402 vs 1.3615h for robotic-assisted (P value = 0.304); laparoscopic cholecystectomy was 1.692 vs 1.634h for robotic-assisted (P value = 0.196). Time to discharge, was 38.26 forlaparoscopic vs 28.349h for robotic-assisted appendectomy (P value = 0.010), and 35.95 for laparoscopic vs 28.46h for robotic-assisted cholecystectomy (P value = 0.002). Intraoperative conversion to open; only laparoscopic procedures were converted,one appendectomy and nine cholecystectomies. None in therobotic-assisted procedures. Readmissions, none in the appendectomy group and three in the cholecystectomy group. One laparoscopic and two robotic-assisted cholecystectomy patients were readmitted. Intraoperative times for robotic appendectomy and cholecystectomy were notlonger thanlaparoscopic approach. Robotic approach shortened the time to discharge and the likelihood for conversion to open procedure.

Robot-assisted cholecystectomy in children

Robot-assisted cholecystectomy in children

Laryngeal Cancer Surgery: History and Current Indications of Transoral Laser Microsurgery and Transoral Robotic Surgery.

The development of transoral laser microsurgery (TLM) was an important step in the history of conservative laryngeal surgery. TLM reported comparable oncological outcomes and better functional postoperative and rehabilitation outcomes than open partial laryngectomy. TLM is currently considered as the standard surgical approach for early-stage laryngeal carcinoma. However, TLM has many limitations, including the limited view of the surgical field through the laryngoscope, exposure difficulties for some tumor locations, and a long learning curve. The development of transoral robotic surgery (TORS) appears to be an important issue to overcome these limitations. The current robotic technologies used in surgery benefited from the research of the U.S. Military and National Aeronautics and Space Administration (NASA) in the 1970s and 1980s. The first application in humans started in the 2000s with the first robotic-assisted cholecystectomy in the US, performed by a surgeon located in France. The use of robots in otolaryngology occurred after the development of the Da Vinci system in digestive surgery, urology, and gynecology, and mainly concerns cT1-T2 and some selected cT3 oropharyngeal and supraglottic carcinomas. With the development of a new robotic system with smaller arms and instruments, TORS indications will probably evolve in the next few years, leading to better outcomes for laryngeal or hypopharyngeal carcinomas.

Robotic assisted cholecystectomy – A retrospective cohort study of experience of 106 first robotic cholecystectomies in versius robotic platform

IntroductionLaparoscopic cholecystectomy is currently the standard of care for symptomatic cholelithiasis as well as for chronic and acute cholecystitis. The incidence of bile duct injury in laparoscopic cholecystectomy is still higher than that in open surgery. Surgical robots aim to bridge this gap. With the greater availability of surgical robots and cheaper alternatives to the Da Vinci system, surgeons can take advantage of the better manoeuvrability and better vision that a surgical robot offers. This is likely to make robotic assisted cholecystectomy a very safe option. Here, we present our early data on the robotic procedures performed by the Versius robotic system by CMR (Cambridge Medical Robotics). MethodsIt is a retrospective study, with data collected from our prospectively maintained database at Swagat Super Speciality Surgical Institute and NH, maintained collectively by CMR and our surgical residents. The first consecutive 106 planned robotic cholecystectomies that were performed by a single surgeon were included in the study. ResultsOut of 106 serial planned robotic assisted cholecystectomies (101 robotic assisted cholecystectomies + 5 combined with other procedures), no bile duct injury was reported, with a mean console time of 54.16 min and a mean setup time of 9.29 min. One procedure had to be converted to open for malignancy, and another patient had to be converted to laparoscopy due to dense adhesions with the duodenum. Three chronic liver disease (CLD) patients underwent partial cholecystectomy. A total of 70.75% of patients had no pain – visual analogy scale (VAS) pain score of 0 at POD 1 with minimal blood loss in most of the procedures. No learning curve for robotic assisted cholecystectomy was seen. ConclusionAlthough robotic assisted cholecystectomy was mostly chosen for patients in whom difficult cholecystectomy was clinically anticipated, it fared quite well. The learning curve was essentially non-existent. Robotic assisted cholecystectomy is a safe and feasible option in both simple and difficult cases of gallbladder disease.

Micro-Hand Robot-Assisted Versus da Vinci Robot-Assisted Cholecystectomy: A Multi-centre, Randomized Controlled Trial.

To evaluate the clinical effectiveness of micro-hand robot-assisted cholecystectomy (MRC) by comparing the clinical outcomes of patients with benign gallbladder disease treated with micro-hand or da Vinci robot-assisted cholecystectomy (DRC). This is a prospective, multi-centre, single-blind, and randomized controlled trial. In this study, 166 patients of benign gallbladder disease were randomized enrolled into two groups and received MRC or DRC (83 in the MRC group; 83 in the DRC group). The primary endpoint was surgical success rate. Secondary endpoints were the docking time, console time, total operation time, intraoperative blood loss, gallbladder breakage rate, postoperative pain, time of first flatus, the comprehensive complication index (CCI), and the hospital stay of the subjects. The duration of follow-up was 30days. No conversion occurred. Compared with MRC, the DRC group showed longer docking time (12.04min vs. 16.39min, P = 0.025) and higher gallbladder breach rate (4.8% vs. 15.7%, P = 0.021). The MRC group showed higher postoperative pain scores compared to DRC (4.0 vs 3.0, P = 0.038). The console time, intraoperative blood loss, and gallbladder breach rate were comparable in these two groups (P &gt; 0.05). No differences were observed in postoperative outcomes and complications between the two groups (P &gt; 0.05). In patients with benign gallbladder disease, the MRC showed no obvious clinical disadvantage compared with the da Vinci surgical robot. MRC is effective and safe and provides more options for surgical treatment. This study was registered at ClinicalTrials.gov (NCT04122261). URL: https://clinicaltrials.gov/ct2/show/NCT04122261.

The effectiveness of extremely low-pressure pneumoperitoneum on pain reduction after robot-assisted cholecystectomy

BackgroundThe robot-assisted cholecystectomy could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (ELPP; 4 mmHg) by the robot arm lifting the abdominal wall upward. This study aimed to investigate the effect of ELPP on the postoperative outcomes in benign gallbladder disease. MethodsA retrospective study was designed to compare the postoperative pain in addition with operation time, estimated blood loss, length of hospital stay, and complication of three types of cholecystectomy for benign gallbladder disease: 75 ELPP single site robot-assisted cholecystectomy (SSRC), 114 standard-pressure pneumoperitoneum (SPP) SSRC and 110 SPP conventional laparoscopic cholecystectomy (CLC). ResultsThere was no difference in whole operation time between ELPP SSRC and SPP SSRC group (p = 0.159). Postoperative pain score was significantly less in ELPP SSRC group as compared to SPP SSRC or SPP CLC group at 6, 12, and 24 h postoperatively (p = 0.004, p = 0.004, and p = 0.013 respectively). The incidence of shoulder pain was also significantly lower in ELPP SSRC group (p < 0.001). The rate of postoperative complication and length of stay were not different among the three groups. ConclusionsThis study shows that ELPP technique using robot is feasible without increasing postoperative complications in the process of cholecystectomy and the use of the ELPP can reduce postoperative pain and shoulder pain compared to the use of the SPP.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

BackgroundIatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.Case presentationWe report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.ConclusionsEven with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Comment on The Early (2009-2017) Experience With Robot-assisted Cholecystectomy in New York State.

Comment on The Early (2009-2017) Experience With Robot-assisted Cholecystectomy in New York State.

Preoperative planning method based on a MOPSO algorithm for robot-assisted cholecystectomy.

Surgical robots have multiple manipulators with complex mechanisms and need to work in a narrow space in the patient's body. Therefore, for robot-assisted minimally invasive surgery (RMIS), it is very important to develop a reasonable preoperative planning before surgery. A preoperative planning method based on the premise of no collision between surgical instruments and endoscope, an evaluation index with visibility, operability and hand-eye coordination was proposed in this paper. To consider the balance relationship of global optimization index, a multi-objective particle swarm optimization (MOPSO) algorithm was adopted. Because the physical characteristics of each patient are different, the method can determine the selectable area of the incision based on the relevant knowledge of anatomy. The simulation taking the cholecystectomy as an example was performed on a minimally invasive surgical robotic system. The analysis result showed that the proposed preoperative planning method based on the MOPSO could provide surgeons with a reasonable and effective preoperative planning. The proposed preoperative planning method based on the MOPSO is suitable for patients with different physical characteristics, and can provide a guidance for surgeons and effectively reduce the preoperative planning time and improve the safety and efficiency of the operation, especially a novice surgeon who lacks robot-assisted minimally invasive surgery experience.

Robotic-assisted surgery: yesterday, today, tomorrow

Analysis of development of «robotic surgery» on the basis of historical prerequisites, review of the possibilities of the new Senhance robotic surgical system and determination of further perspective. A prospective group of 51 patients with surgical pathology who underwent surgical interventions using the new Senhance robotic system was analyzed. The study included 51 patients. Robot-assisted cholecystectomy was performed in 20 patients, 31 patients underwent robotic transabdominal preperitoneal plastic surgery. A short-term analysis of intraoperative and early postoperative data showed the safety of using the Senhance robotic complex for the patient. The ergonomics of this system contributes to significantly less fatigue of the surgeon during the operation, increasing its efficiency and safety. The emergence of competitive robotic systems contributes to the dynamic development of robotic surgery, which in turn will lead to a reduction in the cost of these technologies in the future. Innovative solutions used in modern robotic complexes are based on the principles of machine learning, which in due time will make the «robot surgeon» not just a tool, but a full-fledged member of the operating team.

Evaluating the feasibility and effectiveness of extremely low-pressure pneumoperitoneum for robotic-assisted cholecystectomy

Standard-pressure pneumoperitoneum (12 to 15 mmHg) has been used to create an adequate working space during the laparoscopic surgery, but it has adverse effects such as postoperative pain, especially in the shoulder. Attempts are being made to reduce the postoperative pain by keeping low-pressure insufflation (7 to 10 mmHg). With advances in operative technology, the robotic-assisted cholecystectomy using da Vinci Xi could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (4 mmHg) by the videoscope pushing the abdominal wall upward. This study aimed to compare the postoperative outcomes using standard- and extremely low-pressure pneumoperitoneum in patients undergoing laparoscopic or robotic-assisted cholecystectomy. A retrospective study was designed to compare the postoperative outcomes of 53 extremely low-pressure robotic-assisted cholecystectomy (ELRC), 116 standard-pressure robotic-assisted cholecystectomy (SRC) and 105 standard-pressure laparoscopic cholecystectomy (SLC). The surgery took longer in robotic-assisted cholecystectomy than laparoscopic cholecystectomy (p < 0.001). Postoperative pain score was significantly less in ELRC group as compared to SRC or SLC group at 6, 12, and 24 hours (p = 0.004, p = 0.005, and p = 0.009, respectively). However, there was no significant difference between groups in the number of demands for analgesic. The incidence of shoulder pain was significantly lower in ELRC group (p < 0.001). The rate of postoperative complication and length of stay were no difference between groups. The use of the ELRC is associated with a significantly lower postoperative pain and shoulder pain. This study also shows that extremely low-pressure technique is feasible without increasing postoperative complications.

Robotic-assisted cholecystectomy is superior to laparoscopic cholecystectomy in the initial training for surgical novices in an ex vivo porcine model: a randomized crossover study

BackgroundRobotic-assisted surgery (RAS) potentially reduces workload and shortens the surgical learning curve compared to conventional laparoscopy (CL). The present study aimed to compare robotic-assisted cholecystectomy (RAC) to laparoscopic cholecystectomy (LC) in the initial learning phase for novices.MethodsIn a randomized crossover study, medical students (n = 40) in their clinical years performed both LC and RAC on a cadaveric porcine model. After standardized instructions and basic skill training, group 1 started with RAC and then performed LC, while group 2 started with LC and then performed RAC. The primary endpoint was surgical performance measured with Objective Structured Assessment of Technical Skills (OSATS) score, secondary endpoints included operating time, complications (liver damage, gallbladder perforations, vessel damage), force applied to tissue, and subjective workload assessment.ResultsSurgical performance was better for RAC than for LC for total OSATS (RAC = 77.4 ± 7.9 vs. LC = 73.8 ± 9.4; p = 0.025, global OSATS (RAC = 27.2 ± 1.0 vs. LC = 26.5 ± 1.6; p = 0.012, and task specific OSATS score (RAC = 50.5 ± 7.5 vs. LC = 47.1 ± 8.5; p = 0.037). There were less complications with RAC than with LC (10 (25.6%) vs. 26 (65.0%), p = 0.006) but no difference in operating times (RAC = 77.0 ± 15.3 vs. LC = 75.5 ± 15.3 min; p = 0.517). Force applied to tissue was similar. Students found RAC less physical demanding and less frustrating than LC.ConclusionsNovices performed their first cholecystectomies with better performance and less complications with RAS than with CL, while operating time showed no differences. Students perceived less subjective workload for RAS than for CL. Unlike our expectations, the lack of haptic feedback on the robotic system did not lead to higher force application during RAC than LC and did not increase tissue damage. These results show potential advantages for RAS over CL for surgical novices while performing their first RAC and LC using an ex vivo cadaveric porcine model.Registration numberresearchregistry6029Graphic abstract

Proposed training pathway with initial experience to set up robotic hepatobiliary and pancreatic service.

Although robot-assisted hepatobiliary and pancreatic (HPB) surgery has gained momentum over the last 2decades, only a handful of units in the world perform major robotic resections. Adaptation of robotic surgery in the UK lags behind its European counterparts and this is mainly because of cost implications in a publicly funded National Health Service (NHS). We describe our experience of setting up a robotic HPB programme with clinical outcomes and propose a training pathway that would help prospective centres in setting up their own robotic HPB service with robust clinical governance oversight. After gaining colleagues' and departmental support, approval from the hospital clinical governance, finance department and new intervention procedure committee was sought. A team of two consultant surgeons, three assistants and three theatre staff went through a structured training programme sponsored mainly by the industry. Surgeon training consisted of online modules, simulation, wet lab, cadaveric training, case observations, proctored procedures followed by independent practice. All major cases were recorded and videos reviewed to improve performance. A total of 111 procedures were successfully completed with robotic assistance between April 2018 and March 2020. The programme started with robot-assisted cholecystectomy as index procedure and progressed on to more complex liver and pancreatic resections including major hepatectomy and Whipple's procedure. The training pathway followed by our team has been effective in setting up a safe robotic HPB programme and could be considered as a roadmap to start new Robotic HPB services.

Comparative analysis of robotic-assisted versus laparoscopic cholecystectomy in pediatric patients

Background: Despite increased utilization of robotic-assisted surgery in the pediatric population during the past decade, reports of comparative analysis between robotic surgery and laparoscopic surgery are lacking. Our aim was to evaluate outcomes between pediatric robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC).Methods: A single institution retrospective analysis of 299 patients undergoing either RC or LC, between January 2015 and December 2018 was performed. Demographic data as well as clinical characteristics and related outcomes were abstracted and compared using univariate analysis. Related hospital costs were estimated using a charge to cost methodology.Results: The median age of the cohort was 15.5 years (IQR 14.0–17.0); 76% females and 70% white, with 74% (n = 220) undergoing LC and 26% (n = 79) undergoing RC. The majority of RC were performed using single-site technique and RC proportion increased with time (10% in 2015 vs. 41% in 2018, p<0.001). The majority of RC were more commonly attributed to patients with nonacute indications for cholecystectomy compared to acute clinical indications (87% vs. 13%). Median operative time was 98 min vs. 79 min for RC and LC respectively (p<0.001). Median postoperative LOS was similar between groups (22 h). There were no significant differences in postoperative complication, in-hospital opioid utilization and 30-day readmissions. Average total hospital costs for RC were $15,519 compared to $11,197 for LC.Conclusions: Pediatric robotic-assisted cholecystectomy is feasible with similar outcomes compared to laparoscopic cholecystectomy. However, it is associated with longer operative times and higher costs. The single-site RC technique may provide a potential cosmetic benefit.

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. MethodsThe 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. ResultsOf an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (β: $2,398, P < .001). ConclusionUsing the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

AB010. Robotic assisted cholecystectomy and common bile duct exploration for symptomatic choledocholithiasis: the first Irish case

Background: Choledocholithiasis is a common presentation of gallstone disease. Sequelae of choledocholithiasis can be severe, including ascending cholangitis and gallstone pancreatitis. Although the majority of cases are now treated endoscopically, a proportion still requires surgical common bile duct (CBD) exploration. Laparoscopic CBD exploration is safe and feasible, although technically and ergonomically challenging. This is the first reported robotic assisted CBD exploration in Ireland using the dual console DaVinici Xi system.

Robot-assisted cholecystectomy is a safe but costly approach: A national database review

BackgroundThis study sought to evaluate surgical outcomes, cost, and opiate utilization of patients who underwent laparoscopic (LC) or robotic cholecystectomy (RC). MethodsThe Vizient database was queried for patients admitted with mild to moderate severity of illness (SOI) scores who underwent LC or RC from January 2015 through December 2017. Rates of overall complications, postoperative infection, mortality, LOS, cost, and opiate utilization were compared between groups using IBM SPSS v.25.0, α = 0.05. Results91,849 patients (LC:N = 89,878; RC:N = 1,971) met the inclusion criteria. Robotic approach was associated with more complications (LC:0.9%, RC:1.7%; p < 0.001), postoperative infections (LC:0.2%, RC:0.4%; p = 0.033) and a higher direct cost (LC:$6782 ± 3421, RC:$9354 ± 5497; p < 0.001). Opiates were prescribed more frequently in the laparoscopic group (LC:98.3%, RC:97.2%; p = 0.002). ConclusionThe direct cost of RC is significantly higher than LC with no added benefit. Routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.

Robotic-Assisted Transrectal Cholecystectomy in a Porcine Model.

Background. With increasing experience and technological advancement in surgical instruments, surgeons have explored the feasibility of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). These techniques aim to further reduce surgical trauma, but are not popular due to their inherent pitfalls including clashing of instruments, lack of counter traction, lengthy operating time, and so on. A novel surgical robotic system was designed to overcome the limitations of the existing technologies. Animal trials were conducted to demonstrate its feasibility in performing robotic-assisted transrectal cholecystectomy in a porcine model. Method. The Novel surgical robotic system is a high dexterity, single access port surgical robotic system that enables surgeons to carry out single-port surgical procedure or NOTES. The proposed system's main features include the ability to perform intraabdominal and pelvic surgeries via natural orifices like the vagina or rectum. The system is equipped with multiple miniaturized (16 mm diameter) internally motorized robotic arms, each with a minimum of 7 degrees of freedom, a dual in vivo camera system, a cannula, and an external swivel system. Results. Robotic-assisted transrectal cholecystectomy was successfully performed in 3 adult male pigs. The estimated blood loss was <10 mL in all 3 cases. There were no intraoperative complications. The system provided good dexterity and clear vision. Conclusions. The trial demonstrated that the system can provide the surgeon a stable platform with adequate spacing for the transrectal insertion of robotic arms, 3-dimensional vision, and enhanced dexterity in performing NOTES cholecystectomy.