Single-site Robotic Cholecystectomy Research Articles

Robotic single-site cholecystectomy in the obese: outcomes from a single institution

BackgroundRobotic single-site cholecystectomy (RSSC) has been shown to be a safe alternative to the laparoscopic approach in selected patients. Patient exclusion criteria have prevented RSSC as a surgical option in many obese patients. This study reports the feasibility of performing RSSC in obese patients (body mass index [BMI]≥ 30). MethodsBetween November 2012 and February 2014, a total of 200 patients underwent RSSC at our institution. All patients were offered the robotic procedure regardless of their BMI, age, previous surgery, and acuity of their disease with no exclusion criteria. All patients with BMI≥30 were included in the study and were compared to nonobese patients for demographic characteristics, co-morbidities, and postoperative outcomes. Data were compared to RSSC performed in nonobese patients by the same surgeon, as well to published data for standard laparoscopic cholecystectomy (LC). ResultsA total of 112 cholecystectomies were successfully performed with the robotic approach in patients with BMI≥30 without conversion to open, laparoscopic, or multiport procedures. The mean BMI was 39.5 (range 30.1–62.3). Twenty-eight patients had a BMI≥40 (25%), and 13 patients had a BMI≥50 (11.6%). Fifty-two patients (46.4%) had a history of prior abdominal surgery. Most procedures were nonelective (78.6%) with patients presenting with acute symptoms. Pathology showed chronic cholecystitis and cholelithiasis in 79 patients (70.5%), acute cholecystitis in 26 patients (23.3%), cholelithiasis in 4 patients (3.5%), and gangrenous cholecystitis in 3 patients (2.7%). Total mean operative time was 69.8 (26) minutes for obese patients compared to 59.2 (19.7) minutes in the nonobese, which was statistically significant (P = .0012). After a mean follow-up of 6 months, there were no major complications recorded including bile leak, hematoma, or ductal injury. There was 1 umbilical (incisional) hernia (0.9%) reported, and zero wound infections. When comparing RSSC performed in obese patients, RSSC in nonobese patients, and published data for standard LC, we found no difference in operative time, with less conversion to open. ConclusionsRobotic single-site cholecystectomy is a feasible option in the obese patient population with excellent short-term outcomes. Patients should not be excluded based on their high BMI although further study is needed to determine long-term outcomes.

Single-Site Robotic Cholecystectomy in a Broadly Inclusive Patient Population

To describe our initial experience with single-site robotic cholecystectomy (SSRC) and its applicability to a broad segment of patients. At the initiation of our study, there were only 3 published reports on SSRC. These initial studies had limited inclusion criteria. We present our experience with the technical aspects and patient outcomes of SSRC in a broadly inclusive patient population. Prospective cohort study from January 2012 to January 2013, in which 95 patients underwent SSRC. Procedural times, postoperative complications, delayed hospital discharges, and re-admissions were evaluated. Patients were predominantly female (71.6%) had mean age of 45.2 ± 6.1 years and mean body mass index (BMI) of 30.1 ± 7.1 kg/m. Overall, mean total operative time (TOT) for all patients (n = 95) was 88.63 ± 32.0 (range: 49-220) minutes. SSRC was not completed in 8 (8.42%) patients: 6 conversions to laparoscopy, 1 conversion to open, and 1 aborted case. The group of patients who were able to complete SSRC (n = 87) had a mean TOT of 83.5 ± 24.5 minutes and mean operative robotic time (RT) of 39.6 ± 15.2 minutes. RT was longer in patients with intra-abdominal adhesions (P = 0.0139) and higher BMI (P = 0.03). A minority of patients required hospital admission (11.6%), readmission (6.3%), or reoperation (1.1%). No bile duct injury or death occurred. SSRC is safe and has a manageable learning curve. Patient factors, such as obesity, did not significantly affect conversion rates or TOTs. SSRC is a promising new technique, which can be offered to a wide array of patients.

Current Status of Single-Site Robotic Cholecystectomy, Its Feasibility, Economic and Overall Impact

This paper reviews recent, though limited, articles on the topic of robotic single-site cholecystectomy (RSSC), a relatively new approach that is rapidly advancing in both research and clinical application. Laparoscopy has typically been the standard method of performing a cholecystectomy, but recent medical advances have led to usage of the da Vinci® Surgical System robot technology to assist in performing the procedure. Several studies have compared outcomes of the RSSC to single-port laparoscopic cholecystectomies and to the traditional multiport laparoscopic cholecystectomies. Single port advocates think it as a tool with better cosmetic results and questionable less post-operative pain; however, single port also limits the maneuverability of the instrument arms, making some tasks more difficult, bigger single incision, more chances of post operative hernia. Overall, the RSSC is considered as safe with no worse outcomes regarding pain, hospital stay length, operative time, and patient satisfaction when compared to other cholecystectomy methods. Future direction includes expanding use of the miniature instruments and further advanced tools to overcome manipulation and visualization limitations. Thus far, though, there may be enough evidence with these smaller studies to support lack of harm with more use of resources.

Single-site robotic cholecystectomy.

Background:Laparoscopic single-incision surgery is fraught with significant technical drawbacks but has witnessed increased growth mainly for its presumed aesthetic advantages. Recently, a single-site robotic platform has been introduced to alleviate some of the technical challenges with laparoscopic single-site surgery, although literature on this topic is scant. The aim of this study is to analyze the experience of a single surgeon with single-site robotic cholecystectomies since the U.S. Food and Drug Administration gave its approval in December 2011, and to evaluate the robotic platform's safety and short-term surgical outcomes.Methods:From February 1st 2012 to February 28th 2013, patients who underwent single-site cholecystectomy at an academic institution in the United States were retrospectively reviewed from a prospectively maintained database. The following variables were analyzed: age, sex, body mass index, previous surgeries, total operative time, port insertion time, docking time, console time, estimated blood loss, closure time, conversion to open or multiport approach, postoperative outcomes for wound infection, bile leak, biliary ductal injury, right hepatic artery injury, reoperations, readmission, and mortality. Indication for cholecystectomy was symptomatic gallbladder disease. No exclusion criteria were used and no cost analysis was performed.Results:During the study period, 31 patients were enrolled. The mean patient age, body mass index, weight, and operative time was 33.6 years, 32.2 kg/m2, 86.3 kg, and 81.4 minutes, respectively. There were no conversions to the open or traditional multiport approach, and no major complications of biliary ductal or hepatic artery injury, bile leak, reoperations, or mortality occurred. There was 1 case of superficial wound infection.Conclusions:Single-site robotic cholecystectomy is feasible and safe and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy.

Robotic single‐site cholecystectomy

Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy. From February 2011 to February 2013, all consecutive robotic single site cholecystectomies (RSSC) were prospectively collected in a dedicated database. Demographic, intra- and postoperative data of all patients that underwent RSSC at our institution were analyzed. Data were evaluated for the overall patient cohort as well as after stratification according to patient BMI (body mass index) and surgeon's experience. During the study period, 82 patients underwent robotic single site cholecystectomy at our institution. The dominating preoperative diagnosis was cholelithiasis. Mean overall operative time was 91 min. Intraoperative complications occurred in 2.4% of cases. One conversion to open surgery due to the intraoperative finding of a gallbladder carcinoma was observed and two patients needed an additional laparoscopic trocar. The rate of postoperative complications was 4.9% with a mean length of stay of 2.4 days. No significant differences were observed when comparing results between robotic novices and robotic experts. Patients with higher BMI trended towards longer surgical console and overall operative time, but resulted in similar rates of conversions and complications when compared to normal weight patients. Robotic Single-Site cholecystectomy can be performed safely and effectively with low rates of complications and conversions in patients with differing BMI and by surgeons with varying levels of experience.

Cholecystectomy by using a surgical robotic system

Because of their frequency, hepato-biliary procedures have been the gateway for innovation to permeate into the realm of general surgery. Robotics and single-incision techniques are the latest manifestation in the evolution of minimally invasive surgery. Enthusiasm for the latter has increased due to its inarguably superior cosmetic result. Nevertheless, there are several technical disadvantages associated with this approach that have raised several concerns. The robotic platform may provide a solution to these issues. We analyze the strengths and weaknesses of the robotic system for cholecystectomy and its relation to single site technology. We review all available literature addressing robotic single site cholecystectomy. Due to the advent of specific robotic single site technology, many of the challenges commonly associated with single site cholecystectomy have been alleviated. Although this novel approach has not yet been extensively tested, the available evidence suggests that it is at least equivalent to LC in selected patients. Robotic single site cholecystectomy is safe and feasible and adequately compensates for many of the challenges commonly associated with conventional single site cholecystectomy. Large, high-quality studies are needed to further clarify the role of this procedure and its value as part of the surgeon's armamentarium.

Learning curve and early clinical outcomes for a robotic surgery novice performing robotic single site cholecystectomy

A rapid training protocol has been developed for robotic surgery novices to learn robotic single-incision techniques. This study assesses the learning curve and early clinical results for a robotic surgery novice starting single-site cholecystectomy. A chart review was performed on the surgeon's first 55 patients to undergo this procedure. Average patient age was 46.01 ± 4.25 (range 21-86) years and BMI was 26.57 ± 4.25 (range 19.4-36.6) kg/m(2) . The mean port placement with docking time was 11.34 ± 3.74 (range 7-23) min. Mean console time was 28.74 ± 11.04 (range 15-66) min. Average total OR time was 61.84 ± 14.66 (range 40-105) min. All procedures were successfully completed without conversion or added ports. Complications included several minor procedural gall bladder perforations and miscellaneous postoperative symptomatic complaints. Robotic single site cholecystectomy can be safely performed by a robotic novice within a minimal learning curve and have early clinical results that are comparable to the published data of robotic experts.

Real-time near-infrared fluorescent cholangiography could shorten operative time during robotic single-site cholecystectomy

With the introduction of a new platform, robotic single-site cholecystectomy (RSSC) has been reported as feasible and safe for selected cases. In parallel, the development of real-time near-infrared fluorescent cholangiography using indocyanine green (ICG) has been seen as a help during the dissection, even if the data are still preliminary. The study purpose is to report our experience with ICG RSSC and compare the outcomes to standard RSSC. From February 2011 to December 2011, 44 selected patients underwent RSSC for symptomatic cholelithiasis. Among them, 23 (52.3%) were included in an experimental protocol using the ICG, and the remainder (47.7%) underwent standard RSSC. There was no randomization. The endpoints were the perioperative outcomes. This is a prospective study, approved by our local Ethics Committee. There were no differences in terms of patients' characteristics, except that there were more male patients in the ICG group (47.8 vs. 9.5%; p = 0.008). Regarding the surgical data, the overall operative time was shorter for the ICG group, especially for patients with a body mass index (BMI) ≤25 (-24 min) but without reaching statistical significance (p = 0.06). For BMI >25, no differences were observed. Otherwise, there were no differences in terms of conversion, complications, or length of stay between both groups. A RSSC with a real-time near-infrared fluorescent cholangiography can be performed safely. In addition, for selected patients with a low BMI, ICG could shorten the operative time during RSSC. Larger studies are still required before drawing definitive conclusions.

Single‐site robotic cholecystectomy: efficiency and cost analysis

Single-incision surgery has gained in popularity, and the recent development of specialized robotic and laparoscopic instruments may remove some of the ergonomic and technical difficulties associated with this approach. However, questions of cost and efficiency remain. We prospectively collected perioperative outcome and efficiency (operative time, case volume) data for our single-site robotic cholecystectomy cases and retrospectively reviewed data for our single-incision laparoscopic cholecystectomy cases. There were no differences in patient characteristics or perioperative outcomes between the robotic (n = 20) and laparoscopic (n = 10) groups; operative times were equivalent (84.6 vs 85.5 min; p = 0.8737) and blood loss and complications were minimal. There was a higher robotic case volume, with an average of two robotic cases (range 1-4)/day vs one/day for laparoscopic cases (range 1-1; p = 0.0306). Streamlined instrument costs were essentially equivalent. Robotic single-site cholecystectomy is a safe, cost-effective alternative to single-incision laparoscopic cholecystectomy in a robot-existing model.

Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study

Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy and the primary cause is misinterpretation of biliary anatomy. This may occur more frequently with a single-incision approach due to difficulties in exposing and visualizing the triangle of Calot. Intraoperative cholangiography was proposed to overcome this problem, but due to multiple issues, it is not used routinely. Indocyanine green (ICG) near-infrared (NIR) fluorescent cholangiography is non invasive and provides real-time biliary images during surgery, which may improve the safety of single-incision cholecystectomy. This study aims to evaluate the efficacy and safety of this technique during single-site robotic cholecystectomy (SSRC). Patients presenting with symptomatic biliary gallstones without suspicion of common bile duct stones underwent SSRC with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. During patient preparation, 2.5 mg of ICG was injected intravenously. During surgery, the biliary anatomy was imaged in real time, which guided dissection of Calot's triangle. Perioperative outcomes included biliary tree visualizations, operative time, conversion and complications rates, and length of hospital stay. There were 45 cases between July 2011 and January 2012. All procedures were completed successfully; there were no conversions and at least one structure was visualized in each patient. The rates of visualization were 93 % for the cystic duct, 88 % for the common hepatic duct, and 91 % for the common bile duct prior to Calot's dissection; after Calot's dissection, the rates were 97 % for all three ducts. Mean hospital stay was 1.1 days and there were no bile duct injuries or any other major complications. Real-time high-resolution fluorescent imaging to identify the biliary tree anatomy during SSRC using the da Vinci Fluorescence Imaging Vision System was safe and effective.

Intra‐operative fluorescent cholangiography using indocyanin green during robotic single site cholecystectomy

Very recently, robotic single site cholecystectomy (RSSC) has been reported feasible and safe for selected cases. While an intra-operative cholangiography can be performed, data is scarce with respect to its use. Indocyanin green (ICG) has been shown to be a viable option to visualize biliary anatomy. Since the introduction of a new near infrared camera integrated to the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA), the surgeon is able to assess the biliary anatomy by a non-invasive and non-ionizing method. This paper presents the first report of ICG imaging during a RSSC. Twelve consecutive patients presenting symptomatic cholelithiasis were prospectively enrolled. They underwent RSSC approximately 45 minutes after intravenous administration of ICG (2.5 mg). The biliary anatomy was analyzed using a near infrared camera integrated to the robot before and after the robotic dissection. Eight women and four men underwent the procedure. There was a port addition in one case and no peri-operative complications. Mean operative time was 85 minutes (range: 57-125). The cystic, common bile and common hepatic ducts were recognized by fluorescence imaging before the dissection in 91.7%, 50%, and 33.3% of patients, respectively. At least one structure was visualized in 100% of patients. After the completion of Calot's triangle dissection, the cystic, common bile, and common hepatic ducts were recognized in 100%, 83.3%, and 66.7% of cases respectively. RSSC using ICG for biliary tree fluorescence imaging can be performed safely. Fluorescent cholangiography enabled real-time identification of the extra-hepatic biliary anatomy using a near infrared camera integrated to the robot. Its routine clinical use merits further investigations.

Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves. First European experience

Single-incision laparoscopic surgery is an emerging procedure developed to decrease parietal trauma and improve cosmetic results. However, many technical constraints, such as lack of triangulation, instrument collisions, and cross-handing, hamper this approach. Using a robotic platform may overcome these problems and enable more precise surgical actions by increasing freedom of movement and by restoring intuitive instrument control. We retrospectively collected, under institutional review board approval, data on the first 25 patients who underwent single-site robotic cholecystectomies (SSRC) at our center. Patients enrolled in this study underwent SSRC for symptomatic biliary gallstones or polyposis. Exclusion criteria were: BMI > 33; acute cholecystitis; previous upper abdominal surgery; ASA > II; and age >80 and <18 years. All procedures were performed with the da Vinci Si Surgical System and a dedicated SSRC kit (Intuitive). After discharge, patients were followed for 2 months. These SSRC cases were compared to our first 25 single-incision laparoscopic cholecystectomies (SILC) and with the literature. There were no differences in patient characteristics between groups (gender, P = 0.4404; age, P = 0.7423; BMI, P = 0.5699), and there were no conversions or major complications in either cohort. Operative time was significantly longer for the SILC group compared with SSRC (83.2 vs. 62.7 min, P = 0.0006), and SSRC operative times did not change significantly along the series. The majority of patients in each group were discharged within 24 h, with an average length of hospital stay of 1.2 days for the SILC group and 1.1 days for the SSRC group (P = 0.2854). No wound complications (infection, incisional hernia) were observed in the SSRC group and in the SILC. Our preliminary experience shows that SSRC is safe, can easily be learned, and performed in a reproducible manner and is faster than SILC.

Single-Port Robotic Cholecystectomy

To report our results from a first human use clinical study with the da Vinci Surgical single-site instrumentation in patients with gallbladder disease and to perform a retrospective comparison with traditional multiport laparoscopic cholecystectomy. Ten patients underwent robotic single-port cholecystectomy performed with the da Vinci Si robot and novel da Vinci single-site instrumentation. Outcomes and operative times were compared with patients undergoing traditional multiport laparoscopic cholecystectomy during the same period. Tertiary care Veterans Administration hospital. Outpatients older than 18 years with an American Society of Anesthesiologists class of 1 to 3, no prior upper abdominal surgery, and diagnosis of noninflammatory biliary disease. Single-site robotic cholecystectomy. Operative time, complications up to 30 days, pain scores, and overall satisfaction. Nine of 10 patients had completion of robotic single-site cholecystectomy. Average operating room time was 105.3 minutes compared with an average of 106.1 minutes in the standard laparoscopic group. There were no serious adverse events in the robotic surgery group, with an average follow-up of 3 or more months. Robotic single-port cholecystectomy is feasible and comparable with standard laparoscopic cholecystectomy in the Veterans Administration medical center setting.