Robotic multiport cholecystectomy

Patient selection

RMPC can be performed on a variety of types of patients and for a variety of biliary diseases. Although some surgeons restrict the use of RMPC to complex cases, these criteria may be inappropriate because it is difficult to predict which patients will have complex findings, and elective cholecystectomies often prove to be more challenging than anticipated. Even in low-complexity cases, the advantages of improved visualization and instrumentation can improve safety and efficiency.

I encourage the surgeons I train to use RMPC for all of their cholecystectomies. In addition to the patient benefits, it has been shown that RMPC is a good tool for helping surgeons develop the robotic skill set required for more complex surgical procedures. It has also been shown that low-volume robotic surgeons experience significantly more complications, longer lengths of stay, and higher costs of care. As cholecystectomy is typically a high-volume procedure for general surgeons, it can be a good tool for raising robotic case volumes and improving outcomes overall. Certainly, the additional experience is valuable for the surgeon, but I believe that the improved outcomes also result from the additional experience gained by operating room staff in high-volume robotic centers, improving the quality and efficiency of all robotic procedures performed across specialties.

To gain robotic experience, I recommend that surgeons begin their robotic cholecystectomy experience using all four robotic arms so that they can practice using the fourth arm to provide their own retraction, a skill that is essential for more advanced procedures. Once proficient with the robotic platform, they can switch to the three-arm technique, using a bedside assistant to retract the gallbladder fundus superiorly, saving the expense of the additional robotic instrument. Both options will be described here.

Required equipment

Both the da Vinci Si and Xi platforms can be used for RMPC. All wristed robotic instruments can be used in this technique as desired. Monopolar and bipolar cautery instruments are available for hemostasis. Robotic bipolar instruments include the Fenestrated Bipolar, Force Bipolar, and Bipolar Maryland ( Fig. 26.1 ). Bipolar energy is especially useful for managing the bleeding that results from a torn cystic duct artery or the posterior branch of the cystic artery, or from the liver bed, all of which can be especially problematic with monopolar cautery alone. Most general surgeons are not experienced with bipolar cautery because the monopolar hook or spatula have historically been popular for LC, so additional training and experience with the robotic bipolar instruments is essential. Once the use of bipolar energy is mastered, it becomes useful for many other procedures where bleeding from the mesenteric or short gastric vessels and other causes of significant bleeding can be controlled quickly.

As with LC, creating a standard set of instruments that can be used for all cholecystectomies will reduce cost and improve efficiency. Have this limited set of instruments open on the sterile field for every cholecystectomy, including a grasper, dissector, and clip applier. My preferences are the Force Bipolar, Monopolar Hook, and medium-large clip applier ( Fig. 26.2 ).

Limiting instruments allows for efficient back table setup ( Fig. 26.3 ). The entire setup includes:

• 1.

  Force Bipolar for grasping

• 2.

  Monopolar hook for dissection

• 3.

  Medium-large clip applier. Two clip appliers are opened for efficiency so that one can be reloaded while the other is in use. As clip appliers are charged per use, this does not add expense.

• 4.

  A disposable 5-mm optical trocar for initial entry

• 5.

  Three robotic 8-mm trocars

• 6.

  A standard set of reusable laparoscopic and open instruments is also routinely opened for retracting and retrieving the gallbladder and closing the incisions.

We have additional less frequently used instruments nearby, individually wrapped sterilely, and ready to be opened for special circumstances ( Fig. 26.4 ). Maryland dissectors, bipolar or unelectrified, are helpful for difficult dissection around ductal and vascular structures. Cobra graspers are effective for grasping the thickest gallbladders. The dual blade retractor can retract the liver or fatty tissue. The suction irrigator is wristed, and both suction and irrigation are controlled by the surgeon and can be used to maintain a clear field, as well as for blunt dissection, retraction, and hydro-dissection. Staplers are occasionally required for transecting and ligating very thick cystic ducts.