Robotic single-site cholecystectomy

Indications

Laparoscopic cholecystectomy has been the standard for removal of the gallbladder since the 1990s. Attempts to introduce single-incision cholecystectomy in order to improve cosmetic outcomes were met with difficulty due to struggles during surgery, prolonged operative times, and inability to apply to all patients. In 2011, Intuitive Surgical, Inc. (Sunnyvale, CA, USA) released the single-site platform to overcome all these limitations. It was a novel platform that included a silicon port and curved cannulas/trocars, which accommodate semirigid trocars. These components allowed recreation of the triangulation important for safety in minimally invasive surgery.

Indications for cholecystectomy using the robotic single-site platform are similar to those for conventional laparoscopic cholecystectomy. Although there is no absolute limitation for elevated body mass index (BMI), when BMI reaches the 50s, the thickness of the abdominal wall makes placement and maintenance of the port difficult. The extent of the gallbladder disease will also influence the complexity of the procedure. A preoperative diagnosis other than biliary dyskinesia or symptomatic cholelithiasis will make the cholecystectomy more challenging and increase the probability of a postoperative complication. This platform has also been used for patients with more extensive gallbladder disease, such as acute cholecystitis and biliary pancreatitis.

Prior abdominal surgeries need to be considered in the planning of surgery and selection of the approach. A previous midline incision does not disqualify the patient from an attempt to use the robotic single-site approach but must alert the surgeon that abdominal access via a different approach may be needed.

Patient preparation

Education before surgery is important to set expectations for the postoperative course. Therefore, careful description of the surgical procedure, risks, and benefits should be shared with the patient. Explanation of the operative time, recovery, and return to daily activities are discussed with the patient and family as appropriate. Patients are asked to bath with 4% chlorhexidine (Hibiclens, Norcross, GA, USA) the night prior to and the morning of surgery. They also should be fasting for no less than 12 hours prior to the induction of general anesthesia.

Patients are also asked not to shave any body hair as this will be clipped in the hospital preoperative suite. Antibiotic prophylaxis should be prescribed to all patients via the intravenous route when en route to the operating theater. Indocyanine green (ICG 2.5 mg/5 ml) is given at least 45 minutes prior to incision in the preoperative suite in order to obtain adequate excretion in the biliary tree.