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In 1985, Prof. Dr. Erich Mühe of Germany performed the first laparoscopic cholecystectomy and began a new era of minimally invasive surgery in the field of general surgery. Laparoscopic cholecystectomy (LC) proved that minimally invasive surgery could reduce morbidity and speed recovery for patients. It has become the standard of care for all varieties of biliary procedures, including acute and chronic diseases of the gallbladder and biliary tree. Its success then led to the development of minimally invasive procedures for most intra-abdominal operations.
A second revolution in general surgery began when robotic instrumentation was added to the laparoscopic techniques. Robotics added three-dimensional vision and wristed instruments, improved ergonomics and scalable movements, and incorporated advanced bipolar, stapling, and fluorescence imaging technologies.
Just as LC led the development of laparoscopic general surgical techniques, robotic multiport cholecystectomy (RMPC) has been the gateway through which most general surgeons have entered robotic surgery and has been applied to the same indications as LC.
Now that more than a million procedures have been performed across a variety of surgical specialties, robotic surgery has been accepted as a viable new technology. It has also provided valuable experience that has helped surgeons progress to new, advanced robotic techniques.
When applied to cholecystectomy, the three-dimensional vision and wristed dexterity afforded by robotic instruments can aid with dissection, especially in complex operations such as for acute cholecystitis and chronic scarring or when dealing with adhesions from previous operations. The addition of fluorescence imaging with the robotic camera system adds enhanced visualization of the biliary anatomy, aiding in identifying and dissecting anomalies of the biliary tree.
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.
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:
Force Bipolar for grasping
Monopolar hook for dissection
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.
A disposable 5-mm optical trocar for initial entry
Three robotic 8-mm trocars
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.
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