Robotic-Assisted Laparoscopic Interval Cholecystectomy

CHAPTER 1

Hi, I am Charu Paranjape, I am the Chief of General Surgery and Acute Care Surgery here at Newton Wellesley and also a staff surgeon at Massachusetts General Hospital. Today we are gonna see some of the key aspects of a robotic laparoscopic cholecystectomy, which is the removal of the gallbladder, done through the robotic approach. The key steps of the surgery would be: access to the abdomen, the dissection of what we call the critical view, and then clipping of the duct and the artery followed by removal of the gallbladder from the bed of the liver.

CHAPTER 2

A little background, he had acute cholecystitis not too long ago and had many days of symptoms and on imaging it showed like a very advanced acute cholecystitis with a very thickened gallbladder wall and history that was more than a week. And when we see that, typically, the risk of having a minimal invasive surgery go open is significantly higher in those situations. And so typically, we like to see how they do with antibiotics and then do what's called the interval cholecystectomy, which is what we are doing today. So, we know that there will be significant inflammation, but hopefully with the antibiotics that he got, it will not be that bad. Symptomatically, he's feeling a lot better in that he was able to sort of go back to work in the meantime. And so, we're hoping that the inflammation will be significantly less. Now today, we're doing it robotically instead of laparoscopically, and that is the, sort of the teaching point is that most of the times, because the inflammation is pretty significant, I think the robot has a significant value to help in doing it as minimally invasively and doing it relatively straightforward fashion compared to laparoscopic. So, we will see, but that's why he's, this case has been chosen to be done robotically. So I just go straight through the belly button. There, this knife to her. It's a little dirty - lap. It's gonna be here. Straight to the jaws, all the way down to like here. To all the way to the base, yeah. Incision at 23. So this is one way of getting into the abdomen is transumbilical. It's relatively faster and also cosmetically much more pleasing. And go down here and go up or you can go here to do down. Okay, this is yours. Keep the knife now. No, no, keep the knife. Gonna connect the dots. Take the Schnidt. And keep everting that. And, fat in the middle is your target, which you're gonna divide in half. So keep going. All this stuff, yeah, this is just yeah, skin, yeah. And then keep everting this guy, and this I keep all the way - this is, the target is here. So yeah, keep everting. So I would go right there in the middle, correct. I'll take the second Schnidt. Keep that in second. So this way you're quickly into the abdomen. Right there. I'll take a Kocher. I'll take the port. There's the 9 or the 8 port? 12, I guess. And take this guy. Can we have reverse T about 12 degrees, please? Camera, please. I'll take the reducer. And then table down all the way. Thank you. So the port placement is similar to laparoscopic but just typically in one line. So at least one fingerbreadth here. I'll take the knife. It just looks like a little adhesion there. So the incision is from - it's a classic McBurney's incision. And this one you can cheat a little bit. So I'm gonna go here - a little bit. So it's just a flimsy incision there. So you need at least like another fingerbreadth, so it can go like there. Okay, put - okay, another one. So we're controlling the entry with the left hand - we'll trade. So then Claire is gonna put one, typically another fingerbreadth, so it's like somewhere here. Let me clean my camera. Transfer's eight. Do you mind if I level him out? Yes, of course. His blood pressure is kind of... Yeah, no problem. Do you want us to lower the pneumo? Yes. Yeah, keep going. Yep, you're good. We can - we can come in.

CHAPTER 3

So Trong, I've opened that port just to let you know. When she's in, then you can close the port. Can we have a reverse T of whatever he can tolerate? Yeah, I'm just gonna check one more blood pressure. Okay. 10 degrees will be also good. Okay. Thanks. Should I wait until... No, we can keep going. Yep, yep. Do you wanna - do you want to clean it once? Yeah. Yeah. Right here? Yep. So you can already see the gallbladder is a little angry and also edematous. So, showing that it's inflamed. The choice of instruments here can be different. Typically, some people use the camera in number two and then use the number four arm to retract the gallbladder over the liver. I like to do it the traditional way where we'll have two graspers in number one and number two, and then typically a Maryland for the dissection in number four. Watch the tip of that cannula, please. It needs to be in the view, please. So I just find this just like a natural progression from laparoscopic because the grips and their grasps are similar. Like I said, some people have the camera in two and then they use the number four to retract the fundus up over the liver.

CHAPTER 4

I'm just gonna get started for you. So I'm gonna use this arm to... You can see here already, there is some adhesions there. Is my Maryland hot? Yes, your Maryland's hot. It's on three though. So these are the telltale signs, obviously, of the pretty significant inflammation from before. May have to burp my number one? Okay. Whenever you're ready. Yep. Okay, bumping. You can see the gallbladder is partially covered in the - adhesions. So there is recent - as you know, there is the Parkland classification of the severity of the disease. Might need the neuro pattie. Okay, we got some. Like I said, this is, you know, I'm using my wristed instruments here to expose this is laparoscopically significantly difficult.

CHAPTER 5

The lateral part is always safer, as you can see here, you don't see anything clearly. So, we're gonna start laterally because we know it's pretty safe... To define. So most likely, or what you can see is, this is the lymph node most likely there. I'll take the neuro pattie when you get a chance. Again, I'm not completely dissected yet, but this is a lymph node and typically the artery's right behind the lymph node, as we know. And so that's one landmark that's very important in difficult cases. And so I'm gonna hold the gallbladder laterally, and this helps me many times as you can see. So it's sort of a blunt dissection. It's just like what you would do with a peanut, you know? One of the things robotically is that you really don't know how hard you're pulling. And so it's very important to look at the tension of the tissues as you do this. And you can use this to your advantage and kind of do this a few times. It looks like a nothing move, but I do this even laparoscopically with a Kittner, and it actually opens up that plane, most of the time. So again, what we just did, you know, laparoscopically again, it's a little bit harder to do because we have wristed instruments here, and so it's slightly easier to just do what we just did. So, you can see the artery, it's right here. And it's most likely just like in front of the duct. I'm using this blunt dissection. I'm gonna do that medially just to see... All this tissue. As you can see, again, significant inflammation here. Setting the duct is behind. Right there. When in doubt, go back to the basics, right? So you're gonna just open up the back wall. It's very scarred in. I mean this could be CBD tented up. And I think it is. See that? Look at this, right here. So, you know how it's tenting... And this is how, you know, the bile duct injuries happen, that you, you know, tent it up and then you think this is the cystic. If we were not to dissect this, you'll feel like this is the cystic. It's very, you know, tented, it's very teased. I think this is the cystic. It's very short and stubby, you know? It's very... See that? Yeah. So the artery is anterior. We still have to clean all this stuff to make sure there's nothing else. Cannot be more than two things. Can I have a fresh neuro pattie? Yeah. And this still is like, as you can see it's looks very chubby here, right? Okay. You can take this guy and give us a new one. So I'm gonna work on this here to make sure that this is all nothing. We have the base of the gallbladder. It's probably a posterior branch here, right here? I'm trying to clear this. So this could be a little posterior branch, but we'll define it a little bit better. What was that? Your fourth left pull arm hit your camera. Okay, so we have liver here. The base of the gallbladder here. We have probably a post- very tiny posterior branch here. This is the artery, and this is the duct. I'm just gonna expose the base of the gallbladder a little bit. We can see this is the base of the gallbladder here. I mean you can look at this thing from the other side, but other than that I think we have the view. Do you agree? Sure. Which one? This? That's probably a posterior branch. I'll take a new pattie again. Neuro pattie out. All right, there we go, better. You can see that much clearly now, right? So this is the base of the gallbladder right there. The posterior branch is also dividing actually, in there. This is the... So, this is the anterior cystic, duct, posterior branch, and base. Okay, you agree? Any questions? Would you do anything more, less? Comments, Claire? No. You're happy? You happy with this? Yeah. Yeah? Good? Okay.

CHAPTER 6

We're gonna take the clips, and then she'll take over. Okay. Okay. All right, coming out? Yep. Coming in. All right, coming out. Coming in. Probably take scissors after this just to get that artery out of my way. - [Male Voice] Okay. Coming out. Coming out with scissors. Coming in. Coming out. Yep. Take three clips. Yes? Yep. Sorry, we were just struggling with the clip. Okay. Let me tell you, this would be very difficult laparoscopically. Scissors. Okay, coming out. Coming in. Scissors with no heat. Okay. Coming out. Okay, we can have heat on the scissors. Okay.

CHAPTER 7

Okay, so over to you. So you're gonna be in this plane, here. You should be able to just take your time. Just don't get into the gallbladder. So you can see the edema. Yeah. I can see it's still very, very inflamed. So the advantage here, Claire, is you can really pull with your left hand now that everything is free. You can really pull at the same time. Use your wrist here. Try to do this if you want, like do this, and you can have this angles there, you know? Again, this is harder laparoscopically. Here you can stay in that plane. It's almost like the perfect... Take your time. Turn it over. Do we have the smoke evacuator or? Yep, it's on. Okay, all right. You have high flow. Okay. Ready? Start here, just do this one first, yeah. Yep. Yeah, I would complete that. Zoom in just a touch. Keep it in the center and kind of... You can zoom in a little bit there if you want to. Do you want this open, or...? Yep. Right here. I would grab it here, lower, grabbing here is not gonna be helpful. Zoom in. Right there. You can see that clear plane right there. Just keep it steady on your left hand. Don't try to move too much. You got a nice thing, just keep going where you have the plane. So you're way over there, and this is all like superficial so I would, you know, do this first right here and then maybe even flip it. So wait, you can't see so just flip it. Just, just, you know, don't have to go in the clot. Yeah, start there, exactly. Easy, slow. Do you have a neuro pattie to clean, if you want to clean? Yeah, there you go, yeah. Don't want to get into the gallbladder. You're doing so well. Okay, it's okay. You can continue this way if you want, that's easy. And all the way if you want, yeah. That's the plane, correct? Yeah. Let it separate on its own. Yep. Just keep working there, yep. You can clean your tips if you want. Maybe go anteriorly and see. Here, I would suggest, let me just show you what I mean and then you take over. Since you're struggling there a little bit. What I would do is just, you know, do the easy part first, right? So, see what I'm doing? So, I know that this is gallbladder here, so I'm just gonna, you know, go in this plane that I know it's good, you know? Like right here. I think the plane is like right here. This is the hepatic capsule actually. Ah, almost. Can you suction? Yep. Can I take out your trigger? Yeah. Thanks. Go ahead and suction there for a minute. Yep. Oh, suction right there. Suction. Yeah. Perfect. I'm trying not to suck all the... That's okay. Yeah. All right, good. It's good. Suction here, right there. So I think this is, it's like, such a fine plane. Like here's the hepatic capsule like right there. And then this is the plane right there. Okay, I'll take the scissors back. Actually can you suction one more quick time? Inside too, yeah. Okay. Yeah, yeah, yeah. I'll take the scissors. Smoke evac is still on. What's the...? If it's on, can you put it on 300? Can you put it to 350? You think here? We will probably need a little suction here just to clean stuff. Okay. One sec. Yeah, go ahead. More here up top. Okay. Do you want scissors back? Yeah. So I'm gonna just stay on top of the liver here. Big stone there. We're crossing for no reason. Need a little suction and then this thing back again. It's big, very ratty, and that's why it looks like that. But it's like, you know, 50 CC. Yeah. Yep. I think we have a stone there. Yeah, just make sure we remember that. Yep. Two stones, right? Can we clean the tips of this? Don't go in the liver, yeah. Sorry Claire, it was sort of not optimal. The liver is so friable. Smoke evacuator seems to be a little bit... 370 maybe? You're gonna be ready for the camera? Yep.

CHAPTER 8

Okay. Okay. All right, coming out the fourth. You give me another instrument. Don't close, we have a couple of stones here. This you can remove differently. I need an instrument rather than scissors. Okay, coming out with your scissors then. Yeah. Can you clean the camera also? Okay. There are a couple of stones here, but we have to suction here first. Just laterally, stay lateral. Don't go close to the clips, yeah. I think your thing is clogged. Suction will never hide, one for that smoke evacuator thing. All right. We can undock. A couple of stones here, actually. I would like to get that. So as you can tell, very inflamed, extremely inflamed gallbladder wall. And like I said, you know, not easy laparoscopically, most likely we would have opened. Because you don't get that view. And then when there is a small hole, it becomes a big hole. That's a usual story. But I'm glad we stayed laparoscopic. Yeah. And can you give him an instrument? So if you can come in and just hold the liver, yeah. Can you depress this a little bit? The suction is really, really weak. Like, I don't know, even now it's weak. This is just irrigation. Still weak. Can we put it on 350 or something? It's actually not bad. Look at the - I mean it's pretty clear. I just wanted to see if I can see those couple of tiny stones that were there. Be careful there what you're retracting. And it wasn't like - it looked on the thing very magnified and the bleeding - it was not nothing. That's fine. Yeah. Less than... I would say less than - yeah, maybe 50. I don't see any big stones. Do you? We could look around. I don't see any. Yeah, I think it was just very magnified on the, we got the big ones in the bag. I'll take the rest. Can you level him? Wait for the rest - I want to make it really dry. So I would wait. I'm gonna take it from my port. Okay. Then I have a straight shot. Okay, can you zoom out and show me this port? Can you hold that port? Yeah. And direct it towards the liver, please. Yeah, keep directing. You have to direct. Yeah. Direct it up. Yes. Zoom in. No, with the... Yeah, perfect. Yeah, that's it. All right. Local on the needle.

CHAPTER 9

How much are you gonna use up this time? That hundred. The full hundred? Yeah. Okay. So 50 plus 50. How much does he weigh? He weighs 67. Oh yeah, so 50 for 50. Yeah. More than 50. Okay, more local. I don't know if you can look here. Maybe use this guy. So this is the laparoscopic TAP block that we're administering to the anterior abdominal wall to decrease postoperative pain. And the principle here is you take the needle and go almost into the preperitoneal plane, then come back a little bit, and now you can see the transversalis kind of getting raised. The neurovascular bundle is between the transversalis and internal oblique. So this way you are injecting in that plane to sort of, you know, give the anesthesia to the anterior abdominal wall. Nice, yeah. So half of it on that spot and then half lower. So I think a little bit in the preperitoneal plane there. So you come back a little bit. You can choose another point if you want to, yeah. Okay, go there. Let's go here. Okay, yeah. There, okay, that's fine. Yep. Just inject all of it, yep. Gas off and all lights on, please.

We can use that for the fascia, to increase the fascia. It's a big stone and big gallbladder. We need two S retractors and table up, please. And we need him relaxed for just like 10, 15 minutes. Thank you. Thanks. Is it up and on? Okay, let's do it on this side as well, I think. You get the stones if you want. Like to squeeze the stones in the upper part. You think skin? No, just a big gallbladder. All right, we'll listen to Trong. Or Bovie. God, feel that. All right, now that we have made a little bigger incision, we're gonna close the fascia with multiple sutures. So Kochers times two. All right, stitch. So we'll do one up top one in the bottom. So we'll do two bigger, away, yeah. Let's go under here maybe, yeah. Hemostat that? And another one. Don't cut it, yeah, just snap. Yeah, snap. Now you wanna hold this guy, maybe? Yeah. And show you the corner. I think it's all the way. Let's regrab. So if you wanna regrab this with the Kocher. And I'll go here and then we'll do a third one to hit this? We'll need another stitch. Okay, let's clean that corner, yeah. The new stitch. I think it's the layer below. Wait one second. Let me regrab this. I would tie this one first. Yeah, go ahead. Yeah. You start up here? Yeah. Each suture has a needle. I think this is like caught in something. Let me... Don't cut yet. Don't cut. We'll cut at the end. S retractor, please. And the fascia's closed. Four, five. Okay, so can we do another one? Okay. So keep that one. But these two you can cut Or maybe even actually cut this guy. Just this guy. Okay reload the needle on those and just incorporate the skin. Thank you. So essentially this creates the belly button. Essentially you're gonna do this so you can take yours. Sure. Yeah. And it will be the top part of the belly button for you. Yeah. One, two. Yep. You have your two? So, okay, you're gonna close this to that. So you've got one side, you're gonna get the other. But before that, let me do this side here. Okay, you can cut. No tail, please. Perfect. Needle back. 4-0, it's right there. Sorry. Cut mine, please. Thank you. There's that needle back. I'll take a 4-0.

CHAPTER 10

So as you saw, the procedure went well. The key difference between a robotic approach with a laparoscopic approach is essentially the visualization of the gallbladder and the essential structures, and importantly, some of the wristed movements that we have inside the abdomen. Most of the gallbladder surgery, as we know, is done laparoscopically. However, for individuals who have higher BMI or those who have a very big liver, where the gallbladder is difficult to retract over the liver or essentially those patients who have had previous interventions such as percutaneous cholecystostomy have a significant advantage when we do this robotically. Patients who have had previous cholecystostomy tubes placed have significant inflammation and which makes the dissection significantly difficult. However, with robotic approach we can see that this dissection and the critical view, is far easier compared to the laparoscopic approach.