Robotic Versus Open Extrahepatic Biliary Reconstruction for Iatrogenic Bile Duct Injury

Emergency robotic surgery: the experience of a single center and review of the literature

BACKGROUNDS

Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review.

METHODS

We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases).

RESULTS

36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%.

CONCLUSIONS

Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.

Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective?

BACKGROUND AND OBJECTIVES

We aimed to describe our outcomes of robotic resection for perihilar cholangiocarcinoma, the largest single institutional series in the Western hemisphere to date.

METHODS

Between 2016 and 2022, we prospectively followed all patients who underwent robotic resection for perihilar cholangiocarcinoma.

RESULTS

In total, 23 patients underwent robotic resection for perihilar cholangiocarcinoma, 18 receiving concomitant hepatectomy. The median age was 73 years. Operative time was 470 min with an estimated blood loss of 150 mL. No intraoperative conversions to open or other intraoperative complications occurred. Median length of stay was 5 days. Four postoperative complications occurred. Three readmissions occurred within 30 days with one 90-day mortality. R0 resection was achieved in 87% of patients and R1 in 13% of patients. At a median follow-up of 27 months, 15 patients were alive without evidence of disease, two patients with local recurrence at 1 year, and six were deceased.

CONCLUSIONS

Utilization of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with excellent perioperative outcomes. Further studies are needed to determine the long-term oncological outcomes.

Delayed Repair of E2 Bile Duct Injury With Robotic Roux-en-Y Hepaticojejunostomy

Bile duct injury is a rare complication in the modern era of minimally invasive laparoscopic and robotic surgery; however, it can lead to serious short- and long-term consequences. Repair of bile duct injury with Roux-en-Y hepaticojejunostomy is a technically complex operation, especially when undertaken laparoscopically. Newer robotic technology improves surgeon's dexterity for fine suturing tasks such as in creating a delicate hepaticojejunostomy, which overcomes technical limitations of conventional laparoscopic approach. As surgeons accumulate more experience in minimally invasive bile duct surgery for benign and malignant diseases, the accepted surgical approaches gradually transition from open to robotic technique. In this video, we describe our robotic technique for delayed repair of an E2 bile duct injury.

Impact of Intraoperative Nefopam on Postoperative Pain, Opioid Use, and Recovery Quality with Parietal Pain Block in Single-Port Robotic Cholecystectomy: A Prospective Randomized Controlled Trial

Background and Objectives: This study explored how nefopam, a non-opioid analgesic in a multimodal regimen, impacts postoperative pain, opioid use, and recovery quality in single-port robot-assisted laparoscopic cholecystectomy (RALC) patients with a parietal pain block, addressing challenges in postoperative pain management. Materials and Methods: Forty patients scheduled for elective single-port RALC were enrolled and randomized to receive either nefopam or normal saline intravenously. Parietal pain relief was provided through a rectus sheath block (RSB). Postoperative pain was assessed using a numeric rating scale (NRS) in the right upper quadrant (RUQ) of the abdomen, at the umbilicus, and at the shoulder. Opioid consumption and recovery quality, measured using the QoR-15K questionnaire, were also recorded. Results: The 40 patients had a mean age of 48.3 years and an average body mass index (BMI) of 26.2 kg/m2. There were no significant differences in the pre- or intraoperative variables between groups. Patients receiving nefopam reported significantly lower RUQ pain scores compared to the controls, while the umbilicus and shoulder pain scores were similar. Rescue fentanyl requirements were lower in the nefopam group in both the PACU and ward. The QoR-15K questionnaire scores for nausea and vomiting were better in the nefopam group, but the overall recovery quality scores were comparable between the groups. Conclusions: Nefopam reduces RUQ pain and opioid use post-single-port RALC with a parietal pain block without markedly boosting RSB's effect on umbilicus or shoulder pain. It may also better manage postoperative nausea and vomiting, underscoring its role in analgesia strategies for this surgery.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience

BACKGROUND

Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes.

METHODS

This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD).

RESULTS

From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3 ± 0.5; the MELD score was 9 ± 4.1; the Child-Pugh score was 6 ± 1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272 min, and the average blood loss amounted to 79 mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4 days, with a readmission rate of 15% within 30 days. During an average follow-up period of 33 months, one patient had to undergo a revision at 18 months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities.

CONCLUSIONS

Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Minimally invasive surgery for post cholecystectomy biliary stricture: current evidence and future perspectives

Postcholecystectomy bile duct injury (BDI) remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs. Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI, the absolute number remains high as cholecystectomy is a commonly performed surgical procedure. Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent long-term results in most patients. As with many hepatobiliary disorders, a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery. Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy, laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive. While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management, most are retrospective analyses with small sample sizes. Also, long-term follow-up is available only in a limited number of studies. The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches. The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture. Despite increasing use, lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture. High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.

Systematic review: robot-assisted versus conventional laparoscopic multiport cholecystectomy

Laparoscopic cholecystectomy has become the standard of care for the treatment of symptomatic gallstone disease. In the context of the increasing uptake of robotic surgery, robotic cholecystectomy has seen a substantial growth over the past decades. Despite this, a formal assessment of the evidence for this practice remains elusive and a randomised controlled trial is yet to be performed. This paper reviews the evidence to date for robotic multiport cholecystectomy compared to conventional multiport cholecystectomy. This systematic review was performed conducted using the Medline, Embase and Cochrane databases; in line with the PRISMA guideline. All articles that compared robotic and conventional laparoscopic cholecystectomy were included. The studies were assessed with regards to operative outcomes, postoperative recovery and complications. Fourteen studies were included, describing a total of 3002 patients. There was no difference in operative blood loss, complication rates, incidence of bile duct injury or length of hospital stay between the robotic and laparoscopic groups. The operative time for robotic cholecystectomy was longer, whereas the risk of conversion to open surgery was lower. There was marked variation in definitions of measured outcomes, and most studies lacked data on training and quality assessment, leading to substantial heterogeneity of the data. Available evidence on multiport robotic cholecystectomy compared to conventional laparoscopic cholecystectomy is scarce and the quality of the available studies is generally poor. Results suggest longer operating time for robotic cholecystectomy, although many studies included the learning curve period. Postoperative recovery and complications were similar in both groups.

Online calculators for predicting the risk of anastomotic stricture after hepaticojejunostomy for bile duct injury after cholecystectomy: a multicenter retrospective study

BACKGROUND

Anastomotic stricture is a common underlying cause of long-term morbidity after hepaticojejunostomy (HJ) for bile duct injury (BDI) following cholecystectomy. However, there are no methods for predicting stricture risk. This study was aimed at establishing two online calculators for predicting anastomotic stricture occurrence (ASO) and stricture-free survival (SFS) in this patient population.

METHODS

The clinicopathological characteristics and follow-up information of patients who underwent HJ for BDI after cholecystectomy from a multi-institutional database were reviewed. Univariate and multivariate analyses of the risk factors of ASO and SFS were performed in the training cohort. Two nomogram-based online calculators were developed and validated by internal bootstrapping resamples ( n =1000) and an external cohort.

RESULTS

Among 220 screened patients, 41 (18.64%) experienced anastomotic strictures after a median follow-up of 110.7 months. Using multivariate analysis, four variables, including previous repair, sepsis, HJ phase, and bile duct fistula, were identified as independent risk factors associated with both ASO and SFS. Two nomogram models and their corresponding online calculators were subsequently developed. In the training cohort, the novel calculators achieved concordance indices ( C -indices) of 0.841 and 0.763 in predicting ASO and SFS, respectively, much higher than those of the above variables. The predictive accuracy of the resulting models was also good in the internal ( C -indices: 0.867 and 0.821) and external ( C -indices: 0.852 and 0.823) validation cohorts.

CONCLUSIONS

The two easy-to-use online calculators demonstrated optimal predictive performance for identifying patients at high risk for ASO and with dismal SFS. The estimation of individual risks will help guide decision-making and long-term personalized surveillance.

Minimally invasive biliary anastomosis after iatrogenic bile duct injury: a systematic review

Major bile duct injuries (BDIs) may require complex surgical repairs that are usually performed with a conventional open approach. This study aims to analyze current evidence concerning the safety and the outcomes of the minimally invasive (MI) approach for biliary anastomosis in post-cholecystectomy BDIs. A systematic search of MEDLINE, Embase, and Web-Of-Science indexed studies involving MI (laparoscopic or robotic) biliary anastomosis in patients with iatrogenic BDIs was performed. The quality of the studies was assessed using the MINORS criteria. A total of 13 studies involving 198 patients were included. One hundred and twenty-five patients (63.1%) underwent a laparoscopic biliary anastomosis, while 73 (36.1%) received an analogue robotic procedure. All the included BDIs were types D and E (E1-E5). The mean OT varied between 190 and 330 (mean = 227) minutes. Ten studies reported the mean intraoperative blood loss that ranged between 50 and 252 (mean = 135.9) mL. No conversions occurred in the robotic series, while four patients required conversion to open surgery among the laparoscopic ones. The mean length of postoperative hospital stay was 6.3 days. The reported overall morbidity was similar among the robotic and laparoscopic series. During the follow-up period, no surgery-related mortality occurred. A growing number of referral centers are showing the safety and feasibility of the MI approach for biliary anastomosis in patients with major BDIs. Further prospective comparative studies are needed to draw more definitive conclusions.

Current status of robotic surgery for hepato-pancreato-biliary malignancies

INTRODUCTION

Robotic surgery is an emerging aspect of gastrointestinal surgery. Hepato-pancreato-biliary surgery is currently being explored for a broad spectrum of indications, entities, and postoperative outcomes. Noninferiority and financial aspects are the focus of studies. In this review, the impact on oncological therapies is assessed.

AREAS COVERED

An extensive literature review was conducted, and relevant studies and articles and reviews for robotic surgery in the field of hepato-pancreato-biliary surgery were examined. Special attention was given to the oncological aspects of robotic surgery and its possible impact on the therapy of malignant neoplasms.

EXPERT OPINION

Robotic-assisted surgery for oncological indications is promising, in part, an established technique that has already shown its advantages in the last decade, although high-quality studies are missing. Upcoming experience must consider the oncological benefit and putative new indications in a rapidly changing field of anti-neoplastic regimens. Also, robotic surgery may possess the ability to accelerate digitalization and AI-based augmentation in this context.

Does Preoperative Thrombocytopenia in Patients Undergoing Robotic Hepatectomy for Liver Tumors Predict Poor Outcomes? A Propensity-Score Match Analysis

INTRODUCTION

Thrombocytopenia is a known surrogate marker for cirrhosis and portal hypertension and has been associated with increased risk of poor perioperative outcomes when studied in "open" operations. This study was undertaken to assess thrombocytopenia as an independent risk factor for undesirable perioperative outcomes after robotic hepatectomy.

METHODS

We retrospectively reviewed 279 patients who underwent robotic hepatectomy at our institution. Patients were stratified into two cohorts based on preoperative platelet counts. Thrombocytopenia was classified as having a platelet count less than 150 /μL. Patients were 2:1 ratio propensity-score matched based on IWATE score and age. Data are presented as median (mean ± SD).

RESULTS

Thirty-six patients with thrombocytopenia were matched to 72 patients without thrombocytopenia. Patients with thrombocytopenia had higher MELD scores [p = 0.02] and higher Child-Pugh Scores [p <0.001]. Intraoperatively, patients with thrombocytopenia had shorter operative duration [p = 0.03] but similar estimated blood loss (EBL) [p = 0.78]. Postoperatively, there were more fresh frozen plasma transfusions in patients with thrombocytopenia [p = 0.04]. There were no differences in IWATE scores, tumor size, conversions to "open" operations, intraoperative complications, patient length of stay (LOS), Clavien-Dindo score ≥ III complications, perioperative RBC transfusion, in-hospital mortality, or 30-day readmissions.

CONCLUSIONS

In our propensity-score matched study, patients with thrombocytopenia had more severe liver disease; however, there were no differences in their EBL, LOS, or perioperative complications. Preoperative thrombocytopenia, while being an indicator of severity of liver disease potentially promoting perioperative bleeding, does not negatively affect the perioperative course of patients undergoing robotic hepatectomy.