Robotic Cholecystectomy for Porcelain Gallbladder and a 6.8-cm Stone

CHAPTER 1

I am Rushin Brahmbhatt. I'm an HPB surgical oncologist here at Penn State Hershey Medical Center. The case we're about to see is a 72-year-old woman who presented to me with imaging evidence of a porcelain gallbladder as well as a large gallbladder stone. So she initially presented with some vague epigastric discomfort symptoms. She was evaluated with some imaging which demonstrated calcification of the wall of a gallbladder, and she was referred to me for consultation regarding porcelain gallbladder. The main indication for initial consultation was really the porcelain gallbladder and concern for malignancy. So we know that patients who have calcification of the wall of gallbladder can have increased risk of underlying malignancy or lifetime risk of malignancy. In this setting, there is some literature to the effect that the appearance of that calcification can be related to the risk of malignancy. In particular, complete wall calcification is associated with a slight increased risk of gallbladder adenocarcinoma, whereas selective mucosal calcification can be associated with even a higher risk of malignancy. In order to ensure that we had adequate workup prior to proceeding to the operating room, we obtained an MRI as well. This demonstrated a large 6.8-centimeter gallstone within the gallbladder. She was relatively asymptomatic from this; however, she did have those epigastric discomfort symptoms. With the gallstone present as well as the porcelain gallbladder, I recommended proceeding with cholecystectomy. My approach for cholecystectomy is minimally invasive, so either laparoscopic or robotic. In this situation, I proceeded with a robotic cholecystectomy. The outcomes of robotic and laparoscopic cholecystectomy can be fairly comparable. However, there are some benefits to the robot in terms of degrees of freedom and also surgeon-related factors. There have been two larger studies recently that have compared robotic to laparoscopic cholecystectomy. In one, there was identification of an increased risk of bile duct injury with robotic compared to laparoscopic cholecystectomy. However, there is some controversy about whether that difference is clinically significant. And then there was a more recent study that evaluated a cohort of patients that underwent cholecystectomy in 2022, which is also after a lot of the learning curves that influenced the results of the prior study. And that demonstrated that there was a significantly lower rate of conversion to open from robotic as compared to laparoscopic cholecystectomy. Traditionally, robotic cholecystectomy follows a similar pattern or procedure as a laparoscopic cholecystectomy. The gallbladder is grasped and retracted towards the right shoulder to expose the infundibulum and the hepatocystic triangle. The hepatocystic triangle is dissected completely. The Calot's triangle is completely cleared. The structures within the hepatocystic triangle are skeletonized. The lower third of the gallbladder is dissected away from the underlying liver to establish what's known as the critical view of safety. And the three components of the critical view of safety are dissection of hepatocystic triangle, dissection of the lower third of the gallbladder away from the liver bed, as well as identification of two and only two structures entering the gallbladder. And that is the plan to basically retract the gallbladder and dissect the hepatocystic triangle to identify our two structures which can be clipped and transected, and then take the gallbladder off the cystic plate. The difficulty in this particular case is likely going to be the presence of that 6.8-centimeter stone. That can sometimes hinder our ability to retract the gallbladder adequately. Additionally, this patient has some evidence of steatosis of the liver, which will also be something we'll need to watch out for. The critical view of safety is very well-known approach to doing a laparoscopic cholecystectomy. Its use to decrease common bile duct injuries has been demonstrated in laparoscopic cholecystectomy, and that should be translated to robotic cholecystectomy. The approach to dissection should be similar. In particular, paying attention to two elements when you're approaching robotic cholecystectomy. One is to keep your dissection above the line that goes from Rouviere's sulcus to the peritoneal reflection at the base of segment IVB, which we'll see hopefully in today's dissection, as well as establishing a good critical view of safety.

CHAPTER 2

ASIS, costal margin. We'll go somewhere around here, okay? Today, I wanna be a little bit higher because we can take advantage of this space, right? Gallbladder goes pretty low. Yeah. And so we're gonna do Pfannenstiel somewhere where we can get up there, do something like here. Okay. Can I get a ruler please? Something like here, we can go a little bit lower if we need to. This thing is 6.8 centimeters. That's how big the mass is in one direction, right? This is the maximum that our incision would need to be if we took out the... We can put in just a 12 or a eight if you have it. And we can go from there. Okay. Yeah. An eight. Hold on a second. Let me make sure. Yeah, right there. Go ahead. Knife back. Incision. A little bigger? Nope, that's good. Can we turn the OR lights down please? Perpendicular to be abdominal wall? Yup, talk yourself through the layers. Okay, this is sub-q fat. I'll twist this. That's maybe fascial, not yet, still sub-q fat. She's got about 3.8... Centimeters of that. Oh, there's Scarpa's. Good. Sub-q fat, big twists. We're gonna reach the anterior sheath. Maybe that's that. Good. Potentially. Big twists. I see some rectus. And there is posterior sheath. Peritoneum should happen. Yeah, I saw some preperitoneal fat. Keep going. There we go. That's how it should look, okay? And then you can also notice that when you move this, that'll move separately. Like that fat, right? And so that... I think that's correct this time. All right, can we get gas on please? Yeah, what you wanna really look for is that circle that you see there, plus the change in the character of the fat. Low flow. And then the fat will move relative to the tip of your trocar. Thank you. And then we can watch as we insufflate, right? We wanna look at our pressures. Pressures are a little high and that doesn't look right. Does that? Let me see here. Yeah, that looks okay. I want you to lift up a little bit so you can get out of the momentum. Right there is good. Am I just always too low? This is like five for five. Too deep you mean? Or too, yeah. Yeah, Sorry, too deep. It was just a little deep. I think even right now, we have the omentum up and if we were to go up a little bit... And then if you point the camera down, that omentum slips off the tip of that and then you can see now your tip is free, right? Okay. Now you go to free space, there's parietal peritoneum up, omentum down. So you can go free space and insert, right? Syringe. Can we go to high flow please? And go directly back in. And take a look straight down, make sure we haven't injured anything. Okay, good. Knife down. Knife's here. I did. All right. All right, let's take a look at the gallbladder. So first of all, this is a potential for a cancer. So we do look around, do a diagnostic laparoscopy. So do we see any peritoneal disease? No. Well, do a thorough diagnostic laparoscopy. Look at the right. So we can see at some point, we were insufflating the preperitoneal space, right? We see some preperitoneal gas. Small bowel looks okay. The right diaphragm. - [Rushin] Yes. And along the Falc. As we pull back, we'll see the base of the falciform ligament there. Good. And then look up the umbilical fissure. So pull back. Keep pulling back and look right there and look straight down. Yup. There you are. Okay, good. And then take a look at the left diaphragm. Amber, what do you notice about the liver? It does not look smooth and pretty. No, what does it look like? Cirrhotic. Okay. Why do you say cirrhotic? Right? Cirrhotic is a disease, but what do you see? It looks bumpy. Nodular, right? Nodular. Nodular-appearing liver. And you can see those yellow speckles in there. So this is a steatotic, nodular liver. It's fatty. Okay? Patient did not have any evidence of portal hypertension preoperatively. Okay? In general, when I do see this, I usually will get a liver biopsy so that we can assess degree of fibrosis. Okay. All right, can we get... Actually, why don't we put this port in before we change the position of the patient? Okay, knife, please. Thanks. This is... Do you want an eight or a...? An eight. So this is very much not traditional port placements for a chole or a robotic chole, right? Can we get 15 degrees, head up please? Or 15 degrees, reverse Trendelenburg please. That's 15 degrees. All right, come on back. I think what you were looking at was just a little piece of liver. All right, knife, please. I wanna go as low as I can here, but also, I wanna make sure that when my arm comes out that I'm not gonna be hitting either the leg or the anterior superior iliac spine. In thinner patients, that can be of concern. I'll take another one. So look at the origin of the port. There we go. But this is how you start the air seal, right? You can put that on, and it initiates the airs seal without having to press the button. Right? Go ahead. We're gonna hand off the laparoscopic equipment and we're gonna dock the robot.

CHAPTER 3

Unfortunately, I've trapped this underneath this. Can we get this retraction working on working arm? But you're like one of the 1 1/2 people that use this. That's great, thank you. I don't use forward to retract. I use number one. You use this to pull it up? Oh yes, I do like that when I'm doing... So we are gonna have to target, I think today because... Yeah, so why don't we target? All right, go ahead and target. We're gonna move the robot again, If you could watch the patient's tube. That's great. Raise arm two just a little bit. There we go. Go ahead.

CHAPTER 4

All right, Andy, so - you know, the principle is that we need to retract the gallbladder to visualize hepatocystic triangle, right? Okay, so we should think about sequentially, what we're gonna do, right? What does the gallbladder look like? So it looks not inflamed, right? No evidence of masses, no evidence of inflammation or injection. It's soft. Okay, great. Then we can treat this almost like a traditional gallbladder like we would do, right? So it looks like the fundus is soft enough that you could grasp, right? So what I would suggest is to do that with your tip up. And what that would allow you to do is retract it like that above the liver. Okay? Yup, exactly. Good. And what I would do is grab it across the top like that so that you can, and what it may be that you need another... Yeah, perfect. That works great, all right. So I want you to lift it up. Now, in general, the way you have it here means that the tips of your tip ups are gonna go into the liver. So I would suggest turn it 90 degrees. And what you may need to do is grab it with this so that you can set yourself up for your tip up. Grab it right at the tip and lift it up in the air towards the ceiling. Okay? Good. Now come across up here so that when you... Yup, good. Good. The other trick is that this one, when you have something that's under a little bit of tension with the tip up, what you can do is turn it 90 degrees and that increases the grip strength in that. Or what is perceived grip strength, right? Okay, so pull it up in that direction slightly more. That's good there. I think that's about as much as you can get. Look at how much tension there is. You see that? I want you to release some of the tension. Okay, that's good enough. Okay, let's go down here and push that duodenum down. Does the patient have an OG or NG tube? She does, yeah. Okay, is it on suction? -It is. -Okay, are you getting anything back? All right, Annie, one second. I'm gonna bump your camera. Okay, now, position your camera again. You can, but it's gonna be too tense. All right, so that's gonna be two tense, right? So let go of... One of the things is I think, by grabbing this, you're making the rest of the gallbladder a little tense. So maybe you might want to just open it and do the push, like we were saying. Yup. And you see how it's folding here? You may wanna do that with your tip up. So, you know, maybe we can give you a Cadiere in number four so that you can actually use that instead of the hook. Okay, I'm gonna take the hook out. Let's get the retraction set up. I sort of wanna tuck this liver back behind if possible. I don't know if that's gonna be possible. This liver's gonna be stiff. You can try but remember, the fatty liver also means that it's going to be very fragile. Actually, where this instrument is, is where I want your tip off. So why don't you take that out of the equation there. Move your fenestrated bipolar out of the way. Just move it and park it down at the bottom of the screen. Now use your two instruments to get that retraction. Imagine what's happening inside, right? That stone is falling to the bottom. I want you to kind of take advantage of that and put your instrument right there. I want you to try to move that stone. Yeah, I want you to move that stone up into the gallbladder fundus, and then retract up on. There, you see how the stone is moving up? Let go with this hand here. Now use that and push up and cephalad but just gently. Oof, don't try grabbing it. Just leave it open. Leaving it open. You're gonna end up putting your tips of your tip up into the liver, right? So do that again. No, that was good. You had the stone up. I want you to get that stone up again. Do you know what I mean by that? What? Do you know what I mean by that? Yeah, hook it up and then try to this underneath. Yeah, but you can even use your elbow. Look at me. So the stone is like this, right? I want you to open your tip ups, put it here so the stone moves up into the fundus of the gallbladder, and then you can actually use your elbow to kind of lift up like that. Okay? Okay, let go with your right hand. Yup. When you get your fenestrated tip up in there. Okay, good. Now let go with your right hand. Yup. That's okay. I want it to flop on your arm. There you go. Now retract that up because you can start to see infundibulum here. I need you to be back a little bit. I think your fenestrated tip up should be right here. Like that. You're just a little bit too deep. Yeah, it's complicated. So the purpose of this move is to get enough movement of the gallbladder. So you can see the infundibulum and the hepatocystic triangle, right? Yeah. Okay, so let me help. Let me show you what I mean and then you can get it. All right. Can you see that? So, you wanna use the stone... To put some tension... Okay. So now, what you can see down here. Now the duodenum is out of the way, right? Yeah. And you can get that view there, right? And then they're gonna get it higher up, or not really? Probably not. Probably not, all right. I think it works. One thing you could do is that you, you are gonna be fighting that stone, right? Alright. And so that's about... What you really want to do though, is get this away from the duodenum, right? You know, and what I want? Yeah, that's fine. I'll use the bipoles to play around with the infundibulum. Which is what you would do anyways, right? Infundibulum should be a bipolar... You should be grabbing the infundibulum with a bipolar, right? I want you to basically use the stone inside to retract the gallbladder. No, I need to be able to, you see how I cannot see the infundibulum yet, right? The point is to retract so you can see the infundibulum. Yup, let it flop. It's okay. Huh? Let it flop, that's okay. There, just like that. Lock your instrument. Okay. Now in general, you wanna be pulling this out, right? What I would do is just don't reposition it, just get control of this arm again, and just pull it back slowly and slightly this direction. So you open up that angle. There you go. That's good. Okay.

CHAPTER 5

The duodenum is right there, right? So let's take a look at this area. Do you see Rouviere's sulcus or the recesses dextra of Gans? Okay. Maybe that, lift. Lift up right here. Right there. Is that it? I see it down, up here. So the - lift that up again, let me see. Yeah, so this may be it or this may be right, but the point is that, move your hook out of the way. So this angle that's made right here to Rouviere's sulcus. This is your plane above which is safe and below which is not safe. Okay? Oh, all right. And so that's the place you wanna start. And then you want to start to develop your critical view of safety. Now remember, your duodenum is right here, right? I would recommend going up. And you wanna go that way and then up. I would be just right there. Good. Probably. Now, where is the cystic duct relative to the common bile duct today? What? Where is the cystic duct relative to the common bile duct today? Did you see the MRCP? I don't know if I noticed on the MRI. Okay, so it goes posterior. There's a posterior insertion, so presumably, it's gonna go like that. Okay? All right. Good. So you opened the space between that and the duodenum, right? Be... Yup. Be careful there. Yeah, I think you're getting a little too close to duodenum for comfort. Okay? Okay. The up camera you think is a good idea, but the problem with the up camera is that it needs to be down here in order to look up, right? What I would do is put your instrument in pointing up and then turn it. Okay there. So let me show you the move, Annie, that I'm talking about. I want you to go in like this. Look at me. I want you to go in like this. So if this is the flap, go in like this and then turn and then hook. Okay? No, no, no. We need to get the back, right? This is infundibular peritoneum, right? You've opened up this right here. We think that your cystic duct artery is gonna be right there. Cystic artery is gonna be there, and then the duct is gonna be here somewhere. Right? So what I need to do now is pull this gallbladder this way and then get the peritoneum on the backside. Just like we do in laparoscopic. The steps of the procedure are gonna be similar, right? Okay, sounds good. Thank you very much, Amber. So let me show you something. There's two ways to retract that, right? One way is what you're trying to do, which is grab it and do this, right? But what I would suggest you to do is actually grab the front, like so, and then lift up, right? Okay. And then that will allow you to get this right here, all right? Like so. Okay? And then what I mean is you can grab, just like we talked about with the one tying into the gallbladder, then grab, and then it'll rotate and flatten out that side, right? And then you can put in your hook like so, and just keep going, okay? And what do we really need is to go down in this direction, right? Because our infundibulum is right here. Yeah. Right? I'm gonna fix your fenestrated tip up for a moment 'cause I think we can get... You see what I mean? This right here should actually be up here, right? And so that when we dissect over here, our cystic duct is gonna be right here, right? You can see bile duct is gonna be there. Do you see the shadow of the bile duct right here? Yeah. Okay. Okay. So really, what this needs to do is go this way and then up. Okay? So that you can see, basically, we wanna get into this space right here. Okay? Okay. And so when the tissue does that, that means there's not enough tension, right? There you go. There you go. So try not to grab the artery, right? It's not necessary. Just grab the gallbladder right there. Small grabs are better. Good. And this allows appropriate opening of the hepatocystic triangle. When you take this peritoneum, what that allows is for that hepatocystic triangle to open up for you. Yup. One more time. You go in there and go back and forth. Lift away from the gallbladder. What's that? Lift away. There you go. That's better. Yup. Keep going. Okay. Yeah, I mean the retraction is gonna be tough, right? It's a big stone in that gallbladder and the liver is stiff, right? Pull away from the gallbladder, there you go. Keep going. Yup, just keep going. Right there is okay. All right. Now be careful here that you don't, yup. Keep going. Keep going there. All I mean is that I want you to make sure that you don't get into the gallbladder there. I think you've gone far enough though if you stop there. And then let's go back down here, right? Okay. I'm gonna dissect in this triangle here, because I think the gallbladder and the cystic duct connect there. Okay, one second now. This looks like, yeah, so this looks like either infundibulum or the tortuous cystic duct back here. Okay? So what we need to do is free up here, down here. We need to free up down here. And we need to make sure that the back of the gallbladder is freed as well. Okay? Those are the basics to start with, right? Around the top. Okay. I'm gonna grab the artery. Good. Yeah, go ahead. Perfect. If you can see yourself, you wanna go one cell layer at a time, like my program director told me, right? You just go one cell layer at a time, if you can see. Yeah, that's peritoneum on the gallbladder, that's gonna be in the path lab soon. So let's concentrate on here. That's not helpful right there. So this is likely, artery is gonna be in here somewhere. All right? I suspect it's gonna be right here. Okay? So yes, go ahead. Go ahead and take that. But now, what you don't also wanna do is leave only the artery on a significant amount of tension. Okay? So I would say start dissecting in there with your hook and see if you can get behind there. Good. Okay, now go down here and do the same thing. And what I would do is suggest getting into underneath this veil of tissue right there. So stop right there. Okay? Go back and I would get in underneath. There you go. Just like that, and go underneath a little, okay. And I would work over here more to the right more, and you'll have more success. There you go. Good. Do that again, Uh-huh, try to take that. Good. Do it again. Okay, now you're almost there. Okay, good. That's good. Next time, oh, be careful with your right hand. All right, good. Yeah, so that's great. Keep going. Do what you're doing. Okay, now yep, there you go. That's a good move. All right? Good. Always be cognizant. Situational awareness of where that duodenum is. Yup. Agreed. Okay, that's okay. We can leave that for, that's all right. No, no, go ahead. If you got it, you got it. Go ahead. Nice. Good job. Good. Away from duodenum, right? There we go. Okay. I want you to... That's okay. I think you're okay. I don't want you to go too much further. Do you want me to go...? Well, no, not necessarily. The goal is not to get the cystic artery more proximally. The goal is to get the cystic duct, right? And so let's do more dissection. There you go. And this one is gonna have to tap, tap back and forth on it. So when I say tap, tap, what I mean is tap, tap and then move back and forth like that on it. Okay? But that's okay. This stuff is clear. You don't need to do that. It's just if a vessel is there. All right, okay. So I think that's a good start. This may be one of the gallbladders where we need to take the artery before we are able to establish a critical view. But what I'd like to do is to get the back of this dissected. So now zoom way out, let go of what you have there with your left hand. And then is there any way to get the gallbladder to be retracted that way with your tip up so we can see the backside of the gallbladder. And basically, stop for a second. So you see the axis of the gallbladder's like this, right? Yeah. Can we make it so that the axis is like this? Yeah. Okay. That's all right. Leave it there. That's all right. No, pull the anterior. First of all, your grab is too big. Okay, grab smaller and then grab the front of it and pull up this way. Are you able to get any of that back? The peritoneum in the back. No, I think that's gonna be... All right, yeah, that's fine. Okay. Right. Agreed. Good. Now be careful of the tension between your two arms that you're not looking at right now. Right? 'Cause you can rip the gallbladder. So zoom out. Okay, good. All right. Keep working where you're working, but keep view of both the instruments because you could pull this arm this way and then that would tear the gallbladder. Okay? Keep going. Keep going, keep going. You had good visualization, right? Don't give it up so easily. There you go. Keep going. Okay, let's go back to here, right? I'm having a little trouble with the visualization. Do you mind if I help with the retraction a little bit? I just wanna see if we can get a better view of that hepatocystic triangle. Oh boy, that makes it... Okay. And what that should allow you to do is dissect in there, right? And get behind the nfundibulum? Yeah. And then get in that space. Okay? Okay. And then we just wanna leave that artery there for now? Yeah. I mean, let's see if we can obtain the critical view of safety. That's the goal always, right? And we have to violate that - if we have to violate that to take the artery early so that we can get the cystic duct, we can do that but we have to understand that that's a violation of the critical view of safety that's supposed to keep us safe, right? So just like you would in lap. What would you do laparoscopically? So you have the instincts. You want to retract that way, right? And you can see. I don't wanna grab this. Okay. Well, you can either grab here or you can grab here, okay? Now be careful of the tension on that all, but that'd be fine if you wanna grab. Good. So what I want you to do is you've developed this already, right? I want you to dissect it back this way, because in my mind's eye, what I'm thinking is that, just pause for a second, all right? No, no, you can keep grabbing. Keep retracting the way you wanna retract. Okay? Don't grab so big. Like you grabbed extra tissue. Just grab the gallbladder. There you go, all right. Now what I'm imagining is that the back of the gallbladder is like this, right? So I want you to dissect this way and open up this space right here. So let go of this 'cause this hand is not doing anything. Let go of it. Grab this flap right here with your left hand. It's unusual. Put your elbow way up in the air up here. There you go. Grab that flap. Grab a better bite of that flap. There you go, all right, go ahead. What's that? Good. I just wanted to hear you say it one more time, that's all. So all of that can stay up, right? You need to be in this plane. But that's fine, that's good. Now go up and down right here. You should be right on gallbladder there, right? So that's okay. If you slip over that, that's okay. Now remember the gallbladder, it looks like it's going like that somehow, right? Either the cystic duct or something. There you go. Good. Nice job. Yup. Keep going. There you go. That's better. That's not working out, right? You've tried that a couple times. Let's try up here into there. Deeper there. There we go. All right, good. I'm gonna regrab this flap. Okay. Go from easy to hard, right? So this stuff up here is easy. Okay, let's go back down here. So now you can switch. So retract the gallbladder instead of the flap now. Uh-huh, good. Uh-huh. Can I grab this and pull down? Sure. Nah, no, no, no. Now, you're digging. So do that again. Do that again. Do that pull. It's right here. Yup, that should go up, right? There's no fat on gallbladder. All that tissue should go up. We should be right on gallbladder. Good. No, go up this way. No, no, that's going back into liver. We don't wanna go back into the hilum. Good. Sure, take some of that, but... You want me to get under it further up? Sure, if you want. Well, yeah, I mean you can, right? That's just fine. I mean, at some point, we have to deal with the hepatocystic triangle and not the cystic plate, right? So what you're dissecting is the cystic plate, right? At the infundibulum, which is appropriate because we do want that retraction. But what I really wanna see at some point is where is the cystic duct? Now what we have... Grab the flap? Now what we have determined is that this artery is unlikely... Stop moving the camera for a minute. So it's unlikely to be going this way and then back up into liver. Right? So the likelihood is that this is a cystic artery. And we can take that if we think it's gonna help with the retraction of this infundibulum out this way. Do you think that's gonna help? I think it is, but let me see if I can just pull this flap towards me first. Okay. Okay. Do that again, but point the hook almost out towards your camera. One more time. Good? Yes. This down here. Good. Is that artery or just... So I think what we're seeing there \is this tortuous cystic duct, right? And so what we're seeing is a fold upon itself, but that's fine. We have to figure out where that cystic duct is, okay? I wouldn't do that. Okay. Let go of what you have with your left hand. Let's figure out a different way to retract that. By working on this stuff. Okay, go ahead. Okay, let me make a suggestion here, okay? So what I would do is grab the infundibulum here and lift it up in this direction. Okay? And there's all this stuff that's right here. All that stuff you can work on, all right? No, no, no. Lift it away from the duodenum. All of this stuff needs to be lifted away from the duodenum. So you need to work on this material right there. All right, I think that artery is under a little bit too much tension and I think we need to take it. Okay, so let me, yep, that's good. Let me just show you a couple things on the, come on up here. That's good. Thanks, Colin. All right, so whenever you do this, you wanna take advantage of that move that you were already almost doing. You wanna go up like this, turn your instrument and then you get all that stuff out, right? Got it. It's just clearing up some stuff there, right? So push it in and then just come out like that and make sure you don't have any attachments on the back there. Okay? Got it. That looks good. We don't have a vessel sealer, right? I didn't open it. Three clips. Good. Perfect. Three clips. Annie? Yeah. So for placement of the clip, you're not gonna be able to just push in, right? You're gonna have to go underneath and aim up, right? I want you to put the most proximal one on first, right? That's good there. Good. And you do a good job with that clip. The other learning point for the clip is when you deploy the clip, right? Sometimes, the parts of the clip that are within that little notch in the clip applier, they stick in there, right? And so it's not really a movement of rotating or opening the clip applier. It's really that you have to roll that clip applier so that the little notch, the little pieces of the clip come out of the notch of the clip applier. Good. And then what do you want after that? Why hot? Leave more of a stump with this patient than the path specimen. Leave more of a stump with the patient than with the path specimen, right? Just the same direction as you placed your clips. There you go. There you go. Good. I feel like the gallbladder really flipped it, pulled up. Yeah. Yup. You're not running anything. Be careful the tension between your two left arms. Figure out this part. So that's a curve. So turn on your Firefly. So that's a curve of your, so your bile. So turn it on again. Take the hook off the duodenum. Just don't put it on there. You know, you could accidentally burn the duodenum. There's no reason for it. Okay? So you have your bile duct here, right? And your cystic duct likely goes like this somewhere around there. The cystic duct on the MRCP goes posteriorly into the common bile duct. Okay? So this is likely just a little turn of the cystic duct. What you have to do is grab the infundibulum and pull it this way so that it straightens out that cystic duct as much as possible. So just grab right here. Just like you would do laparoscopically right now. There you go. What would you do laparoscopically? So what is your goal? Right? Goal-directed dissection. What is your goal? I'd like to clear off the... Get around this stuff if possible. Okay, so how are we gonna do that? Take this. Okay. All right, good. So there's stuff right here that needs to come off of that cystic duct, yes. Being cognizant of the duodenum. Now if I were to do that though, if you're working here, then I would grab the duodenum here, or sorry, the infundibulum here and move that up this way. So that the space between your duodenum and where you're working is more. Oh, you just, yep, exactly. Use what you just did. Nice. Yes. No, no, don't sweep up there. You see there's... That's just a fold. If you work right here... Sweep it down, it's just a fold. Might be a vessel, that's okay. Can I just buzz it, or...? Yeah, why don't you bipolar it first? So hold. I would've held that what you're holding there with your hook. Push that up, but that's okay. You're gonna have to do it somehow, yeah. Ah, maybe. Don't touch the duodenum, all right? There you go. Good. There you go. Not touching anything. Feather your bipolar just a little bit, meaning open it a little bit. Keep it open just a little bit. Go ahead, keep going. Okay, now go ahead and with your hook. In the future, I would dissect that off of the structure a little bit so you have a little bit of space so you can get your bipolar in there and properly bipolar that before you come through it. Hook it properly. Hook it properly. There you go. Up and down, right? Tap, tap, up and down. Tap, tap, up and down. Tap up there, now tap down below. Tap up above, tap down below. There you go. Good job. And that also, you'll notice leaves a stump, right? You can grab with your bipolar if you need to. Sweep down. That's probably a fold in your cystic duct, potentially. Yup. Okay. Go ahead. Nope. There's a little bit more space there, there you go. So, you wanna get in this - you wanna... What you wanna see is the liver on the other side. So the portion of the critical view of safety that talks about being able to see the liver on the other side is to say that the bottom third of the gallbladder has been dissected off the cystic plate, right? And so what you wanna do is you wanna create that, right? So either take that and go up that way and do it on the backside or go through a more, here where you were working earlier. It's up to you. Can you take any more there or are we as far as we can go? I think it feels a little tight here... Pull this part. Stay on the gallbladder, not in the liver. I think we're go okay there. Why don't we go back to the other side? Why don't we go back to the other side of the gallbladder? Or you can take it up there, that's fine too. I mean, that's safe. We don't necessarily need to be up there, but that's safe to take. So grab the infundibulum right here. And not such a big bite and grab it right in the front of it right there. And your elbow should be up. Your palm should be facing the floor. There we go. Do it again. Okay. All right. Yup, right there is where you wanna work. So you wanna take this right here. This is the dissection right there. So this triangle needs to come down. I want you to move your left hand to the screen, left a little more and then retract up. Okay. Nope. I wouldn't do that. You have the gallbladder folded there. Okay? What if I grab right here? Sure, that's fine. So, so stop for a second. I want you right here. Yes. Yes. Good. Nice move. Yup, no, no, keep working there. This is what needs to happen right there. Hold on. Lift it up and turn on the Firefly. Take a look closer, move your hook out of the way. Okay, keep going. Okay, let go of everything, let's reassess. Yup, a hook. Yup, a hook in there. There you go. Good. Do that again. Do it again up against gallbladder. Okay now, look from the front. Let go of what you have. Whenever you look from the front, don't keep grabbing. You need to regrab 'cause the gallbladder needs to be rotated. Not grabbed in one big bite. All right? So put your elbow down. Yeah, I know, put your elbow down. There you go. Okay, there you go, pull. No, no, no, pull. Infundibulum goes which way? Straighten out that cystic duct. Okay. No, I think you're gonna be, I don't think it's necessary. I don't think it's necessary, all right? Okay, that's a good job. So what do you think of that? Big, but is there gonna be, can I get a clip around that? You can, but it's not what I would do, yeah. So can I take a quick look at it? So that's a good job. You've gotten around the infundibulum, you've dissected the bottom third of the infundibulum off. How far would you take it proximally? Yeah, I don't wanna leave any of what I think is infundibulum and the cystic duct can sometimes be long. Right? Why a long cystic duct? I don't know. Okay, so I think your cystic duct, so this is your cystic duct here, right? Infundibulum going in cystic duct. And you can see this is just basically an adhesion, right? That's causing the kind of tortuous nature of the cystic duct, which we normally see, right? And so on the backside, you've got it nice and clean. That's great. And then over here you can see the bile duct right there, right? So you can see bile duct right here. Cystic duct is coming kind of posteriorly there. I don't think we need to really dissect too much there. If you want, you can use your elbow of your hook to kinda hold that up while you kinda dissect there. Okay. And that'll open up the backside of that. But basically, you're around, you might wanna take this. Back here. So the other move is you wanna go in parallel to something. So you wanna go kind of parallel to that adhesion and then hook it out that way. Right? I don't think we're getting much more, and I don't think we're helping this patient by getting much more of this cystic duct given that that's all that's left. Right? So I think we can put our clips on right here and be done. You can sometimes kinda clear off more of this, but really, we risk injury to the cystic duct and it's not necessary. This is definitely cystic duct and not infundibulum. And if you get your clip on right there, I think we can get two clips. Sometimes, I like to use two clips, especially because we're not wasting any clips, right? I mean the clips are already open and that'll prevent some of that bile from leaking if we have a clip that slips or something. Okay? Okay. All right, go ahead. Are you ready for the clips? Get your infundibulum retracted the way you want it.

CHAPTER 6

With our ICG, we can see the bile duct cephalad to the takeoff or the confluence of the cystic duct. And so we know we're safe there. Go ahead. What I would recommend is try to find a place for your camera so you don't need to keep going in and out as you work. Okay? Nice job protecting your clip applier as it comes in. That's great. Here? Uh-huh. And do you want more clip? Yeah, just place another one on the gallbladder side so we don't have any bile spill. And you have to be careful of that duodenum next time a little bit more, but that's all right. It looks good. Oh. All right. Okay, scissors. Okay, hook cautery. Get your scissors up in a safe position. There you go. Good.

CHAPTER 7

Now I don't want you hooking at all again towards the duodenum. All right? So hook up. You can use the heel if you'd like, that's not a problem. I'm just saying that I don't want you going releasing towards the duodenum, okay? Just take care of this stuff and this stuff, this peritoneum here and then this. Oh boy. So you know, every time you move your camera, my markings disappear, right? There we go. Good. Now be careful there, there's a vessel. Can you just pause for a second? Pause. Pause. Come back with your hook. I want you to bipolar this area right here. Keep going, keep going. Good. You want me to bipolar this? Yeah. With the bipolar, you can spend a little more time. Good. All right, keep going. So tension is down here, right? Now don't move the camera. So come back. I want you to do the entire infundibulumr dissection or the cystic plate dissection without moving the camera. Come back. Come back a little bit of the camera. Look up a little bit. Okay, there we go. The rest of the this, try to do it without moving the camera. You can grab it there. Okay, go ahead. Hook underneath. Hook up underneath. There you go. Oh, watch the tip of that hook it's not on the gallbladder next time, okay? There may be a small vessel there. I want you to stay on the gallbladder, okay? You can see it pulsating. Stop for a second. You can see it. Move your hook out of the way. You can see it right here. Can I try to grab the bipole? No, it's an artery. I want you to leave it. Nope, you're too deep. This is the plane right here. Leave that artery behind. There you go. Good. Yup. Keep going. Little longer. There. Stay on the gallbladder. On the gallbladder right there. Start down here, work your way up. Follow the gallbladder wall. Watch that duodenum. You're just a layer off. There's another layer there. Also, you're ignoring this. All right, I have it, sorry. Nope, nope. You're too far off gallbladder and that's through the artery that I'm asking you to preserve. Don't do it. Okay, all right. So what if I do that? Okay, but you need to be on gallbladder, yup. No. You just don't have the retraction so you gotta... It'll work at another spot. So, you need to reposition this arm over here and what I would recommend is perhaps this arm go onto the liver here now and retract the liver towards the patient's left. This arm? Yup. Just let go of the gallbladder. Just let go of it completely. There you go. Okay, now retract the liver up. So what I mean by that is wide. Yup, exactly. Good. There you go. Push up like that, good. All right, now use this hand to roll the gallbladder the other way and just start taking it right here. Right here, start up here. Go down. Grab, with your left hand, grab the flap here. Peritoneum that you've just dissected. Grab this, yeah. You see this peritoneum right here, right? Just grab it and retract it to the left and start taking that off. It's not under tension. It's not under tension. Pull your left hand, pull. Pull with your left hand. Really pull until there's tension there. There you go. Remember how this part of the gallbladder was soft? Grab it. Annie, it's not under tension. You gotta get more tension on there. Start the cautery in the air. Not enough tension. It's gotta be enough tension when you start, right? Annie, stop for a second. Grab the gallbladder right up here where it's soft. There. Pull. Why is your arm bent? Just pull. There you go, okay. On the gallbladder, there you go. Where's the tension? The tension's on the peritoneum up here. Just backhand it there. Cautery on in the air, it's nuts. Okay now, start hooking right there. There you go. Good. Start here. No, just tension and just backhand it. Like this is just the back. What you're seeing is the inside. This, all this stuff is the inside of the peritoneum on the other side of the gallbladder. Do you understand what I mean? Oh okay, I can just go through it. Except for there's an artery right there. I'll take it there. Or clip it. Now backside of this could have duodenum back there, right? So your hand has to pull. There you go. Put that hook right back where you were. Now turn it 180 degrees. There you go. Do it again. There you go. Do you wanna put a clip on that? Is that a posterior branch? It must be. Regardless, it's not diving back down in the liver anywhere. Clip coming in. Good. Bipolar the other side and then transect it somehow. What kind of bag do we have? Excuse me.

CHAPTER 8

How does it look, Annie? Fine. Pretty okay. All right. Good. And I don't see any bile anywhere. Good. I'm gonna take your hook cautery out. I'm gonna give you your suction, clean up a little bit and then we'll put the bag in, do our TAP blocks and then get out. Okay? Can I push down the duodenum with my bipole? Yes. That's okay. Questions on your side. Okay. Suction out the right upper quadrant, infrahepatic space. Make sure our clips look okay. Okay, look under the right lobe of the liver. Kind of more laterally. Push the gallbladder down. All right, suction that fluid right there. Good, take your number one off of the liver. Let the liver flop down. Take your suction out from underneath the liver, good. Now your bipolar's gonna come out but you're gonna stay right where you are. All right? So take your tip up and grab the gallbladder and we're gonna put it into a bag. I'm gonna undock your number two arm. Let me see if I can just see it. Five-millimeter bag is not, this stone isn't gonna fit in there, is it? All right, you wanna let that go? All right, let's just inject some local. Are we good? We have to do anything else, Annie? No drains, No Tisseel. I think that's it. Do you want me to put a TAP blocks in? I'm doing it. If you wanna just give me a visualization here. I hit that small little vessel. Hold on a second. Let me give you a bipolar just 'cause I can't stand it. All right, go ahead. Just bipolar that a little bit. Okay, cool. We're gonna look in the other side.

CHAPTER 9

We are ready to undock the robot. Can we level the patient out? Can we get the OR lights on please? Closing ports. Any specimen? We're gonna have to send a frozen. So Ryan, if you wanna hit the boom button and just bring the boom back, that might help. Keep going, Ryan. Yeah, that's great. Thank you. And then if I could have you hit the stop button on the air seal please. Taylor, do you have another set of 7.5's over there? So Annie, you can see it's like this setup didn't really hinder our ability to retract. It was really the stone that was the important part of the retraction, but it saved an extra five, or sorry, an eight-millimeter versus an extraction port, right? Like if we would've put this up here. So why don't we do that all more often? I do that all the time. That's fine. All right, so we're gonna just... Do you remember how I do this? So we're just gonna go through, take all the sub-q until we get to the point where the it enters the fascia. I'm gonna take this out because I don't want to the cautery to... Oh, it's gotta be bigger. So the purpose of that is to make sure that the hole comes out of the fascia so that you don't spill any of this stuff. And then come down there with that. So still, that's just Scarpa's, right? I want you to retract there and retract there. Another Kelly please. Okay. A little more. That's good. Okay, you are gonna do that on this side. Here you go. So we're just transversely opening up the fascia, the anterior rectus sheath. Here's the... And below. All right, go again. So get underneath that anterior rectus fascia and you can go up pretty laterally there. Do it again. Go ahead. Feels a little deep. It's not sliding as easy as yours is. But it's not muscle. Good. There you go. No, that's it. Nicely done. That's good there. Let's try that. Now the other thing that holds us up sometimes is the peritoneum. So another thing I do is I - get your Army-Navies again and retract. So what I'll do is also sometimes put my finger in. So what I would do is put my finger in sometimes. I can't seem to get my finger in this time. And what I'm gonna have you do is use the Army-Navy to move that, the rectus muscle. Laterally, there we go. Okay. Good. That's slick. Good. Do you avoid it just 'cause of like extra pain or? The rectus muscle? Yeah. Yeah. It's unnecessary. Here you go, hold that. Okay, we're gonna do the same thing on this side. I am gonna take this from you. So I have intraperitoneal here. I'm gonna use this to scrape that muscle away so that we can see the peritoneum there. Here we go. Okay, now see if you can get that out. I think it might need to be a little bit bigger. Okay, other Kelly, you got up Oh, just kidding. It went through something. So way to get it out of the skin. Now pull up on that and then you squeeze down here, right? And pull up and down. Go ahead and pull. And we can make the skin a little bigger if we need to. Go ahead and grab your cautery. Good. All right, go ahead. Good. Nice job. Holy cow. All right. That's huge. Oh my gosh, that's the weirdest thing ever.

CHAPTER 10

Can we hit the stop button on the air seal, Ryan? All right, mosquito times two. And then I'll take a 3-0 Vicryl? What do you use? Yup. 2-0, 3-0 Vicryl, whatever you got. So two up, three, four, five, six, seven. eight, nine, 10, 11, 12. We should be seeing every bite that we're taking. Needles times two. Oh, a little shorter? Okay. All right, I'm gonna head down to the frozen lab. I'll be back, okay? All right. Can I go ahead and close this? Yeah, close that one. The other ones, if you could wait to pull out the ports until I come back. Okay? All right, Andy, we're negative. So you can evacuate the rest of that gas and then pull the ports. Home today or tomorrow, it's up to you. With the Pfannenstiel that big, usually, it's overnight, but if she wants to go today, that's fine too.

CHAPTER 11

As predicted, the retraction of the gallbladder was quite difficult in this case. The 6.8-centimeter stone was quite large and made grabbing the gallbladder very difficult. In addition, we saw a very nodular and stiff liver, which was somewhat more difficult to retract and more easy to injure. Really, the key here was to retract the gallbladder without necessarily grasping it to allow us to see that infundibulum in the hepatocystic triangle. Additionally, we did have to abandon the attempt to obtain the critical view of safety. We were able to dissect out and demonstrate the cystic artery and we were able to dissect it in a fashion that allowed us to be fairly confident that that artery entered the gallbladder and did not return to the liver and was not representing an aberrant hepatic artery. And once we were able to demonstrate that, then we felt comfortable with ligating and transecting that artery. Once we were able to do that, we were able to straighten out the infundibulum and identify our cystic duct. And once we were able to do that, then taking it off the liver bed was fairly straightforward. The difficulty in this case was really retraction of the gallbladder. And additionally, you will notice that my port placement was a little bit different than traditional robotic cholecystectomy. This was in part because I knew that the stone would need to be extracted and given the fairly sizable stone there, I knew that the port through which I would extract that gallbladder would need to be fairly large. And so I tried to place that port in a position that would allow me to create an extraction incision that was associated with less complications. And that's usually a Pfannenstiel type of incision. And so I placed my number two port at the Pfannenstiel location and that allowed me to basically do this operation through four ports. And the extraction port was just expanded at the end of the case. As you can see, the difficulty in this operation was really retraction of the gallbladder. Usually, we like to grab the fundus of the gallbladder and retract it up towards the right shoulder over the liver. The liver was quite stiff and nodular today, so that was very difficult. And then also the presence of the stone prevented that because by trying to grab that fundus, it actually moved that stone down towards the infundibulum and made it more difficult to dissect. So in this case, we used the stone within the gallbladder to basically try to retract that laterally and ventrally so that we could identify the infundibulum. If you run into a gallbladder with a particularly large stone, I think that one of the important things to keep in mind is that the dissection can be kept to local spaces. And what I mean by that is I think a lot of times, we retract the gallbladder by grabbing large bites of the gallbladder. And with the robot, we really have extra degrees of freedom. We have the ability to work in smaller spaces and to retract the gallbladder in a very specific way. And so you'll notice in this case, I will often tell the resident to grab the gallbladder rather than just grabbing the entire infundibulum to grab portions of the infundibulum so that you can actually rotate the gallbladder, which allows you to put certain aspects of that hepatocystic triangle on tension as you're dissecting.