Robotic Cholecystectomy for Chronic Cholecystitis for a Patient with Recurrent Gallstone Pancreatitis and a Percutaneous Cholecystostomy Tube

CHAPTER 1

Hi there, my name is Charles Vining. I am a surgical oncologist and hepatopancreatobiliary surgeon here at Penn State Hershey Medical Center. Today we will be taking care of a patient who has chronic cholecystitis with a percutaneous cholecystostomy tube who has also experienced multiple episodes of gallstone pancreatitis. And so we'll be planning to perform a robotic possible open cholecystectomy today. So this is a patient with a history of an open ileocolectomy for perforated appendicitis in the past, the patient has also developed recurrent episodes of cholecystitis requiring a percutaneous cholecystostomy tube, which the patient currently has, as well as multiple episodes of gallstone pancreatitis, which has also required the patient to have an ERCP and biliary stent. The goal of our operation today is to safely take down his gallbladder in a minimally invasive or open fashion. He has a history of a previous midline laparotomy, and so safe abdominal access is going to be the key in this operation. And then identifying our critical structures. So we will plan to safely take down any adhesions that we may identify. Hopefully we will identify the gallbladder with the percutaneous cholecystostomy tube going into the gallbladder. And we'll plan to try to obtain our critical view of safety and safely remove the gallbladder.

CHAPTER 2

Ideally, we're gonna - we'll see what the adhesion situation is, but we will, you know, that's gonna be the midline one. Yeah, this is gotta be maybe something. Do you wanna get in over here then? Yeah, we'll Optiview in here, right there. And then anterior superior Iliac spine. So we're gonna probably go like... Do you want handsbreadth, port, handsbreadth? I like a handsbreadth between each one if possible. But for him, I don't know if it's gonna be possible, but we'll see what this looks like. Local or non-local? - [Charles] No, we'll do a TAP block at the end. So a knife? Fifteen blade, please. This is our incision. Schnidt, please. Make it for an eight. Okay. Knife back. Camera and port. And you're gonna be going up in that direction. Twist and push. Fascia muscle. Good. I don't think you're in yet. Keep going. Keep going. That second pass. Yeah. And muscle. All our fascia layers. Yeah. A little bit more. This one should be our last. Yeah. We need to get it. There we are, that looked like that one in. Gas on, 15 high flow. Are you okay with that there? Yeah. I think that's in. All right, you can come out with your camera. Gas on, high flow, 15. Thank you. One second. Let's just see, get some insufflation here. It needs to be on. It looks like we're insufflating, which is great. Yeah, drop your camera in. Yep, go in and then we'll Seldinger over top. All righty, that went in nice and safe. As expected everything seems to be midline. So yeah, can you touch something? And then let's take a look around. So... Yeah, we got some adhesions. As expected. As expected. Yeah. This is the area of interest up here. But let's see here. Yep, try to drop your hand and look up at the abdominal wall if possible. Our colon is stuck up. So we're gonna be able to come in there. Yeah, that's clear. Yeah, that's gonna be clear. We can go through that omentum and then over there is clear. Now can you go see if we can look at the actual gallbladder? Yeah, keep looking up that way if possible. That's all colon. That's colon. That's adhesed. Yeah. Okay. You want me to try to swipe the other way? Not yet. Let's put some ports in. Knife? Can you look at the top of where it is? I just wanna see that black part there. Okay. Knife, please. Oh, that's about a handsbreadth. That's better handsbreadth. I think those will all work, so let's go like this. I'm gonna bring this one a little bit lower. What's the reasoning for that? It's just easier with the robot. The robot, you usually have a lot of stretch. You got a lot of room. So we'll get this guy in. We'll just go through a little bit of that omentum, which is absolutely fine. Okay. That's all colon, so... All right, that should be okay there. You okay with that? Yes. Yeah, we're good. Okay, can I get a bullet? Now look from your side? Maybe through this guy. I'm gonna have to take this colon down here. Come on in a little bit. Just wondering. Yeah, I can back it out and then try to pull all of it down through this guy. Just grab it from... Yeah, if you want to try, you can put a grasper in there for sure. So look towards the screen left. Let me just try to see where the edge of it is. Yeah, see if you can start to take it off there maybe. Yeah, very nice. You need to work on getting it off the abdominal wall there. So where is it up to? The anterior abdominal wall. How far back - can we pull this guy back a little bit here? It's gonna be more of a grab and pull than a, make sure you just get in the omentum and not getting any sort of abdominal wall. Why don't you grab that, go into the hole and pull it down. So like with the grasper above and below as if you're gonna pull it, scoot to the left, and just, yeah, right in the middle of that hole and then pull that down. It's okay, needs to come down. I wonder if that's pointless at that spot. Is there a spot right there? Right there above you. Can we get into that? Have a quick look here and feel. That's all that colon, that's all of this. So we just need to get this down somehow. So we just need to do it. Can we have the blunt tip LigaSure. Here we go. Okay. Now it's working. Pull that down. I'll try to take it off the anterior abdominal wall here. Where's our colon? Colon's there. Colon should be down. I don't think there's any colon in this. Yep, just keep holding that down. At some point we're probably gonna be coming up to his tube. Yeah. Here. And Here. It's really... Which is gonna be, therefore we're coming up to it here. There's... That looks like a loop of intestine. Yeah. Yeah, sorry, just keep holding. If I'm working, the more you grab and re-grab, it just slows things down. And so we're coming up to the tube here. There's the tube right in there. Okay. Okay, you can let go of what you got there. Let's do some work over here. Colon is down. I don't think this is anything. Can you hold that up so I can push down against it? There's this tube. There's nothing in this. Want me to hold down? Pardon me? Yeah, you're good. I was gonna pull down on that. Hold that down. I'm gonna stay up here on the abdominal wall and try to sweep all this down here. That looks like it's probably liver. Maybe. Hard to say, where was there a tube was? Tube is here. Tube is here. Right there. Yeah, that's tube right there. Hold that. Hold this stuff down. That's organ. It's probably colon. Maybe that's gallbladder. Maybe a gall bag. Yeah, I guess I'm wondering whether or not we're okay to dock here now. And I think if we dock we'll be much better. I wanna see if I can take some of this down. Angle that up towards me. Just straight, looking like it's looking straight at me. Make sure we didn't do anything. Yeah, just free this port up a little bit. Yeah, if you could pull this stuff down. I don't think I did. Okay. I think I'm okay up here. Have we seen colon definitively? I think that's colon right there. You don't? It looks like - I didn't get a good look. I think it is. Why don't you try to take this piece off here. Can you lift that up towards me again, so I can just take this last band here. That's now nice and free. That's gonna be colon. Our tube is coming in here. I think I'm gonna start on the robot for this one to help with a little bit of this sort of lysis of adhesions and find some structures. This looks like colon down here or duo. I'll try to find some things, of course there's a loop of intestine right here too. And then I'll give it to you. Can we get a little bit more reverse Trendelenburg, please? A little bit of right side up. Any of this up? We're okay? I think we're okay. It'll just come underneath all of it. It's all right. That's good. Right side up. Right side up.

CHAPTER 3

Yeah, swing that all the way out. Keep going, keep going, keep going. Good. We're gonna target, and this is gonna move all the way over. We are gonna want, that's the tube. This area-ish? Yeah. Part of the issue is this is too far over this way. Seems a lot like it's really far over, but... I've never seen it do that. We'll take, yep, and hook over here. All right, we'll take a Prograsp in one and a fen bi in two. This is way too far in. Make sure this is still in the abdomen. Yep. Can you put heat on this guy? And let's get rolling. See if we can find what looks like a gallbladder here.

CHAPTER 4

Okay. As one will go, that's this one. That's the tube site? Yeah, this is the tube. We're very lateral, right? Yeah, I think so. Well, yeah. The tube's gonna be going into the gallbladder, probably lateral, but I'm just trying to basically just mobilize everything. And ideally we could just follow this tube to the gallbladder. Is this all liver? I'm thinking it is. Just to the left of that tube, that's inferior border of liver? I think so. Where's that colon. Colon is here. Hopefully diving down. So inferior border of colon means that hopefully we can take all of this. You think that's the gallbladder? What do you think, Joe, Asha? I'm not convinced yet, potentially. Yeah. Good, I like that answer, that's always good. We have no idea, right? It looks like there's a plane between there and the gallbladder- and the liver. Tube going right into it. So maybe stomach? This is probably stomach down. The gallbladder and liver were pretty stuck, no? Oh yeah. It's not gonna be your biliary colic gallbladder. That should be duo there, right? Well, I'm thinking this is stomach and duo should be here. I guess you mean this right here? Exactly. Yeah, for sure. For sure it could be. I am going to hand you these controls in just a second here, Asha. I just want to, so that's duo down there. I wanna take this off here. All right, let's do this like we usually do. I'm gonna grab this tube and pull this. Let's... Can you cut the tube on the outside? Cut the stitch, cut the tube and pull your side. Actually I'll just have you cut the stitch, cut the tube, and then pull the whole tube out if you can. That's liver. Cut the tube? Yeah, you can cut the tube. You can see the pigtail in there. Okay, and you can pull it out. Beautiful. All right. There's our trick. No. I'm just... We're gonna do a regular chole. Okay. Just trying to free this up. Just a touch here. Bile duct right there. See that? Yeah, I do. Dr. Vining? Yeah? Number one pushing really hard... Okay. That's better. Is that better? Yeah. Thank you for telling me. We need to check that at the end. Okay. Alright, I'm gonna give you these. I want you to just take your time, go nice and slow, and very gently dissect at that hepatocystic triangle.

CHAPTER 5

It looks like you've got like a little lip here. Yep. And just nice and gentle. Yep. Yep. I'm more of a tap, tap, tap type of person. So instead of holding it, just tap, tap, tap as you pull. Great. And actually I think this is probably your cystic artery right here, and your cystic duct is gonna be right beside it here. So you could take this and open this peritoneum up this direction. Very nice. Tap, tap, tap, and pull. Yes. A little more of that. Yep. Do you know what the number one cause of a bile duct injury is, Joe? Sorry, I keep saying Joe. No, you're fine. Asha? You can sweep in there too back and forth. How do people get bile duct injuries when they're doing this operation? I mean, you buzz too close to it. You can ligate it. Get into it. Well, which way is the most common? Buzzing, bite it. No, traction actually. A traction injury. Really? So your left hand pulling, you gotta have traction, but you can't have too much. Very good. Yep, I would just keep... I think it's gonna be up this way. And if it's getting a little bit more, then just come back here, and you know, there's a lot of wispy stuff. You can try to dissect out your artery and your duct there. Very nice. So you can sweep that stuff down. Yeah, just be careful, 'cause your cystic artery's right there. Here's gonna be your node of Calot. And actually your artery may be this thing right here. Okay. Maybe. There's a big vein here. I don't know if that... Oh no, that thing looks like it's pulsing away, so... Yep, love it. Can I show you something here, Joe? This is what I would do, Asha. I'll take 'em all. Yep. With this I pull this up a little bit, and then see how you can like obviously immediately work on your backside. So a lot of it is just sort of knowing where you are and doing what comes easily. So I go like that, and then all of a sudden I've got a good view here. I'm gonna push in here, but instead of doing it, I'm just gonna push that all down, and then I can come around here. Get that wispy stuff. And again. And that's how I'm getting length on my cystic duct here. We're also marching closer and closer to common bile duct. Yeah, which is where? We should just double check. Should it be just like right there right in that area. It's gonna be right here. Now we also have to isolate the two structures out individually. So I'm gonna come up like this. Why don't you do a little bit of work on the backside there. Okay. Love it. Yep. And then there's this superficial lip that you can do first. Yep. And then instead of just going in there, work the tissue. So when you get in there, you know, sweep up and down, and I think it's gonna be up here. And you're gonna be sweeping. There you go. See how that kind of opens it up for you? Yeah. And then go here, and then just push all that tissue down. Push this down. Just keep pushing it down. Just with the heel kind of just, yeah. Good. Can you get that from here? Yep. There's gonna be all, basically you're gonna have to come in through like here and then zip up and around like that. Yep. Tap, tap, tap. Yes, very nice. Good. And I think sweep it down. Yes. Very good. See how this is coming up? Yes. See you're gonna have to, yep. Very good. If you're gonna do that, just pull away from the cystic duct and bile duct. Yep. Good. Yep, there's a little window it looks like you just made here. And if you go in there and then swim naked this way, and then you can follow it up that way. There's a vessel right behind you there. But come up that way. If you can. Yes. Get more length on that. Make sure it's nicer. I want to, you know, work the tissue up and down and wait, 'cause I think you're tearing that - you're bringing that vessel with you. See that vessel back there? I do. Yeah. So maybe we'll go back to the front side. We've done a good amount on the backside here. Yep, I'm okay with that. Try to make that window between your cystic duct and your cystic artery. Yes. Thought actually it was gonna be that crossing vessel. Very nice. There's a little bit of wispy stuff right sort of from the lymph node to there. Yeah, you can do that. But you can drop in between the artery and the lymph node there I think. Yes. Very good. Yep, that's plenty. That's plenty there. I don't think you need to do that. What I would do is just try to make a window here between your cystic duct. Don't, yeah. Do not buzz in there? Yeah. Yeah. You okay with that? Hm-mm. Tap, tap, tap. There you can see the artery in the background there now. I think you're digging into the wall of the gallbladder. Stop for one second. I think what we need to do is, sort of sweep this tissue down. And go under the... We could take this tissue. I don't like that move. That's how you sort of Bovie down. I like always working up, but sometimes if it's this sticky and you need, you know, a lip, you can use that. When we get the artery there, can we work our way like under it? Under the artery? Yeah. Well, you can get around the artery instantaneously, and I'll let you do that. That's not a problem. I'm gonna regrab the infundibulum here a little bit differently. Now, I'm wondering if this is all bile duct, this could just be scarred in, and cystic duct could actually be much higher. Okay. Okay. Clearly the duct clearly going into it. Yeah, I want you to get around the artery now. Okay. And then I want to take more of the gallbladder off the liver as you move up, okay? Okay. But I agree that's clearly cystic duct. Yeah, I think this is the view that you want, and you want to come under it, and you wanna then bring your tip, so it's like pointing towards yourself, and then try to work it that way, yep. Yep, nice and gentle, though. And you can also start to, you know, take the peritoneum up. There's that going up. Yeah, sweep that lymph node to the right. Hm-mm. Yep, sweep it all. Yes. What about like coming in here and going up? Can I take that? Yep. Coming in here? Coming in here and going up this direction. Yes. Just continuing that up. Sorry, just keeping you centered. Okay. Yeah, so I only want you really cooking through stuff that you can completely see through. Okay. Okay? And lots of sweeping, because you can just sweep a lot of this stuff. If you get to the right plane. Yeah, more so I think like down here we wanna just free up the inferior edge of the gallbladder. I think you can come under that lip maybe. I think I can come down on it. Very good. And then you're gonna have a plane underneath the gallbladder that you can follow up this way. Yes. Good, now let's focus on getting around our artery. So that's not the artery, right? I think the artery is... No, the artery is below it. Yeah. Try to get around the artery, because that's all gonna just be stuff that you could just divide once we get around the artery. That's already here. Yeah. So if you go back in that plane that you were in and then you turned your hook 180 degrees, you'll be able to take the stuff off the back. So back... So back in this way? Yeah, get around. No, no, no, no, no. Like, like you're going in like this, and then you're kind of turning around like that, and then you'll be able to come up the backside. You wanna have the hook angling up and taking that peritoneum stuff there. 'Cause basically we're just trying to open up this hepatocystic triangle more. Yeah, correct. And we have at least the exposure of the gallbladder behind. Yeah. There you go. That can just be cooked, you're gonna rip it in a... Yeah, take this, this guy right here. Yep, cook, cook, tap, tap, tap. You have to have a little bit more tension on your hook. Yep. Give yourself better tension with your left hand. There you go, now take all this stuff back here. You don't have to go up here. It's all this stuff here. Yeah, closer to the gallbladder. You need to give yourself better tension with your right hand. There. That stuff. No, Just keep following up the edge over here. Yep. Yes. That's where you want to be. Yes. Yes. So don't rip it, okay? You're doing too much of that blunt. I want you to actually cook it. You know, right now it's fine, but that's where you can get into bleeding. Okay, that looks good. You've done enough on that side. Now we need to come onto this side. You need to get through this peritoneum here, so that the gallbladder is free. Not that way. It's gonna be like this. I'm gonna take this for one second. Okay. Okay, I see. Okay, I think... I can take that? Yeah, I think that's our critical view. So two and only two structures going into the gallbladder, and a third of the gallbladder lifted up off the cystic plate.

CHAPTER 6

All right, so you take these all, so each time you get a clip, just position it over here, so that they can come in and out easily. We'll take clips in number four, please. Two clips down on the cystic duct and then one up on the proximal side. And then the same thing with the artery. And then we'll cut everything. So we'll take a total of six clips now. Good with that? Sure. See how far away you are? Next time move in closer. Like you're trying to get a good look. Now... So that it's easier. Move in with your camera. Right there? Yeah, I'm okay with it. Yeah. There? Hm-mm. I don't have to tell you yes for every clip. So two down on artery too? Yep. Okay, can I get the hook back in? Hm-mm.

CHAPTER 7

You don't have good exposure. You need to give yourself much better exposure. This should be the easy part. So just give yourself exposure, and then zip the gallbladder off. I don't know if it's just me, but it seems like your camera's very far away from what you're trying to do and look at. So I'd bring your camera way in. Should I cut this band a little bit more first? Sure. Stay in the correct plane. I'm sorry? Stay in the correct plane. There's a plane that if you hook into, yeah, you can go that way. Sure. What's going on? Let's divide some tissue. Trying to zip up the side here. Okay. Why don't you come underneath like we always do, and maybe you need to take your second hand off. I need to trap that side. You know, you just need to take it off at this point. Yeah, you can do it there. A little bit to the right. Yep. And keep tension on that gallbladder. Yep. Yes, please. Lift it up. Up? Yeah. Be mindful of your clips down there. Don't rip it off the liver. There's a plane that you should be able to go through. Right there you should be able to see it. A little bit to the left That's gonna go, that's not the plane. Here? Yep. And you always wanna go with the area of maximal tension, yeah. Stop. Lift it up. There's a plane there you should be able to just follow. No, on the backside. Yeah. More attention with your left hand. Lift it up so you can get to the corner. Under it so you can get to the crotch, Up to the screen right. Look at the crotch. You've also got an extra hand that you're not using. You gotta use all available instruments to you. Yeah, you can do that. That's fine. Just take all that fat with it. Thank you. Perfect. All right, I'm taking number four out.

CHAPTER 8

Okay, do you want me to buzz any of this lower bit here? Sure. I think it looks good. Okay. Dr. Vining? Yeah. Take the bag. We gotta put the gall bag into the, can I get the bag? Where's the gallbladder? Over there. You got two hands. See how that hand is just kind of in the way limiting everything? Yes. So maybe pull the bag down or push it in. Okay, come scrub in. Can we get the robot out?

CHAPTER 9

Let me look at the tip of my instrument. Are we gonna take the Foley out? Yeah, we'll take the Foley out. Did you guys take the drain out? Yeah. Yes. We did. Is it staying out? Yes. Take a look at it? I think we got it. Okay. Alright, let's look at the gallbladder fossa. Can I get a snap? Cystic duct, cystic artery. It looks good. We're not bleeding. That colon all looks okay. We watched it come in. I think it's all okay. Can I get a grasper? Actually, the next thing we're gonna do is TAP blocks. Small intestine and colon's looking perfectly healthy. Good. All right, TAP blocks stuff to Joe. So you gotta go to a point where we're not going through the liver. Yep, right there is good. How much does he weigh? Yeah, 30 each. That's 15 there. Good. With the robot, I want you to focus on efficiency, less wasted movements. Okay. And just being more aware of your three-dimensional space, and what you need to do to accomplish what we're trying to do. There are times where you're just leaving one of your hands and not working it as much as I think you could. You're not giving yourself the exposure that you need to. It just takes time. And I'm gonna ride you guys, 'cause I want you guys to get better. Okay. To the right here. So right there at the end when I had two arms left in, they're both on the left side though, so I can't... Yeah, so you could do one, hold it over the way, hold a certain way, and... Yeah, I mean, can I tap over to have both? No, because then you don't have the hook, which is the main thing that you need. No, but at the end when you took the hook out, all I had was the two graspers left. Oh, when you mean... To have the bag in? To get the bag in, that's not a big issue. It's just more so like with the gallbladder, you know? Okay. Lifting up or pulling this way, and then using your other one to lift up. But just... To help give me exposure. Yeah. The other thing is this didn't get pulled out. So otherwise you can get a little abscess here. That needs to come out. All right. Yep. Okay, Thank you. Thank you.

CHAPTER 10

So we're all done today with our case. I would say everything went very well today. When we started with getting abdominal access, we were safely able to get pneumoperitoneum, and there was a significant amount of adhesions, and so we had to take the adhesions off the anterior abdominal wall, and that probably took us about 30 to 45 minutes. Once we were able to safely gain access to the abdomen and take down adhesions, we were able to identify the percutaneous cholecystostomy tube coming from outside of the abdomen and going into the gallbladder. We started by dissecting this out and then had the percutaneous cholecystostomy tube removed from the patient. We then retracted the gallbladder cephalad, identified the infundibulum, and took down a bunch of scar tissue. We were able to identify the cystic duct and cystic artery. We cleaned all the fibrofatty tissue away from the hepatocystic triangle, and we were able to take the gallbladder off of the cystic plate approximately a third of the way up the gallbladder to obtain our critical view of safety. Once we had obtained our critical view of safety, we clipped our cystic duct and our cystic artery, divided those structures, and then were able to take the gallbladder off of the cystic plate. Everything went very well. We were able to do this very safely and in a robotic fashion. And the patient should go home today with minimal discomfort and no longer having a percutaneous cholecystostomy tube.