Temporal and institutional trends in robotic surgery.

Robotic surgery has become increasingly prevalent in general surgery practice. While previous studies have shown the safety and efficacy of robotic assistance in laparoscopic general surgery procedures, few studies have evaluated the temporal and regional trends in implementation. In our retrospective population-based study, we aim to evaluate the national trends in robotic surgery. National Inpatient Database (NIS 2009-2014) was used to identify adults who underwent robotic assisted surgery (ICD 9 codes 17.41 to 17.49). Robotic procedures related to seven abdominal organ systems were compared against the trends of Urology, Gynaecologic, and Orthopedic robotic procedures. Discharge weights were applied to calculate National temporal trends separated by hospital size, teaching status and US geographic region. 894,163 patients received a robotic assisted procedure between 2009 and 2014 with 64% increase in utilization. The largest percent change was witnessed in biliary robotic procedures with 2984% change in utilization, followed by hernia (1376%). Lowest percent change was witnessed in esophageal procedures with 114% increase. Medium sized hospitals had the largest change in robotic utilization (41%), with large institutions seeing 18% decrease. Gastric procedures were the most common robotic procedure performed at small institutions (7917 total cases; 316%). Large institutions saw an overall decrease in gastric (- 47%), esophageal (- 17%), small and large intestinal (-16%), and hepatic (- 7%) robotic procedures. Rural non-teaching hospitals saw the largest increase in robotic surgery (274%). Urban non-teaching hospitals saw a decrease of 29%. While urban teaching institutions saw a 20% and 6% increase in gynecological and urological procedures, an overall decrease was seen in esophageal (- 10%), gastric (- 12%), intestinal (- 11%), hepatic (- 17%), biliary (- 10%), pancreatic (- 11%) and hernia procedures (- 14%). Biliary procedures saw the largest increase in rural institutions (740 cases; 392%), followed by hernia (144% increase). South region of the nation had the largest increase in robotic procedures (23%). No change was seen in the use of robotic surgery in the northeast region with the midwest and west seeing an overall decrease (- 4% and - 22%, respectively). Our study highlights the increase in use of robotics for both general and specialty surgery, with an increase in utilization over time. Increased incidence of robotic surgery in smaller, rural institutions with overall decrease in larger, urban teaching hospitals suggests increasing comfort in robotic surgery in the community setting. Further studies are necessary to evaluate the factors associated with increased utilization in smaller institutions.

Comparative analysis of robotic single-site cholecystectomy outcomes between novice and expert surgeons.

Single-incision laparoscopic cholecystectomy (SILC) has declined in popularity, posing a challenge for novice surgeons. However, robotic single-site cholecystectomy (RSSC) has gained popularity in hepatopancreatic surgery, suggesting a paradigm shift in minimally invasive procedures due to the advantages of robotic platforms. The purpose of this study was to compare the surgical outcomes and learning curves between experts and novices without SILC experience, and discuss the utility and potential of RSSC for novice surgeons. A total of 235 patients underwent RSSC between April 2019 and June 2023 at the OOO University Hospital. Among them, 31 cases from novice and expert surgeons were selected to compare their initial experience. Comprehensive demographic and perioperative factors were analyzed and statistical comparisons were made, including cumulative sum analysis (CUSUM) for learning curves. The demographic factors showed no statistically significant differences between the two groups. Although the docking time (P < 0.001) and hospital stay (P = 0.014) were statistically significant, the total operative time and other perioperative factors were comparable. Novice surgeons demonstrated a shorter absolute total operative time, primarily attributed to differences in docking time. The CUSUM analysis indicated a shorter learning curve for novice surgeons. This study shows that the inherent benefits of the robotic platform make it an accessible and reproducible technique for novices. The benefits of integrating observational learning into robotic surgery training programs and the intrinsic advantages of the robotic platform in minimizing the learning curve for RSSC were also highlighted.

Laparoscopic versus robotic cholecystectomy: a systematic review with meta-analysis to differentiate between postoperative outcomes and cost-effectiveness.

Background: Robotic cholecystectomy (RC) has shown promising outcomes in multiple studies when compared with the gold standard laparoscopic cholecystectomy (LC). The objective of this study is to compare the postoperative surgical outcomes and cost in patients undergoing RC versus LC. Methods: Studies reporting postoperative outcomes and costs in patients undergoing RC versus LC were selected from medical electronic databases and analysis was conducted by the values of systematic review on the statistical software RevMan version 5. Results: Six trials on 1,013 affected individuals for post-operative outcomes and cost comparison were used. Random effect model analysis was used in the analysis. Duration of operation (mean difference: -10.23, 95% CI: -16.23 to -4.22, Z=3.34, P=0.0008) was shorter in the LC group with moderate heterogeneity. Bile leak (odds ratio: 3.34, 95% CI: 0.85 to 13.03, Z=1.73, P=0.08) and no heterogeneity was seen, Postoperative complications (odds ratio: 1.49, 95% CI: 0.50 to 4.46, Z=0.72, P=0.47) with moderate heterogeneity. Both were statistically similar. LC had reduced cost (standardised mean difference: -7.42, 95% CI: -13.10 to -1.74, Z=2.56, P=0.01) with significant heterogeneity. Conclusions: RC failed to prove any clinical advantage over LC for postoperative outcomes including longer duration of operation moreover LC was more cost effective. Due to the paucity of randomised control trial (RCT) and significant heterogeneity, a major multicentre RCT is required to strengthen and validate the findings.

Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform.

BACKGROUND: The Hugo RAS™ system (Medtronic, Minneapolis, MN, USA), approved for gynaecological and urological procedures, has been recently certified for the use in few general surgeries. Only bariatric and colorectal procedures have been described so far. METHODS: Here, we report the first worldwide experience with three cases of full-robotic cholecystectomies with the Hugo RAS™ system. RESULTS: A description of the operative room setup, of the docking angles and details of the procedures is reported. Docking time was 12, 10, and 6 min, respectively. The total operative time was 105 min in the first case, 100 min in the second and 88 in the third case. Intra- and post-operative courses were uneventful. CONCLUSIONS: With this pre-defined set up, the innovative conformation of Hugo RAS™ system can safely allow performing full robotic cholecystectomy avoiding the need for additional ports.

A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy.

BACKGROUND: The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases. METHODS: Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables. RESULTS: Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively. CONCLUSION: This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.

Surgery of the alimentary tract for benign and malignant disease with the novel robotic platform HUGOTM RAS. A first world report of safety and feasibility.

INTRODUCTION: As robotic surgery increases its reach, novel platforms are being released. We present the first 17 consecutive cases of alimentary tract surgery performed with the HugoTM RAS (Medtronic). METHODS: patients were selected to undergo surgery from February through April 2023. Exclusion criteria were age <16 years, BMI>60, ASA IV. RESULTS: 17 patients underwent ileocaecal resection for Chrons disease (2 M and 1 F) and pseudo-obstruction of the terminal ileum (1 M), cholecystectomy (3 M and 5 F), subtotal gastrectomy with D2 lymphadenectomy (1 F), sleeve gastrectomy (1 F), hiatal hernia repair with Nissen fundoplication (1 M), right hemicolectomy (1 M) and sigmoidectomy (1 M). No conversion to an open approach or any arm collisions requiring corrective actions were reported. CONCLUSIONS: Our preliminary experience with the HugoTM RAS point to safety and feasibility for a rather wide spectrum of surgical procedures of the alimentary tract.

A review of the first 100 robotic cholecystectomies with a new cart-based surgical robot at a tertiary care centre.

Background: Robotic cholecystectomy appears to be a natural evolution of the well-established gold standard procedure for gallstones, namely laparoscopic cholecystectomy. Akin to the early days of laparoscopy, robotic surgery is associated with a learning curve. We present our experiences in adapting to robotic surgery after the first 100 robotic cholecystectomies at a minimal access surgery tertiary care hospital. Material and Methods: The first consecutive 100 robotic cholecystectomies performed by a single surgeon on the Versius robotic surgical system (CMR Surgical, UK) were included in the study. Patients unwilling to give consent and complex pathologies such as gangrene, perforation and cholecystoenteric fistulas were excluded from the study. Operative time, robotic setup time, incidence and indication for conversion to manual (laparoscopic) procedure were recorded while subjective assessment of interruptions due to machine alarms and errors was made. All data were compared between the first 50 and last 50 procedures. Results: Our data revealed a gradual reduction in operative time from 28.53 min for the first 50 procedures to 22.06 min for the last 50 procedures. An improvement in draping and setup times was also noted, reducing from 7.74 to 5.14 min and 7.96 to 5.32 min, respectively. There were no conversions during the last 50 procedures, though the first 50 procedures resulted in 3 conversions to a laparoscopic procedure. In addition, we also noted a subjective reduction in the incidence of machine errors and alarms as we became more versed with the robotic system. Conclusion: Our single-centre experience indicates that newer modular robotic systems present a rapid and natural progression for experienced surgeons looking to venture into robotic surgery. The well-established advantages of robotic surgery in the form of enhanced ergonomics, three-dimensional vision and improved dexterity are validated as indispensable aids in a surgeon's armamentarium. Our initial experience reveals that robotic surgery for more common surgical procedures such as cholecystectomies will be rapidly accepted, safe and effective. There is a need to innovate and expand the range of instrumentation and energy devices available.

Do the outcomes of robotic cholecystectomy in elderly worsen with age?

The elderly population are at an increased risk of perioperative morbidity and mortality due to their disease profile. Minimally invasive surgery and in particular the robotic approach may improve the outcomes of cholecystectomy in the elderly. Patients who underwent robotic cholecystectomy (RC) and were older than 65 at the time of the procedure were included in this retrospective study. Pre-, intra-, and postoperative variables of the whole cohort were initially reported and then compared between three different age ranges. In total, 358 elder patients were included. Mean age ± Standard deviation was 74.5 ± 6.9 years. Males constituted 43% of the cohort. American Society of Anesthesiologists (ASA) scores were mostly ASA-3 (64%). One hundred and fifty-seven (43.9%) were emergent procedures. Conversion to open surgery rate was 2.2%. Median hospital length of stay was 2 days. With a mean follow-up of 28 months, overall complication rate was 12.3%. After subdividing into three age groups (A:65-69; B:70-79; C:80 +), we noticed significantly higher comorbidities in group C. Same-day discharge was lower in the older patients. However, overall complications and conversion to open remained comparable between the three groups. This is the first study to investigate the outcomes of RC in patients older than 65. RC provided low conversion and complication rates, that are also comparable between the different age ranges, despite the higher comorbidities in patients older than 80.

Obesity and mid-term outcomes following robotic cholecystectomy.

BACKGROUND: As obese adults often suffer from gallbladder disease, more data on postoperative outcomes following robotic cholecystectomy(RC) is needed. METHODS: RC candidates with a body mass index(BMI) > 30 kg/m2 were included. Postoperative course was documented and analyzed. A logistic regression analysis was performed to determine possible risk factors associated with complications. RESULTS: 617 patients with a BMI of 35.9 ± 6.4 kg/m2 were included of which 65 had complicated gallbladders (gangrenous, fistulated, or abscessed). Eight cases were converted to open. Sixty-five(10.5%) patients revisited the emergency department within 30 days, and 35(5.7%) were readmitted to the hospital. Average follow-up time was 35 months. Fifty(9.1%) patients experienced complications, eight(1.5%) underwent reoperation. Postoperative complications were associated with chronic obstructive pulmonary disease[p < 0.001, Odds-Ratio(OR):8.418, 95%-Confidence-interval(CI):4.029-17.585], BMI(p < 0.024, OR:1.045, 95%-CI:[1.006-1.086]), class-III obesity (p < 0.021, OR:2.221, 95%-CI:[1.126-4.379], and complicated gallbladders (p < 0.001, OR:3.659, 95%CI:[1.665-8.041]). CONCLUSION: This is the first study to establish a link between higher obesity classes and postoperative complications following RC.

Our initial single port robotic cholecystectomy experience: A feasible and safe option for benign gallbladder diseases.

BACKGROUND: Although single-port laparoscopic cholecystectomy has been performed for over 25 years, it is still not popular. The narrow working space used in this surgery limits the movement of instruments and causes ergonomic challenges. Robotic surgery not only resolves the ergonomic challenges of single-port laparoscopic surgery but is also considered a good option with its additional technical advantages, like a three-dimensional display and not being affected by tremors. However, the extent to which these technical and ergonomic advantages positively affect the surgical outcomes and how safe the single-port robotic surgeries need to be assessed for each particular surgery. AIM: To evaluate the feasibility and safety of single-port robotic cholecystectomy for patients with cholelithiasis. METHODS: The electronic records of the first 40 consecutive patients with gallbladder lithiasis who underwent single-port robotic cholecystectomy from 2013 to 2021 were analyzed retrospectively. In addition to the demographic characteristics of the patients, we analyzed American Society of Anesthesiologists (ASA) scores and body mass index. The presence of an accompanying umbilical hernia was also noted. The amount of blood loss during the operation, the necessity to place a drain in the subhepatic area, and the need to use grafts during the closure of the fascia of the port site were determined. Hospital stay, readmission rates, perioperative and postoperative complications, the Clavien-Dindo complication scores and postoperative analgesia requirements were also evaluated. RESULTS: The mean age of the 40 patients included in the study was 49.5 ± 11.6 years, and 26 were female (65.0%). The umbilical hernia was present in 24 (60.0%) patients, with a body mass index median of 29.3 kg/m2 and a mean of 29.7 ± 5.2 kg/m2. Fifteen (37.5%) of the patients were evaluated as ASA I, 18 (45.0%) as ASA II, and 7 (17.5%) as ASA III. The mean bleeding amount during the operation was 58.4 ± 55.8 mL, and drain placement was required in 12 patients (30.0%). After port removal, graft reinforcement during fascia closure was preferred in 14 patients (35.0%). The median operation time was 93.5 min and the mean was 101.2 ± 27.0 min. The mean hospital stay was 1.4 ± 0.6 d, and 1 patient was readmitted to the hospital due to pain (2.5%). Clavien-Dindo I complications were seen in 14 patients (35.0%), and five (12.5%) complications were wound site problems. CONCLUSION: In addition to the technological and ergonomic advantages robotic surgery provides surgeons, our study strongly supports that single-port robotic cholecystectomy is a feasible and safe option for treating patients with gallstones.

Feasibility and Efficacy of Single-Port Robotic Cholecystectomy Using the da Vinci SP® Platform.

Background: Single-incision laparoscopic cholecystectomy, first introduced in 1995, features acceptable cosmetic outcomes and postoperative pain control. The outcomes of single-port cholecystectomy by laparoscopy and robots were recently examined in many studies owing to surgeon and patient preference for minimally invasive surgery. A next-level da Vinci robotic platform was recently released. This study aimed to evaluate the feasibility and efficacy of robotic cholecystectomy (RC) using the da Vinci SP® system. Methods: In this retrospective observational single-center study, we analyzed the medical records of 304 patients who underwent RC between March 1, 2017 and May 31, 2021. Results: Of the 304 patients, the da Vinci Xi® (Xi) was used in 159 and the da Vinci SP® (SP) was used in 145. The mean operation time was 45.7 mins in the SP group versus 49.8 mins in the Xi group. The mean docking time of the SP group was shorter than that of the Xi group (5.7 min vs 8.8 min; p = 0.024). The mean immediate postoperative numerical rating scale (NRS) score was 4.0 in the SP group and 4.3 in the Xi group, showing a significant difference (p = 0.003). A separate analysis of only patients with acute cholecystitis treated with the da Vinci SP® showed that the immediate postoperative NRS score in the acute group was higher than that in the nonacute group. Conclusions: This study demonstrated acceptable results of single-site cholecystectomy using da Vinci SP®. Thus, pure single-port RC using the da Vinci SP® for various benign gallbladder diseases may be an excellent treatment option.

Operating costs, fiscal impact, value analysis and guidance for the routine use of robotic technology in abdominal surgical procedures.

BACKGROUND: This study was designed to define the value, cost, and fiscal impact of robotic-assisted procedures in abdominal surgery and provide clinical guidance for its routine use. METHODS: 34,984 patients who underwent an elective cholecystectomy, colectomy, inguinal hernia repair, hysterectomy, or appendectomy over a 24-month period were analyzed by age, BMI, risk class, operating time, LOS and readmission rate. Average Direct and Total Cost per Case (ADC, TCC) and Net Margin per Case (NM) were produced for each surgical technique, i.e., open, laparoscopic, and robotic assisted (RA). RESULTS: All techniques were shown to have similar clinical outcomes. 9412 inguinal herniorrhaphy were performed (48% open with $2138 ADC, 29% laparoscopy with $3468 ADC, 23% RA with $6880 ADC); 8316 cholecystectomies (94% laparoscopy with $2846 ADC, 4.4% RA with a $7139 ADC, 16% open with a $3931 ADC); 3432 colectomies (42% open with a $12,849 ADC, 38% laparoscopy with a $10,714, 20% RA with a $15,133); 12,614 hysterectomies [42% RA with a $8213 Outpatient (OP) ADC, 39% laparoscopy $5181 OP ADC, 19% open $4894 OP ADC]. Average Global NM is - 1% for RA procedures and only positive with commercial payors. CONCLUSION: RA techniques do not produce significant clinical enhancements than similar surgical techniques with identical outcomes while their costs are much higher. The produced value analysis does not support the routine use of RA techniques for inguinal hernia repair and cholecystectomy. RA techniques for hysterectomies and colectomies are also performed at much higher cost than open and laparoscopic techniques, should only be routinely used with appropriate clinical justification and by cost efficient surgical providers.

Robotic surgery enables safe and comfortable single-incision cholecystectomy: A comparison of robotic and laparoscopic approaches for single-incision surgery.

BACKGROUND: Although single-incision robotic cholecystectomy (SIRC) overcomes various limitations of single-incision laparoscopic cholecystectomy (SILC), it is associated with high cost. In this study, we intended to investigate if SIRC is recommendable and advantageous to patients despite its high cost. MATERIALS AND METHODS: We prospectively collected and analysed data of patients who had undergone either SILC (n = 25) or SIRC (n = 50) for benign gallbladder diseases, with identical inclusion criteria, between November 2017 and February 2019. RESULTS: SILC and SIRC showed similar operative outcomes in terms of intra- and post-operative complications and verbal numerical rating scale (VNRS) for pain. However, the SIRC group exhibited significantly longer operation time than the SILC group (83.2 ± 32.6 vs. 66.4 ± 32.8, P = 0.002). The SIRC group also showed longer hospital stay (2.4 ± 0.7 vs. 2.2 ± 0.6, P = 0.053). Although the SILC and SIRC groups showed no significant difference in VNRS, the SIRC group required a higher amount (126.0 ± 88.8 mg vs. 87.5 ± 79.7 mg, P = 0.063) and frequency (3.0 ± 2.1 vs. 2.0 ± 1.8, P = 0.033) of intravenous opioid analgesic administration. During surgery, the critical view of safety (CVS), the prerequisite for safe cholecystectomy, was identified in only 24% (n = 6) of patients undergoing SILC and in 100% (n = 50) of patients undergoing SIRC (P < 0.05). CONCLUSION: We conclude that although SILC and SIRC have similar operative outcomes, SIRC is advantageous over SILC because of its potential to markedly enhance the safety of patients by proficiently acquiring CVS.

Robotic cholecystectomy with a new port placement: Is it really beneficial?

OBJECTIVE: This study compared the effect of robotic cholecystectomy (RC) with a new port placement versus that of laparoscopic cholecystectomy (LC) on surgical pain and postoperative complications. METHODS: We prospectively collected medical data from 100 patients who underwent cholecystectomy (RC = 50, LC = 50) from March 2017 to January 2019. In the RC group, ports were positioned in the left-lower, mid-lower, and umbilical areas. In the LC group, ports were placed in the xiphoid, right-upper, and umbilical areas. RESULTS: Patient characteristics were similar between the two groups. Pain levels at 2, 4, and 8 h were significantly lower in the RC group than in the LC group (p = 0.04, 0.02, and 0.02, respectively). The LC group received more analgesics after surgery (RC = 0.3 ± 0.5 vs. LC = 0.7 ± 0.9, p = 0.03). However, the total medical cost was significantly higher in the RC group (RC = 7355.2 ± 1270.9 USD vs. LC = 4814.8 ± 1572.5 USD, p < 0.01). Mean operative time, length of hospital stay, and postoperative complications were not significantly different between the two groups. CONCLUSION: Regardless of the surgical procedure, postoperative complications were similar. RC with the new port placement can be recommended for patients who are more concerned about postoperative pain, incision, and hospital stay than surgical cost.

Early Outcomes of Robotic Single Site Cholecystectomy Using the DaVinci Xi® System.

PURPOSE: Robotic surgery has become an established alternative to conventional laparoscopy or single site laparoscopy by solving the problems of angulation, improving the ergonomics of single-incision technology, and overcoming the intrinsic limitations of single-incision laparoscopy. Although the robotic single site technology is non-wristed and, unlike other conventional robotic instruments, only provides rotation, the ergonomics are nevertheless excellent. Therefore, the objective of this study is to present our initial experience in robotic single site cholecystectomy (RSSC) by a surgeon. Through this, we suggest that RSSC could be a feasible and safe procedure for overcoming the shortcomings of single incision laparoscopic cholecystectomy (SILC). METHODS: This study is a retrospective data review of 74 patients who underwent RSSC between April 2019 and August 2020 at our institution. The demographic, pre-, and postoperative data were retrospectively collected. RESULTS: A total of 74 patients underwent RSSC. The mean age of patients was 44.7 ± 9.5 years, and their mean body mass index was 24 ± 3 kg/m2. Symptomatic gallbladder stone (56.8%) was the most common pre-operative diagnosis. Mean of total operation and docking times was 39.3 ± 12.5 (20 - 85) and 7.6 ± 3.1 (4 - 20) minutes, respectively. There was no conversion, additional port insertion, bleeding, or intra-operative complication; however, one patient had wound seroma. CONCLUSIONS: RSSC for uncomplicated gallbladder disease may serve as an excellent alternative to SILC or conventional laparoscopic cholecystectomy because of its low complication rates, good cosmesis, and ease of reproducibility without a substantial learning curve.

Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients.

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9 years, men = 77.9%, BMI = 31.2 ± 6.3 kg/m2) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2 years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3 kg/m2; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9 days, p < 0.001), EBL (32.3 ± 52.3 vs. 17.0 ± 43.1; p = 0.001), and conversion to open (6.6% vs. 0.6%, p = 0.001) were all superior with the robotic platform. Thirty-day overall morbidity (9.8% vs. 12.3%, p = 0.4), skin-to-skin OR time (84.5 ± 33.5 vs. 88.0 ± 35.3 min, p = 0.2), and total OR time (129.2 ± 36.8 vs. 129.7 ± 39.7, p = 0.9) were similar between the LC and RC groups. Despite being older and having more comorbidities, Veteran patients undergoing robotic cholecystectomy experienced equivalent OR time and a moderate improvement in conversion rate, EBL, and hospital LOS compared to those undergoing conventional laparoscopy, therein demonstrating the safety and efficacy of the robotic platform for this patient population.

Propensity score-matching analysis for single-site robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A retrospective cohort study.

BACKGROUND: Although the single-site robotic cholecystectomy(SSRC) has been performed with expectation of overcoming the limitation of single-incision laparoscopic cholecystectomy(SILC), there exists a lack of comparison studies involving SILC and SSRC. This study aimed to analyze surgical outcomes of single-site robotic cholecystectomy and single-incision laparoscopic cholecystectomy by propensity score-matching analysis. MATERIALS AND METHODS: From March 2009 to August 2015, 290 consecutive patients underwent SSRC or SILC at Severance Hospital, Seoul, Korea. Potential confounding factors for operative outcomes were adjusted by propensity score-matching analysis. One hundred four patients from each group were evaluated for perioperative outcomes and compared for a retrospective cohort study. RESULTS: There was no difference in potential cofounders such as gender, age, body mass index (BMI), and perioperative cholecystitis-related symptoms between two groups after propensity score-matching. However, mean operation time was shorter (56.69 ± 13.65 vs. 101.57 ± 27.05 min; p < 0.001) and median bleeding amount during surgery was less (0 (0-50) vs. 0 (0-100) mL; p < 0.001) in the SILC group. There was no significant difference between the two groups regarding conversion to conventional multiport cholecystectomy. Bile leakage due to perforation of the gallbladder during surgery was more common in the SILC group (6.7% vs. 17.3%; p = 0.019). Moreover, bile spillage rate was significantly increased in conjunction with a higher BMI in the SILC group, whereas BMI did not affect the bile leakage rate in the SSRC group. CONCLUSIONS: SSRC is not superior to SILC except regarding bile spillage incidence. However, the technical stability and clinically undetected advantages of SSRC are expected to prompt surgeons to perform this more reliable procedure.

Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study.

OBJECTIVE: The role of robotic surgery in general surgery (GS) continues to expand. Several programs have integrated robotic-based simulators and models into surgical education; however, residents' robotic experience in the operating room is currently limited. We sought to assess the safety and feasibility of robotic cholecystectomy (RC) when independently performed by GS chief residents. METHODS: From June 2016 to October 2018, RC and laparoscopic cholecystectomies (LC) performed independently by chief residents on a resident staff surgical service were prospectively included. Patient demographics, intraoperative variables, and postoperative complications were analyzed and compared between both cohorts. RESULTS: A total of 20 RC and 70 LC were included. Patient characteristics, indications for surgery, and comorbidities were similar in both groups. RC was more likely to be performed electively (95% vs. 17.1%, p < 0.001). No difference in operative time, estimated blood loss, intraoperative bile duct injury, or conversion to open was observed. Patients undergoing LC had an overall longer mean length of hospital stay (2.7 days ± 2.1 vs. 0.8 days ± 0.4, p < 0.001); however, length of hospital stay was similar between RC and LC performed electively (p = 0.946). No difference in postoperative complications and 30-day readmission was observed. CONCLUSIONS: RC can be safely and independently performed by GS residents with similar outcomes as LC. Efforts should be directed toward creating a platform to bridge competent simulator skills into safe performance in the operating suite. The integration of robotic training into the core GS curriculum should be encouraged.

Robotic Biliary Surgery.

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.