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Page 2 of 13 Zhu et al. Mini-invasive Surg 2023;7:12 https://dx.doi.org/10.20517/2574-1225.2022.117

INTRODUCTION
Cholecystectomy represents one of the most common surgical procedures, with more than 500,000
performed minimally invasively annually in the US, according to the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES) . Although cholecystectomies are extremely common, the procedure is
[1]
not always simple. Inflammation and ambiguous or distorted anatomy are the hallmarks of a “Difficult
Gallbladder” and these qualities have been correlated with higher postoperative complications including bile
[2]
duct and vascular injuries that can be life-altering .
Published strategies to address these risks focus on obtaining a critical view of safety (CVS) and liberal use
of cholangiography . We and others have published modifications and alternatives to “routine” total
[3-5]
cholecystectomy, including a modified fundus-first subtotal approach, posterior infundibular, antegrade
approaches, and subtotal fenestrating and reconstituting cholecystectomy [6-10] . As every operation is
different, surgeons must have the knowledge of different techniques to move through their operation safely.
There are several avenues to pursue when faced with a difficult gallbladder. Conversion to open
cholecystectomy provides haptic feedback but does not always improve visualization of the anatomy. As a
result, the expectation that conversion will turn a difficult gallbladder into a straightforward case is
frequently not realized. Simply aborting the procedure or placing a cholecystostomy tube are options that
can delay the timing of definitive management and may be appropriate in the setting of severe acute
inflammation or to defer the case to a more experienced surgical team . Subtotal cholecystectomy, where a
[11]
portion of the gallbladder is removed and a small remnant is either left open (fenestrating) or closed
(reconstituting) with or without internal closure of the cyst duct, is often preferred as it provides durable
management [5,12] .

The use of robotic instruments has the potential to bring specific value to complex or difficult cases. In our
experience, we have found the use of the wristed instruments, three-dimensional camera, and the ability to
use indocyanine green (ICG) with integrated fluorescent imaging to be particularly useful in tackling the
challenges associated with resecting difficult gallbladders. Here we describe four cases of complex
cholecystectomies that highlight the algorithms and principles of approaching the difficult gallbladder using
a robotic-assisted laparoscopic (RAL) approach.

CASE REPORT
Case presentation 1: RAL fundus-first subtotal reconstituting cholecystectomy
A 62-year-old female patient presented with a week of nausea, vomiting, epigastric pain, anorexia, fever,
elevated liver function tests (LFTs), and ultrasound demonstrated choledocholithiasis without evidence of
cholecystitis. At the time of Endoscopic Retrograde Cholangiopancreatography (ERCP), she was found to
have three common bile duct (CBD) stones and underwent sphincterotomy and balloon sweep with stone
removal. She then underwent RAL cholecystectomy.

Per our usual routine, every patient is given 2.5-5 mg of indocyanine green (ICG) IV prior to induction. We
employ liberal use of indocyanine green, near-infrared (NIR) fluorescence cholangiography and robot-
integrated fluorescent imaging to image the biliary system. Since this procedure requires a specimen
extraction site, we prefer a longitudinal intraumbilical incision, which provides the best cosmesis. The
abdomen is insufflated with a Veress needle at the umbilicus and entered with an 8 mm bladeless robotic
trocar and optical obturator. This port, for the second robotic arm, is changed to a 12 mm port under direct
vision after the placement of an 8 mm port at the level of the umbilicus on the right for the first robotic arm.
This approach avoids harm caused by the attempted insertion of the blunt 12 mm robotic port. Under
direct laparoscopic visualization, a third 8 mm port is placed at the level of the umbilicus in the left