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Zhu et al. Mini-invasive Surg 2023;7:12 https://dx.doi.org/10.20517/2574-1225.2022.117 Page 3 of 13

Figure 1. Robotic instruments helped identify biliary anatomy. (A) The wristed instrument enabled clockwise rotation of the fundus
(white arrows) to displace the infundibulum anteriorly fused between the infundibulum and common hepatic duct (green oval); (B) use
of white light illumination; and (C) near-infrared fluorescence cholangiography with indocyanine green identified the absence of bile in
the putative cystic artery (white arrow).

Figure 2. A distended infundibulum with poor mobility was visualized by (A) fundal retraction using the wristed instruments and (B)
lateral retraction with 0-vicryl.

Figure 3. Clear bile was identified emanating from the cystic duct orifice, suggesting the creation of a biliary fistula if left open. A
reconstituting approach was thus taken.

midclavicular line, and the last 8 mm port is placed above the left anterior superior iliac spine. After the
robot is docked, the camera is placed in arm 2, the 12 mm port, for most of the procedure, then moved to
arm 3 for extraction of the specimen.

In accordance with the principles of the SAGES Safe Cholecystectomy Program, we first sought to
determine whether the CVS could be identified. We firmly grasped the thickened fundus and rolled it
clockwise toward the right shoulder to anteriorly displace the infundibulum [Figure 1A]. We identified the
common hepatic duct (CHD), confirmed the absence of bile flow in the putative cystic artery, and
confirmed one, and only one, bile containing tube exiting the gallbladder. The infundibulum was difficult to
manipulate and seemed tethered to the CHD. Based on the possibility that the cystic artery was contributing