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Page 4 of 13 Zhu et al. Mini-invasive Surg 2023;7:12 https://dx.doi.org/10.20517/2574-1225.2022.117

to our inability to manipulate the infundibulum, we elected to take it first. Identification of the cystic artery
was confirmed by its proximity to Calot’s node, the observation that it bifurcated onto the gallbladder wall,
its caliber, and the absence of ICG. [Figure 1B and C] The cystic artery was clipped with a large plastic clip
and divided.

We tied a 0-vicryl tie around the infundibulum to facilitate sufficient lateral retraction and confirmed that
the posterior extent of the infundibulum, distended by stones, was drawn medially, and appeared to be
fused to the right side of the CHD. Using ICG fluorescent cholangiography dynamically, it appeared that
the infundibulum was distended by many large stones and moved with the CHD as one [Figure 2].

It was clear that a CVS could not be achieved, and the decision was made to proceed with a fundus-first
subtotal reconstituting cholecystectomy. A laparoscopic specimen retrieval bag was placed under the
infundibulum as the fundus was circumferentially dissected off the cystic plate. The 4th robotic arm was
brought in from under the left rib cage at the left anterior superior iliac spine and retracted the liver. The
liver was protected by a portion of a radiographically tagged sponge to diffuse the pressure of the robotic
grasper and avoid liver injury. After the gallbladder was placed in the specimen bag, the infundibulum was
opened, and ten 1-cm stones were removed without spillage. The wristed instruments helped to avoid
crushing gallstones or spilling stones or bile into the peritoneal cavity. Clear bile emanated from the orifice,
suggesting an increased likelihood of biliary fistula if the cystic duct was left open [Figure 3]. The
infundibular cuff was sutured from the inside to create a 2 cm pouch with a 3-0 V-lock suture in two layers
using a deep horizontal mattress and then superficial running stitch, which was easily accomplished due to
the dexterity and articulation of the robotic arms [Figure 4]. A radiographically tagged sponge was left over
the infundibular pouch while hemostasis was obtained and ICG reassuringly confirmed there was no bile
leaking from the pouch. A drain was left in place in the hepatorenal recess out of an abundance of caution.
The patient recovered from anesthesia and was discharged from the Post-Anesthesia Care Unit (PACU) in
stable condition. She returned to the clinic on postoperative day 5 for drain removal. Pathology showed
chronic cholecystitis.

Case presentation 2: RAL fundus-first subtotal fenestrating cholecystectomy
A 52-year-old male patient with hypertension and morbid obesity presented with choledocholithiasis
requiring multiple ERCPs. During the last procedure, the 1.1 cm CBD stone was successfully removed with
lithotripsy and balloon sphincteroplasty, and a covered metal stent was placed for tamponade of blood
oozing [Figure 5]. This procedure was complicated by E. coli bacteremia on postoperative day 1. After he
recovered, he was taken for RAL cholecystectomy. There were extensive adhesions between the omentum
and transverse mesocolon and the gallbladder. We worked laterally to get down the Gerota’s fascia and then
medially to accurately identify the gallbladder. We cleared the omentum off the porta hepatis and noted an
extensive fibrofatty scar anterior to the CBD obscuring most of the view. The infundibulum appeared to be
fused to a tubular structure we presumed to be the CBD [Figure 6].

The biliary anatomy was unclear, and no plane could be developed, so we proceeded fundus-first. The
gallbladder fundus was severely inflamed. A fundectomy was performed to retrieve a large gallstone and the
classic finding of “white” bile was identified, suggestive of persistent cystic duct obstruction, as expected
with the prior placement of the covered metal stent [Figure 7].

All retrieved gallstones and resected portions of the gallbladder wall were placed in a laparoscopic retrieval
bag. After the removal of the large gallstone, it became clear that the infundibulum remained fused to the
CBD, likely due to the covered metal stent. The tissue quality in this area was thick and fibrotic and would