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Zhu et al. Mini-invasive Surg 2023;7:12 https://dx.doi.org/10.20517/2574-1225.2022.117 Page 11 of 13

silicone drain was left in the hepatorenal space adjacent to the duodenal repair. The patient did well
postoperatively, and the drain was removed on postoperative day 5. Pathology showed cholelithiasis without
cholecystitis.

DISCUSSION
The robot was a helpful tool in our management of these difficult gallbladders. Tao et al. found that robotic
cholecystectomies had a shorter hospital length of stay, less estimated blood loss, and less conversion to
[13]
open compared to laparoscopic cholecystectomies . In their series, thirty-day overall morbidity and total
operating room time were similar between groups. However, because surgery for benign gallbladder disease
generally has low complication rates, low blood loss, and quick recovery, results like these are not
consistent [14,15] . For minimally-invasive surgeons comfortable with using the robot, they may preferentially
use it to manage the complex biliary disease, so randomized control trials between robotic and laparoscopic
surgery are not practical.

The robotic approach provides value to other complex minimally-invasive biliary surgeries. Magge et al.
describe the definitive management of 6 cases of Mirizzi syndrome with the robot. They perform careful
dissections and Roux-en-Y hepaticojejunostomy reconstruction for three patients without conversion to
open . Similarly, Marino et al. successfully performed robotic-assisted hepaticojejunostomy for iatrogenic
[16]
bile duct injuries after laparoscopic cholecystectomy. They managed eight E2 injuries, two E1, and one E3
and E4 bile duct injury . Both authors found that the robotic platform improved their delivery of care with
[17]
selective delivery of energy, enhanced visualization, sophisticated instrumentations, filtering out hand
tremors leading to improved hand-eye coordination, and surgeon endurance and comfort.

We had similar experiences with these four cases that highlight the principles of operative management of
difficult gallbladders. The surgeon’s ability to perform a cholecystectomy safely without conversion to an
open operation is augmented by the use of the robotic platform, including the use of ICG and integrated
fluorescent imaging to evaluate biliary anatomy, superior optics and improved dexterity and precision.

The algorithm of operative decision making is illustrated in these four cases: predicting the success of safe
dissection of the hepatocystic triangle to obtain the CVS, strategic use of a fundus-first dissection to avoid
injury to nearby structures, and pivoting to subtotal fenestrating or reconstituting cholecystectomy when
the CVS cannot be obtained. Dynamic use of ICG cholangiography facilitates a safe dissection of the
hepatocystic triangle and infundibulum. In our experience, if the infundibulum and CHD move together
with lateral retraction, the structures are likely fused, and it would be unwise to pursue an aggressive
dissection in the region of the hepatocystic triangle. Instead, transitioning to a fundus-first subtotal
cholecystectomy and transection of the gallbladder above the hepatocystic triangle affords the opportunity
to leave the infundibular cuff adherent to the CHD and avoid bile duct injury. Once the gallbladder is open,
it is important to remove all the stones and carefully place them in a specimen bag. Our preference is then
to determine if bile emanates from the cystic duct orifice, which is easily seen inside the empty
infundibulum or in pools of accumulated ICG. In such cases, our preference is to close the infundibular
cuff, usually leaving a < 2.5 cm cuff, which is straightforward with the dexterity of the robotic instruments
using barbed absorbable sutures. We have not seen leaks or recurrent gallstones with this approach in 20
cases over 4 years (unpublished observations). If there is no bile emanating from the cystic duct orifice,
simple drainage is adequate. We have not seen postoperative biliary fistulas in these patients. In the rare
case in which a subtotal fenestrating resection is done and bile is seen intraoperatively via the cystic duct
orifice but neither the cuff nor the orifice can be closed due to poor tissue quality, we leave a 12Fr red
Robinson catheter inserted into the cystic duct orifice and a 19-French drain in the hepatorenal fossa. The