A case report of robotic-assisted surgery as a valuable tool against difficult cholecystectomy

Introduction

Background

Cholecystectomy is one of the most commonly performed procedures in general surgery. In the United States alone, almost 1.2 million cholecystectomies per year are performed and 75.8% are done using a laparoscopic approach (1). Even with technical improvements over time, the rate of vasculo-biliary injuries associated with cholecystectomies is 0.2% to 1.1% (2).

Rationale and knowledge gap

Several scoring systems have been developed to define the severity of cholecystitis, a condition that has been the subject of extensive discussion over the years. These systems take into account various clinical and surgical factors to help classify the difficulty of managing these complex cases (3,4). Despite these efforts, no consensus has been developed to objectively define a “difficult gallbladder” scenario. Among literature, factors that define a “difficult gallbladder” includes severe inflammation that distorts the anatomy, making dissection a challenge. Examples include empyema, gangrene or perforation, Mirizzi syndrome, extensive adhesions, prior cholecystostomy attempts. The incidence of complex gallbladder cases is about 31%, with a rate of conversion to open surgery from a laparoscopic approach of 8% (5-7).

To overcome challenges during a difficult cholecystectomy, robotic surgery (da Vinci telesurgical robotic system, introduced in the year 2000 by Intuitive Surgical) has made a significant advancement in minimally invasive surgery. Compared to conventional laparoscopy, the robotic platform offers several advantages, including a high-definition 3D camera that overcomes the limitations of traditional 2D laparoscopic imaging, enhanced dexterity with 7 degrees of freedom (versus 4 in standard laparoscopy), and superior ergonomic design for the operating surgeon. These features contribute to improved precision and control, particularly in complex or technically challenging surgical scenarios (8-10). However, it is still a debate if cholecystectomies should be performed laparoscopically or robotically. Only a few studies are available, and no consensus has been made.

Objective

A previously aborted cholecystectomy typically reflects a highly complex operative field, often resulting from severe inflammation, dense adhesions, distorted biliary anatomy, or inadequate visualization of critical structures. These factors significantly increase the risk of intraoperative complications, particularly bile duct injury, when approached laparoscopically. In such challenging scenarios, the robotic surgical platform offers distinct technical advantages that may enhance safety and facilitate successful completion of the procedure in a series of cases of complex cholecystectomies (7). This report aims to contribute to the demonstration of the potential benefits of employing the robotic approach in the setting of a previously aborted cholecystectomy, highlighting its role in overcoming anatomical and technical difficulties that may otherwise preclude a minimally invasive completion. We present this article in accordance with the CARE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-60/rc).

Case presentation

This case presents a female patient in her 60s with a past medical history of diabetes, hyperlipidemia, hypertension, and a body mass index (BMI) of 26.9 kg/m² who underwent an attempt of laparoscopic cholecystectomy for acute cholecystitis 6 months prior at another institution where she presented with right upper quadrant abdominal pain and nausea. At that time, the procedure was aborted due to the presence of viscerovisceral and visceroparietal adhesions, potentially arising from a long-standing history of chronic cholecystitis, causing the inability to proceed with the dissection of the gallbladder.

The patient was referred to UI Health in February 2024, and was managed non-operatively, with the goal of waiting for the inflammation to temper over time. Laboratory results showed a white blood cell (WBC) count of 8.19×10³/µL, aspartate aminotransferase (AST) of 40 U/L, alanine aminotransferase (ALT) of 40 U/L, and alkaline phosphatase of 151 U/L. The patient improved and remained stable to the point that we were able to wait and plan a delayed cholecystectomy 6 months from the acute event. Since a complex anatomy was expected, the procedure was planned using a robotic-assisted approach. The procedure was explained to the patient and informed consent was signed. The procedure was performed by a trained attending surgeon specialized in minimally invasive and robotic surgery.

At the start of the surgical procedure, pneumoperitoneum was created with the insertion of a Veress needle in the left subcostal space at the intersection with the mammary line. An intraabdominal pressure of 14–15 mmHg of intraabdominal pressure was achieved, and the first trocar was inserted under direct vision in the left upper quadrant, approximately 2–3 cm below the Veress needle using a 5-mm port with Optiview technique. During initial exploratory laparoscopy, the gallbladder was not clearly visible and diffuse omental adhesions were completely covering the liver.

An 8-mm trocar for the robotic camera was placed on the right para rectal line. Two more robotic 8 mm ports were placed, one on the right flank and one on the left side of the camera. Finally, the initial 5 mm port was replaced with an 8 mm trocar for the fourth robotic arm. The port setup is shown in Figure 1. Later, the patient was positioned in reverse Trendelenburg with mild tilt to the left and the robot was docked.

Figure 1 Port setup. Numbers 1–3 indicate robotic arm trocars. S, scope.

The procedure began with the removal of omental adhesions from the liver. The duodenum was also found to be stuck to the area around the gallbladder. We used a mix of sharp dissection, blunt dissection, and monopolar energy to carefully separate these adhesions. After clearing the area, we were able to identify the gallbladder, which was contracted and deeply embedded within the liver (Figure 2). More adhesions were covering the inferior aspect of the gallbladder hilum, which were taken down by advancing from the lateral side of the gallbladder. As dissection progressed, we used indocyanine green (ICG) to identify an inferior structure that was likely the common bile duct (2.5 mg of ICG was administered intravenously 45 minutes before the beginning of the procedure). Due to ambiguous anatomy and the inability to safely achieve visualization of the D-line and safety line, an accepted alternative was to perform the top-down mobilization of the gallbladder to help identifying the cystic duct and the cystic artery. The fundus of the gallbladder was retracted upward using the fourth robotic arm and the gallbladder was dissected free from the liver bed as shown in Figure 3. We noted a large stone at the gallbladder infundibulum.

Figure 2 Omental and duodenal adhesions covering the gallbladder. D, duodenum; L, liver; OA, omental adhesions.

Figure 3 Gallbladder top-down dissection. CD, cystic duct; GB, gallbladder.

We dissected the gallbladder’s infundibulum from the surrounding tissue until a single structure was identified leading into the gallbladder. Using a monopolar cautery hook, we skeletonized the cystic duct. At this stage, ICG was used to clearly visualize the common bile duct and the point where the cystic duct branched off and entered the gallbladder (Figure 4), which was opened later and confirmed the presence of bile. The gallbladder was transected, and the cystic duct was clipped with a hem-o-lock clip.

Figure 4 Identification of CD and CBD with ICG. CBD, common bile duct; CD, cystic duct; GB, gallbladder; ICG, indocyanine green.

Once the gallbladder was taken off the liver bed, the robot was undocked. Using standard laparoscopy, the gallbladder was retrieved through the 8-mm port using an endo-bag. The operative time was 75 minutes and the estimated blood loss 20 mL. The patient was discharged on the same day since there were no perioperative complications and cholecystectomies are considered an outpatient procedure at our institution. The patient was followed up 2 weeks later; no complications were observed.

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Discussion

This case highlights the advantages of robotic surgery in difficult cholecystectomies where a previously aborted cholecystectomy now presents a distorted anatomy and dense adhesions. This supports several previous reports of similar cases published by Zhu et al. showing that a robotic approach is the ideal method in these complex situations (7).

The gold standard treatment for symptomatic cholelithiasis and acute cholecystitis remains the laparoscopic cholecystectomy. However, in difficult scenarios involving anatomical variations, acute inflammation, or extensive adhesions, laparoscopic dissection can become hazardous. In such situations, the decision to convert to an open approach must be carefully weighed. Robotic-assisted surgery offers a valuable alternative by combining the advantages of minimally invasive surgery with enhanced visualization and instrument dexterity. Appropriate port placement, patient positioning, and robotic docking are critical components of the operative strategy. In particular, the robotic fourth arm enables stable retraction, facilitating optimal exposure and minimizing reliance on a bedside assistant. In difficult cholecystectomy cases, the robotic platform allows for fine and meticulous dissection, enabling step-by-step identification of the anatomy. This careful approach helps minimize the risk of injury to vital structures and improves surgical safety (11,12).

In patients with previous surgical history or inflamed fields, careful lysis of adhesions is paramount. Our approach emphasizes a stepwise dissection strategy that begins with blunt dissection to define tissue planes. Sharp dissection and energy devices should only be used in areas that are clearly visible and safe. A core principle of this surgery is to re-establish anatomical landmarks early on, which ensures surgical decisions are based on what can be seen rather than on assumptions. Common techniques used to achieve this include the infundibulum-first, top-down, and semi-top-down (middle-first) approaches (4).

Surgical approaches for gallbladder removal vary based on the situation. The infundibulum-first technique is common but risks bile duct injury by misidentifying the common bile duct. In contrast, the top-down technique begins at the gallbladder fundus and proceeds downward, which can improve visibility. The semi-top-down approach blends these two methods, starting dissection above the infundibulum to provide better retraction before moving to the ducts. When these methods aren’t safe, intraluminal identification is an option where the gallbladder is opened to directly view the cystic duct, ensuring a precise dissection.

Use of the Critical View of Safety (CVS) in difficult cases

Another crucial factor in ensuring a safe cholecystectomy is the accurate identification of biliary anatomy. The primary methods utilized for this purpose include the CVS, intraoperative cholangiography (IOC), and fluorescent cholangiography using ICG.

The CVS, first described by Strasberg et al. requires three key steps before dividing any structure: complete clearance of all tissue and fibrosis from the hepatocystic triangle, identification of only two tubular structures entering the gallbladder (the cystic duct and artery), and detachment of the lower third of the gallbladder from the liver bed to expose the cystic plate (13).

IOC involves cannulation of the cystic duct and injection of contrast, followed by real-time radiography to delineate the biliary anatomy. However, IOC has technical limitations, such as difficulty in cannulating short or fibrotic cystic ducts, and it typically prolongs operative time. Its value depends on accurate interpretation, which requires specialized training and experience (14).

Fluorescent cholangiography with ICG offers several advantages. It does not significantly extend operative time and because ICG fluorescence can penetrate more than 1 cm of overlying tissue, it can be used from the beginning of the dissection to enhance visualization of the biliary anatomy in real time (15).

Advantages of robotic surgery in reoperative fields

The robotic platform provides significant advantages in these complex scenarios. High-definition 3D visualization and articulated instruments allow precise dissection even in confined spaces, such as the subhepatic recess or areas posterior to the liver. In our case, robotic tools enabled fine dissection and stable visualization, which would have been challenging with standard laparoscopy. Moreover, the ability to approach the anatomy from multiple angles without crowding the operative field enhances safety and efficiency. Lysis of adhesions and identification of the cystic duct would have extended the operative time and potentially complicated the surgery without the assistance of the robot.

Giulianotti described the role of robotic surgery in cholecystectomies, where the microsurgical capabilities of the robot provide advantages in difficult cholecystectomies and reduce the risk of biliary injuries. The use of ICG and near-infrared vision facilitates the identification of the anatomy avoiding radiation and lets the expert and less expert surgeons perform a safer procedure (10,16).

The robotic platform can also play a role in other complex fields, facilitating the common bile duct exploration for the management for complex gallstone disease. Latif et al. presented their early experience using intraoperative robotic ultrasound and fluorescence guided surgery in these scenarios showing its safety and effectiveness (17).

Limitations and considerations

Despite these advantages, robotic cholecystectomy faces significant barriers. High costs, limited availability of robotic systems, and the need for specialized training restrict its widespread adoption. Most robotic cholecystectomies for complex cases are currently performed in tertiary or academic centers. Additionally, longer operative times may be observed during the learning curve or in technically demanding cases. It is essential that surgeons be adequately trained and experienced with the robotic platform to maximize its potential benefits while minimizing risks. Ideal candidates for robotic cholecystectomy are those patients with obesity, prior abdominal surgeries, or challenging biliary anatomy.

Ultimately, the safety of the patient must remain the surgeon’s foremost concern. Recognizing when to pause, seek a second opinion, or convert to an alternative approach is a hallmark of sound surgical judgment, not inadequacy (18).

Conclusions

This case along with the literature research highlights that robotic surgery enables the safe completion of a complex cholecystectomy. In challenging biliary scenarios, dense adhesions or distorted anatomy, the enhanced precision, stability, and visualization offered by the robotic platform can provide critical advantages. Given these capabilities, the robotic approach should be considered a valuable tool in the management of complex or difficult cholecystectomies. Despite promising experiences, there remains a need for prospective, comparative studies evaluating outcomes between robotic and conventional laparoscopic cholecystectomy in high-complexity cases. Continued research will be essential to define the role of robotic surgery in expanding the boundaries of minimally invasive treatment in hepatobiliary surgery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-60/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-60/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-60/coif). F.B. serves as an unpaid editorial board member of AME Surgical Journal from May 2024 to June 2026. F.B. received honoraria for proctoring and teaching from Intuitive Surgical. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ng AP, Sanaiha Y, Bakhtiyar SS, et al. National analysis of cost disparities in robotic-assisted versus laparoscopic abdominal operations. Surgery 2023;173:1340-5. [Crossref] [PubMed]
2. Iwashita Y, Ohyama T, Honda G, et al. What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan-Korea-Taiwan multinational survey. J Hepatobiliary Pancreat Sci 2016;23:533-47.
3. Manuel-Vázquez A, Latorre-Fragua R, Alcázar C, et al. Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study. Int J Surg 2022;102:106649.
4. Seshadri A, Peitzman AB. The difficult cholecystectomy: What you need to know. J Trauma Acute Care Surg 2024;97:325-36. [Crossref] [PubMed]
5. Ramírez-Giraldo C, Alvarado-Valenzuela K, Isaza-Restrepo A, et al. Predicting the difficult laparoscopic cholecystectomy based on a preoperative scale. Updates Surg 2022;74:969-77. [Crossref] [PubMed]
6. Abdallah HS, Sedky MH, Sedky ZH. The difficult laparoscopic cholecystectomy: a narrative review. BMC Surg 2025;25:156. [Crossref] [PubMed]
7. Zhu G, Ifuku KA, Kirkwood KS. Robotic-assisted approach for complex cholecystectomies. Mini Invasive Surg 2023;7:12. [Crossref] [PubMed]
8. Zaman JA, Singh TP. The emerging role for robotics in cholecystectomy: the dawn of a new era? Hepatobiliary Surg Nutr 2018;7:21-8. [Crossref] [PubMed]
9. Kawka M, Jawad ZAR, Hakim D, et al. Robotic versus laparoscopic cholecystectomy for difficult gallbladders: an observational study of tertiary centre cases. Surg Endosc 2025;39:2958-63. [Crossref] [PubMed]
10. Giulianotti PC. Why I think the robot will be the future for laparoscopic cholecystectomies. Surgery 2017;161:637-8. [Crossref] [PubMed]
11. Coccolini F, Catena F, Pisano M, et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg 2015;18:196-204.
12. Fried GM, Barkun JS, Sigman HH, et al. Factors determining conversion to laparotomy in patients undergoing laparoscopic cholecystectomy. Am J Surg 1994;167:35-9; discussion 39-41. [Crossref] [PubMed]
13. Strasberg SM. A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review. J Hepatobiliary Pancreat Sci 2019;26:123-7. [Crossref] [PubMed]
14. Massarweh NN, Flum DR. Role of intraoperative cholangiography in avoiding bile duct injury. J Am Coll Surg 2007;204:656-64. [Crossref] [PubMed]
15. Goldstein SD, Lautz TB. Fluorescent Cholangiography During Laparoscopic Cholecystectomy: Shedding New Light on Biliary Anatomy. JAMA Surg 2020;155:978-9. [Crossref] [PubMed]
16. Manueli Laos EG, Schlottmann F, Masrur MA. Robotic Cholecystectomy in a Complete Situs Inversus Totalis Patient: a Game Changer Approach. J Gastrointest Surg 2023;27:3108-10. [Crossref] [PubMed]
17. Latif J, Mountjoy P, Lewis H, et al. Robotic assisted common bile duct exploration for management of complex gallstone disease. Int J Surg 2024;110:6418-25. [Crossref] [PubMed]
18. Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019;11:62-84. [Crossref] [PubMed]