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Prise en charge robotique de maladie biliaire complexe : description vidéo de 3 cas

Complex gallstone disease is amongst the most challenging pathologies encountered by hepatobiliary and pancreatic (HBP) surgeons. Conventionally, this condition requires open procedures in patients with morbid obesity. In this video, we present 3 cases of patients, demonstrating a minimally invasive approach using the da Vinci Xi™ surgical robotic system for the management of complex gallstone disease. The first patient presented with dropped gallstone with fistulisation, the second patient had a Mirizzi syndrome, and the third patient a cholecystocolonic fistula.

Case 1: The patient was a 75-year-old man with a history of diabetes and hypertension. He had undergone a laparoscopic cholecystectomy in its acute presentation phase 6 years earlier, at one of our referral hospitals. Subsequently, he developed a recurrent abscess with chronic discharge in the right flank. After multiple local drainage procedures and endoscopic retrograde cholangiopancreatography (ERCP) procedures, he was sent to our centre for the management of a suspected biliocutaneous fistula. We first suspected a ‘dropped stone' with resultant fistulisation and, since the cutaneous component had been drained recently, we opted for a surgical exploration of the intra-abdominal component of the abscess cavity.

Case 2: The patient was a 36-year-old lady with a BMI of 43. She presented to one of our referral hospitals with cholecystitis during the first wave of the COVID-19 pandemic and she was managed with a cholecystostomy tube. Subsequently, she developed obstructive jaundice. Imaging studies demonstrated a Mirizzi syndrome and a stent was inserted during ERCP. She was then referred for ongoing surgical management.

Case 3: The patient was a 58-year-old lady referred after a laparoscopy, with intent to proceed to a cholecystectomy at one of our referral institutions. Due to a major inflammatory change around the gallbladder, the procedure was abandoned. A magnetic resonance cholangiopancreatography (MRCP) showed the presence of a cholecystocolonic fistula. She was referred for definitive management.

The video chapters are described in the video.





Bibliography:

- Indications and Outcomes of Completion Cholecystectomy: A 5-year Experience From a Rural Tertiary Center. Alser O et al. Am Surg 2023 Nov;89(11):4584-4589. doi: 10.1177/00031348221124331. https://pubmed.ncbi.nlm.nih.gov/36031961/

- Cost analysis of robot-assisted choledochotomy and common bile duct exploration as an option for complex choledocholithiasis. Almamar et al. Surg Endosc 2018 Mar;32(3):1223-1227. doi: 10.1007/s00464-017-5795-3. https://pubmed.ncbi.nlm.nih.gov/28812193/

Robotic management of complex gallstone disease: video description of 3 cases

This is the case of a 71-year-old female patient presenting with colorectal cancer and liver metastases. The patient had previously undergone a laparotomic subtotal colectomy to address intestinal occlusion caused by an adenocarcinoma located in the stenotic descending colon. Six suspected secondary liver lesions were identified in liver segments VII, VIII, IV, VI, and V.

After undergoing 7 cycles of adjuvant chemotherapy, magnetic resonance imaging (MRI) showed a progression in hepatic lesions. A robotic extended right hepatectomy using the intrahepatic extra-Glissonian approach was therefore proposed to the patient.

This surgical technique allows precise control of the liver blood supply, minimizing the risks of bleeding and other surgical complications. Additionally, it provides improved visualization of the bile duct, helping to accurately identify and preserve biliary structures. The extra-Glissonian approach is complex and requires a specialized training and expertise. However, it can improve outcomes in patients undergoing a right hepatectomy.

**Bibliographic references:**

1\. Giordano M, Lopez-Ben S, Codina-Barreras A, Pardina B, Falgueras L, Torres-Bahi S, Albiol M, Castro E, Figueras J. Extra-Glissonian approach in liver resection. HPB (Oxford). 2010 Mar;12(2):94-100. doi: 10.1111/j.1477-2574.2009.00135.x. PMID: 20495652; PMCID: PMC2826666. Link: [https://pubmed.ncbi.nlm.nih.gov/20495652/](https://pubmed.ncbi.nlm.nih.gov/20495652/)

2\. Cresswell AB, Welsh FK, John TG, Rees M. Evaluation of intrahepatic, extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy. HPB (Oxford). 2009 Sep;11(6):493-8. doi: 10.1111/j.1477-2574.2009.00083.x. PMID: 19816613; PMCID: PMC2756636. Link: [https://pubmed.ncbi.nlm.nih.gov/19816613/](https://pubmed.ncbi.nlm.nih.gov/19816613/)

Robotic right hepatectomy using the intrahepatic extra-Glissonian approach and indocyanine green (ICG) fluorescence

Hépatectomie droite robotisée en utilisant la voie d’abord extraglissonienne intrahépatique et la fluorescence au vert d'indocyanine 

Background:

Laparoscopic fenestration (LF) for hepatic cysts is now considered a standard treatment for symptomatic and nonparasitic liver cysts. However, when resecting the cyst wall, it is difficult to identify all bile ducts, especially the smaller ones at risk for leakage. Indocyanine green-fluorescent cholangiography (ICG-FC) has recently been introduced intraoperatively to visualize and provide detailed information about the biliary tree. The authors report a case of LF with the intraoperative assistance of ICG-FC and three-dimensional multiparametric reconstruction (r3D).

Patient and methods:

This is the case of a 70-year-old male patient, ECOG 0, with a BMI of 21, Child-Pugh class A, and with a medical history of emphysema, chronic obstructive pulmonary disease (COPD), and Marfan’s syndrome with an endoscopically treated left aortoiliac aneurysm. In February 2021, shortness of breath, abdominal bloating, upper abdominal pain, and anorexia worsened. CT-scan showed multiple liver and splenic cysts. An r3D was acquired. ICG was administered intravenously at a dose of 0.3mg/kg one hour before surgery.

Results:

Intraperitoneal examination revealed three large cysts. There was a 10cm cyst in liver segments IV and V, another 16cm cyst in liver segments VI and VII, and another 22cm cyst in the left liver lobe, not at the level of the spleen, as erroneously shown on the preoperative CT-scan. The cysts were completely fenestrated. Intracystic bile ducts and bile leaks in the cysts were visualized with ICG-FC and clamping was achieved with a Hem-o-lok™ automatic clip applier. The patient was discharged early in good health condition.

Conclusions:

The use of ICG-FC in hepatobiliary surgery has become commonplace, and its use to identify the biliary tree is safe. ICG-FC and r3D play a key role in the prevention and treatment of bile duct injury during LF to minimize postoperative complications.

Bibliography:

1\. Boni L, David G, Mangano A, Dionigi G, Rausei S, Spampatti S, Cassinotti E, Fingerhut A. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc 2015 Jul;29(7):2046-55. doi: 10.1007/s00464-014-3895-x. Epub 2014 Oct 11. PMID: 25303914 PMCID: PMC4471386 DOI: 10.1007/s00464-014-3895-x

2\. Hanaki T, Yagyu T, Uchinaka E, Morimoto M, Watanabe J, Tokuyasu N, Takano S, Sakamoto T, Honjo S, Fujiwara Y. Avoidance of bile duct injury during laparoscopic liver cyst fenestration using indocyanine green: A case report. Clin Case Rep 2020 Jun 10;8(8):1419-1424. doi: 10.1002/ccr3.2840. eCollection 2020 Aug. PMID: 32884766 PMCID: PMC7455442 DOI: 10.1002/ccr3.2840

3\. Une N, Fujio A, Mitsugashira H, Kanai N, Saitoh Y, Ohta M, Sasaki K, Miyazawa K, Kashiwadate T, Nakanishi W, Tokodai K, Miyagi S, Unno M, Kamei T. Laparoscopic liver cyst fenestration with real-time indocyanine green fluorescence-guided surgery: a case report. J Surg Case Rep 2021 May 17;2021(5):rjab196. doi: 10.1093/jscr/rjab196. eCollection 2021 May. PMID: 34025978 PMCID: PMC8128400 DOI: 10.1093/jscr/rjab196

4\. Wilhelm D, Vogel T, Ostler D, Marahrens N, Kohn N, Koller S, Friess H, Kranzfelder M. Enhanced Visualization: From Intraoperative Tissue Differentiation to Augmented Reality. Visc Med 2018 Feb;34(1):52-59. doi: 10.1159/000485940. Epub 2018 Feb 16. PMID: 29594170 PMCID: PMC5869373 DOI: 10.1159/000485940

Laparoscopic liver cyst fenestration: use of ICG fluorescence 

Fenestration laparoscopique d'un kyste hépatique : utilisation de la fluorescence avec vert d'indocyanine

The advent of robotic systems has propelled minimally invasive surgery forward. However, the adoption of such systems in routine procedures is hindered by high costs and operational complexity (1). This mismatch between conventional telemanipulators and everyday surgical workflows demands innovative solutions to seamlessly integrate advanced robotics into the operating room.

This video showcases the Maestro System™ manufactured by Moon Surgical and its ScoPilot™ feature through a laparoscopic cholecystectomy use case. This dual arm system (2) reflects a significant progress in minimally invasive surgery as it allows for solo surgeries by providing real-time instrument tracking and enhanced ergonomics. First, a human study by Cadière et al. (3) showed surgical efficiency, safety, and surgeon satisfaction.

As artificial intelligence (AI) is gaining ground in the field of laparoscopic surgery with cholecystectomy as a largely studied use case (4), the ScoPilot™ feature, that allows the camera to follow instruments in real time, marks a pivotal shift toward highly efficient solo surgical procedures. By enabling precise real-time instrument tracking and reducing physical demands impacting surgical teams, it streamlines operations and surgical workflow. Its successful application in cholecystectomy cases underscores the system’s potential to improve standard procedures by reducing operative times and physical strain for surgical teams, promising a new era in digitally assisted solo surgeries.

Bibliography:

1. Higgins RM, Frelich MJ, Bosler ME, Gould JC. Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc. 2017 Jan;31(1):185-192. doi: 10.1007/s00464-016-4954-2. Epub 2016 May 2. PMID: 27139704.
2. Feasibility and safety study of the use of a new robot (MaestroTM) for laparoscopic surgery. \[Internet]. 2024 \[cited 2024 Mar 7]. Available from: [https://www.researchsquare.com](https://www.researchsquare.com)
3. Cadière GB, Himpens J, Poras M, Pau L, Boyer N, Cadière B. First human surgery using a surgical assistance robotics device for laparoscopic cholecystectomies. Surg Endosc. 2023 Oct;37(10):7812-7818. doi: 10.1007/s00464-023-10296-3. Epub 2023 Aug 21. PMID: 37605013; PMCID: PMC10520184.
4. Mascagni P, Vardazaryan A, Alapatt D, Urade T, Emre T, Fiorillo C, Pessaux P, Mutter D, Marescaux J, Costamagna G, Dallemagne B, Padoy N. Artificial Intelligence for Surgical Safety: Automatic Assessment of the Critical View of Safety in Laparoscopic Cholecystectomy Using Deep Learning. Ann Surg. 2022 May 1;275(5):955-961. doi: 10.1097/SLA.0000000000004351. Epub 2020 Nov 16. PMID: 33201104.

Empowered surgery using the Maestro System™ with its ScoPilot™ feature: a laparoscopic cholecystectomy use case

Chirurgie assistée par le Maestro System™ avec sa fonction ScoPilot™ : un cas d'utilisation lors d'une cholécystectomie laparoscopique

In this educational video, the authors demonstrate a hepaticojejunostomy for an extrahepatic cholangiocarcinoma type 1 according to the Bismuth-Corlette classification. One of the limitations of robotic surgery is the difficulty in adjusting the operative field once the focus is fixed and the robotic arms are placed on the target anatomy. The technique performed here solves this problem. 

This video shows the case of a 59-year-old male patient with no relevant medical history. The patient presents with a clinical history of asthenia, weight loss, and analytic parameters of dissociated cholestasis (total bilirubin 1.5 mg/dL, direct bilirubin 1 mg/dL, GGT 1993 UI/l, FA 378 UI/l, GOT 274 UI/l, GPT 509 UI/l, CA 19-9 91 UI/l). MRCP and CT-scan show a tumor in the common bile duct of 1cm in size below the hepatic confluence that involves the cystic duct. No signs of distant disease were noted, neither in the abdomen or thorax.



Take-home messages:

It is critical to set all organs in the same working field before docking, in order to decrease the number of movements of the robotic arms. 

The specimen should be removed ‘en bloc’. The gallbladder may be useful to mobilize the common bile duct. 

Intraoperative pathology assessment is needed. A duodenopancreatectomy or hepatic resection should be prepared in case it is indicated. 



Bibliography:

1. Radtke A, Königsrainer A. Surgical Therapy of Cholangiocarcinoma. Visc Med. 2016 Dec;32(6):422-426. doi: 10.1159/000452921. Epub 2016 Nov 30. PMID: 28229077; PMCID: PMC5290435.

2. Guadagni S, Comandatore A, Furbetta N, Di Franco G, Carpenito C, Bechini B, Vagelli F, Ramacciotti N, Palmeri M, Di Candio G, Morelli L. Robotic Hepatectomy plus Biliary Reconstruction for Bismuth Type III and Type IV Hilar Cholangiocarcinoma: State of the Art and Literature Review. J Pers Med. 2023 Dec 21;14(1):12. doi: 10.3390/jpm14010012. PMID: 38276227; PMCID: PMC10817587.

3. Banales JM, Marin JJG, Lamarca A, Rodrigues PM, Khan SA, Roberts LR, Cardinale V, Carpino G, Andersen JB, Braconi C, Calvisi DF, Perugorria MJ, Fabris L, Boulter L, Macias RIR, Gaudio E, Alvaro D, Gradilone SA, Strazzabosco M, Marzioni M, Coulouarn C, Fouassier L, Raggi C, Invernizzi P, Mertens JC, Moncsek A, Rizvi S, Heimbach J, Koerkamp BG, Bruix J, Forner A, Bridgewater J, Valle JW, Gores GJ. Cholangiocarcinoma 2020: the next horizon in mechanisms and management. Nat Rev Gastroenterol Hepatol. 2020 Sep;17(9):557-588. doi: 10.1038/s41575-020-0310-z. Epub 2020 Jun 30. PMID: 32606456; PMCID: PMC7447603.

Common bile duct cholangiocarcinoma managed with hepaticojejunostomy: robotic assisted approach

Cholangiocarcinome de la voie biliaire traité par hépaticojéjunostomie : intervention assistée par robot

video lecture

In this authoritative lecture, Dr. Armando Melani looks into indocyanine green (ICG) fluorescence and 3D CT image-guided robotic colorectal surgery.&#x20;

ICG fluorescence – 3D CT image-guided robotic colorectal surgery

Cure d'éventration ombilicale par technique robot-assistée de type r-TARUP avec renforcement prothétique 

Usually, medium-sized umbilical hernias are treated with an open approach since it is the most used technique. However, in situations of increased risk of surgical wound complications, such as immunosuppression, corticosteroid therapy, obesity or diabetes, as well as other associated hernia defects or diastasis of the rectus and in large hernias (>4cm), the use of the minimally invasive approach is indicated (1, 2). 

This video demonstrates a stepwise TARUP (transabdominal retromuscular umbilical prosthetic hernia repair) technique for hernia repair with mesh placement, with the use of the da Vinci Xi™ surgical robotic system, which offers a certain number of benefits.



References:

1. Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, et al. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. British Journal of Surgery 2020; 107:171–90.

2. Rodrigues V, López-Cano M. Técnica TARUP. Ventajas de la cirugía mínimamente invasiva de la pared abdominal asistida por robot. Cirugía Española 2021; 99:302–5.



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