Minimally invasive cholecystectomy and common bile duct exploration offers single-stage management for complex gallstone disease (cholelithiasis and choledocholithiasis). The Robotic platform presents benefits in improving operative precision, which has not been extensively evaluated in the acute setting of managing complex gallstone disease, as well as in performing transcholedochal or postcholecystectomy common bile duct exploration. The authors report an early series of emergent and expedited robotic-assisted cholecystectomy with common bile duct exploration (RC-CBDE) or robotic common bile duct exploration (R-CBDE) alone.

A retrospective analysis from a specialist unit in the United Kingdom was undertaken from April 2022 to September 2023, inclusive. All patients who underwent RC-CBDE or R-CBDE were included. Data was collated on patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes.

Twenty-three consecutive patients were identified. The median (IQR) age was 51 (33-66) years. Median (IQR) Charlson Comorbidity Index (CCI) was 1 (0-4). Five patients underwent operative intervention as an emergency and 18 on an expedited basis. Two patients underwent postcholecystectomy R-CBDE. Fourteen (61%) were transcholedochal and nine were transcystic (39%) CBDE. Median (IQR) bilirubin was 51 (34-253). Median (IQR) operative time was 176 (124-222) minutes. Median (IQR) postoperative length of stay was 2 (0-4) days. There were no bile leaks requiring intervention. The clearance rate of CBDS was 100%. No patients developed postoperative pancreatitis. One patient required intervention for port site hernia following RC-CBDE. One patient developed subhepatic collection postoperatively and required laparoscopic washout and placement of drains. No patients had retained stones after a 3-month follow-up.

Early experience confirms that RC-CBDE and R-CBDE in feasible, safe, and effective treatment for complex gallstone disease. Integrated adjuncts (intraoperative robotic ultrasound - IORUS and Firefly - fluorescence guided surgery - FGS) and superior ergonomics of the robotic platform may assist in reducing the learning curve and increase wider uptake of this complex procedure.

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

This study aimed to describe the authors' early experience with robot-assisted common bile duct exploration (CBDE) for choledocholithiasis refractory to endoscopic therapy and to compare the outcomes with those of equivalent patients undergoing an open technique.

At our institution, 55 CBDEs were performed between 2005 and 2010. All 19 robot-assisted cases were unselected elective referrals for stone disease. Of 36 open procedures, emergency cases and exploration not for stone disease were excluded, leaving 18 cases for analysis. Cases were analyzed on an intent-to-treat basis. A P value of 0.05 denoted statistical significance.

The patients did not differ in terms of demography, comorbidity, or presenting symptoms. The reasons for endoscopic failure in both groups were similar. The mean operating time was longer for robot-assisted surgery (220 ± 41.26 min) than for open surgery (169 ± 65.81 min) (P = 0.01), but the median hospital stay was shorter (4 vs 11 days; P = 0.02). Four conversions to open surgery (21%) were performed due to severe adhesions. The two groups did not differ statistically in terms of T-tube usage (74 vs 61%; P = 0.414). One death occurred in the robotic group and two in the open cohort. Postoperative complications occurred in seven robotic and ten open cases (P = 0.402). They were mainly respiratory complications in the robot-assisted group, whereas they were cardiac and wound-related complications in the open group. Two of the converted cases had complications similar to those of the open group. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) for retained stones was performed in one open case and three robotic cases.

Robot-assisted CBDE offers some benefit when ERCP fails. Ideal case selection may enhance success.

Robotic surgery has emerged as one of the most promising surgical advances since its launch at the turn of the millennium. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary and pancreatic (HBP) surgery remains relatively unexplored. This article aims to evaluate the efficacy and outcomes of robotic HBP surgery in a single surgical center.

Between May 2009 and December 2010, all patients admitted to our unit for robotic HBP surgery were evaluated. A retrospective analysis of a prospectively maintained database on clinical outcomes was performed.

There were 55 robotic HBP operations performed during the study period. There were 27 robotic liver resections (left lateral sectionectomies n = 17, left hepatectomy n = 1, other segmentectomies n = 2 and wedge resections n = 7), 12 robotic pancreatic procedures (Whipple's operations n = 8, spleen-preserving distal pancreatectomies n = 2, double bypass n = 1 and cystojejunostomy n = 1) and 16 biliary procedures (biliary enteric bypass n = 9, bile duct exploration and related procedures n = 7). The median postoperative hospital stays for robotic liver resections, biliary procedures and pancreatic operations were 5.5 days (range 3-11 days), 6 days (range 4-11 days) and 12 days (range 6-21 days), respectively. Morbidities for liver resection, biliary procedures and pancreatic operations were 7.4, 18 and 33%, respectively. There was no mortality in our series.

Robotic surgery is feasible and can be safely performed in patients with complicated HBP pathologies. Further evaluation with clinical trials is required to validate its real benefits.

Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study.

We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot's triangle. The instruments were crossed to avoid "sword fighting" and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles.

All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70 min (±15) and 60 min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision.

Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.

We present a case of a 32-year-old female patient with the diagnosis of gallstone disease and choledocholithiasis. Prior to in vivo surgery, we practiced the critical steps of the procedure using a proposed inert training model. We performed a robot-assisted laparoscopic common bile duct exploration, obtaining one stone. The operating time was 140 min (console time: 120 min) with no complications during the procedure. The patient was discharged 2 days after the operation. Robot-assisted minimally invasive surgery of the common bile duct is a safe and effective procedure and seems to have some benefits over conventional laparoscopic surgery.

Robotic assistance or telemanipulation is the latest technological advance in minimally invasive surgery. Its future implementation will depend on the advantages that it can provide over standard laparoscopy or open surgery.

All Medline-cited papers (from case reports to reviews) about telemanipulators used in visceral surgery were assessed. The data in each paper were analysed to enable an up-to-date review of robot-assisted abdominal surgery by the most advanced telemanipulator (da Vinci).

Most papers presented case series demonstrating the feasibility of robotic technology in performing a specific procedure. Comparative studies of robot-assisted surgery versus standard laparoscopic or open surgery were usually matched cohort studies. They generally showed an increased operating time for robot-assisted procedures but with similar rates of conversion, intraoperative and postoperative complications, and mortality in comparison to those of laparoscopic surgery. Consistent long-term follow-up data were missing and only one randomized clinical trial was conducted.

Robot-assisted surgery appears safe and feasible for certain standard surgical procedures. However, at its current level of development, it offers no clear, significant advantage over standard laparoscopic techniques.