Systematic review: robot-assisted versus conventional laparoscopic multiport cholecystectomy

Clinical Outcomes of Laparoscopic vs Robotic-Assisted Cholecystectomy in Acute Care Surgery

Importance

The use of robotic-assisted cholecystectomy in acute care surgery is increasing, but its safety and efficacy compared with laparoscopic cholecystectomy remain unclear.

Objective

To compare clinical outcomes and bile duct injury rates between robotic-assisted cholecystectomy and laparoscopic cholecystectomy in acute care surgery.

Design, Setting, and Participants

This was a retrospective cohort study using patient data from a commercial claims and encounter database from 2016 to 2021. Included in the study were adult patients undergoing robotic-assisted cholecystectomy or laparoscopic cholecystectomy in acute care surgery. Data were analyzed from January to October 2024.

Exposures

Robotic-assisted or laparoscopic cholecystectomy in acute care surgery.

Main Outcomes and Measures

The primary outcome was bile duct injury.

Results

A total of 844 428 patients (mean [SD] age, 45.6 [12.5] years; 547 665 female [64.9%]) were included in this analysis. After propensity score matching, robotic-assisted cholecystectomy (n = 35 037) and laparoscopic cholecystectomy (n = 35 037) had similar bile duct injury rates (0.37% [128 of 35 037] vs 0.39% [138 of 35 037]; odds ratio [OR], 0.93; 95% CI, 0.73-1.18; P = .54). Robotic-assisted cholecystectomy had higher major postoperative complications (8.37% [2934 of 35 037] vs 5.50% [1926 of 35 037]; OR, 1.57; 95% CI, 1.48-1.67; P < .001), more postoperative drain use (0.63% [219 of 35 037] vs 0.48% [132 of 35 037]; OR, 1.66; 95% CI, 1.34-2.07; P < .001), and longer median (IQR) hospital length of stay (3 [2-4] days vs 2 [1-4] days; P < .001).

Conclusions and Relevance

In this large, propensity-matched cohort analysis of acute care surgery cholecystectomy, robotic-assisted and laparoscopic cholecystectomy had similar bile duct injury rates, but robotic-assisted cholecystectomy was associated with higher postoperative complications, longer hospital stays, and increased drain use. Further research is needed to optimize the use of robotic-assisted cholecystectomy for acute gallbladder disease. These findings suggest that, under current practice conditions, robotic-assisted cholecystectomy may not offer clear benefits compared with the standard, established laparoscopic cholecystectomy approach.

An online trajectory guidance framework via imitation learning and interactive feedback in robot-assisted surgery

Improving the manipulation performance of surgical instruments is important for novice surgeons, as it directly affects the safety and outcome of robot-assisted surgery. To reduce the difference between expert and novice surgeons, learning the instrument movement trajectories generated by experts is an effective approach for novices to foster their muscle memory and improve manipulation skills. In this work, we propose an online trajectory guidance framework to generate expert-like movement trajectories so that novice surgeons can receive intra-operative trajectory guidance to achieve a similar manipulation performance as experts. First, Dynamic Movement Primitives (DMP) based Imitation Learning (IL) is implemented to model the 3D trajectories demonstrated by experts for adaptive trajectory generation at different start and end points. To introduce the obstacle avoidance capability into IL, we propose a vision-based strategy involving stereo reconstruction, object detection and segmentation to recover the 3D information of obstacles so that they can be coupled into DMP as an obstacle avoidance term. Furthermore, we introduce Augmented Reality (AR) and Interactive Feedback (IF) including visual and force feedback to enhance the trajectory reproduction accuracy of novice surgeons during operation. The experiment was conducted based on a 3D peg-transfer task in two different scenes (with changed start and end points, and with the obstacle present) using a standard da Vinci Research Kit robot. Ten non-expert human subjects were invited to evaluate the online trajectory guidance framework by reproducing the expert-like manipulation trajectories, and the experimental results showed that the novices with the assistance of AR and IF achieved promising trajectory reproduction performance (the mean distance error Emean was reduced by 76.47% and 65.15% in two different intra-operative scenes, respectively), narrowing the manipulation gap with experts.

Cholecystectomy with the Hugo™ robotic-assisted surgery system: the first general surgery clinical study in Korea

BACKGROUND

The Hugo™ Robotic-Assisted Surgery (RAS) System is an emergent device in the robotic surgery field. This study aims to describe the first general surgery-focused clinical study in Korea using the novel Hugo™ RAS System.

METHODS

This study was a prospective, single-center, single-arm, confirmatory clinical study conducted at Seoul National University Hospital where 20 cholecystectomies were performed. To evaluate the safety and performance of the Hugo™ RAS System the incidence of conversion to laparoscopy or open surgery, major complication (Clavien-Dindo Grade ≥ III) rate, overall complication rate, readmission rate, and reoperation rate were evaluated. All parameters were assessed within 30 days post-procedure. Any device deficiencies encountered during our initial experience and device data such as setup, console, and operative times were also reported.

RESULTS

We confirmed that our trial achieved the primary objective with a success rate of at least 95%. This was accomplished with no conversions to other types of surgery due to serious system malfunction and with only one major complication within 24 h post-procedure. The 20 consecutively enrolled patients had a median age and BMI of 58 years old and 23.9 kg/m2, respectively. The major complication rate was 10% (2/20 patients), the overall complication rate was 15% (3/20 patients), the readmission rate was 15% (3/20 patients), and the reoperation rate was 0% (0/20 patients). None of the complications were definitively device related. The median setup, console, and operative times were 16, 17, and 55 min, respectively. The device deficiency rate was 15% (3/20 patients), but all device deficiencies were minor, occurred before the first incision, and did not present a risk to the patient.

CONCLUSION

Based on our initial experience with the Hugo™ RAS System, cholecystectomy is feasible and safe. This trial is registered with ClinicalTrials.gov (NCT05715827).

Single-port robotic versus single-incision laparoscopic cholecystectomy in patients with BMI ≥ 25 kg/m2: a systematic review and meta-analysis

Previous studies have compared single-port robotic cholecystectomy (SPRC) to single-incision laparoscopic (SILC). However, there is not a systematic review and meta-analysis in patient with BMI ≥ 25 kg/m2 even though higher BMI is a risk factor for gallstone disease, a common indication for cholecystectomy. PubMed, Scopus and Cochrane Library were searched for related literature. Studies and data were extracted by two independent reviewers. Inverse variances weighted mean differences (WMD) with random effects model were used for continues values and odds ratios (OR) with random effects model using the Mantel-Haenszel's formula were used for dichotomous value. Heterogeneity using Higgins I2 and p values were calculated. Sensitivity analysis was performed for operative duration and intraoperative complications. In this meta-analysis, six studies involving a total of 734 patients examined SPRC and SILC. The analysis revealed a statistically significant increase in operative duration for SPRC compared to SILC, with a weighted mean difference of 26.67 min (95% CI 14.99, 38.34; I2 = 93%; Pheterogeneity < 0.00001; Poverall < 0.00001). Regarding conversion to multi-port cholecystectomy (MC), no statistically significant difference was found, yielding an odds ratio of 0.94 (95% CI 0.36, 2.45; I2 = 0%; Pheterogeneity = 0.78; Poverall = 0.89). Intra-operative blood loss showed non-significant differences, with a weighted mean difference of - 16.76 ml (95% CI - 48.56, 15.03; I2 = 78%; Pheterogeneity = 0.03; Poverall = 0.30). Length of hospitalization was significantly reduced by approximately half a day for SPRC compared to SILC, with a weighted mean difference of - 0.52 days (95% CI - 0.89, - 0.14; I2 = 0%; Pheterogeneity = 0.52; Poverall = 0.007). Intra-operative complications did not differ significantly between the techniques, resulting in an odds ratio of 0.59 (95% CI 0.19, 1.81; I2 = 70%; Pheterogeneity = 0.04; Poverall = 0.36). Finally, two studies evaluated bile leak rates, concluding no significant difference with an odds ratio of 0.86 (95% CI 0.39, 1.88; I2 = 23%; Pheterogeneity = 0.25; Poverall = 0.70). Sensitivity analyses indicated that no single study unduly influenced the results for operative duration, while one study was identified as a source of heterogeneity in intra-operative complications. SPRC is associated with longer operative duration, but shorter length of hospitalization in patients with BMI ≥ 25 kg/m2, compared to laparoscopic. Future studies should aim to examine incisional hernias rates as well as determine the long-term outcomes. PROSPERO registration: CRD42024602514.

Online videos of robotic-assisted cholecystectomies: more harm than good?

BACKGROUND

Many surgeons use online videos to learn. However, these videos vary in content, quality, and educational value. In the setting of recent work questioning the safety of robotic-assisted cholecystectomies, we aimed (1) to identify highly watched online videos of robotic-assisted cholecystectomies, (2) to determine whether these videos demonstrate suboptimal techniques, and (3) to compare videos based on platform.

METHODS

Two authors searched YouTube and a members-only Facebook group to identify highly watched videos of robotic-assisted cholecystectomies. Three members of the Society of American Gastrointestinal and Endoscopic Surgeons Safe Cholecystectomy Task Force then reviewed videos in random order. These three members rated each video using Sanford and Strasberg's six-point criteria for critical view of safety (CVS) scoring and the Parkland grading scale for cholecystitis. We performed regression to determine any association between Parkland grade and CVS score. We also compared scores between the YouTube and Facebook videos using a t test.

RESULTS

We identified 50 videos of robotic-assisted cholecystectomies, including 25 from YouTube and 25 from Facebook. Of the 50 videos, six demonstrated a top-down approach. The remaining 44 videos received a mean of 2.4 of 6 points for the CVS score (SD = 1.8). Overall, 4 of the 50 videos (8%) received a passing CVS score of 5 or 6. Videos received a mean of 2.4 of 5 points for the Parkland grade (SD = 0.9). Videos on YouTube had lower CVS scores than videos on Facebook (1.9 vs. 2.8, respectively), though this difference was not significant (p = 0.09). By regression, there was no association between Parkland grade and CVS score (p = 0.13).

CONCLUSION

Publicly available and closed-group online videos of robotic-assisted cholecystectomy demonstrated inadequate dissection and may be of limited educational value. Future work should center on introducing measures to identify and feature videos with high-quality techniques most useful to surgeons.

A Retrospective Analysis of Short-Term Outcomes of Robotic and Laparoscopic Cholecystectomy: An Indian Tertiary Care Comparative Experience

Background There has been a gradual adoption of general surgery robotic programs in India. However, we still do not have a single comparative study reporting the initial experience of robotic cholecystectomy (RC) compared to laparoscopic cholecystectomy (LC). This retrospective study is aimed at addressing this clinical data gap. Methods This is a retrospective medical chart review where data related to patient demographics, and intraoperative and postoperative outcomes were collected. All patients underwent either RC or LC for gallstone disease, performed by a single surgeon from January 2020 to September 2023. The surgeon had passed the learning curve for RC and this data collection reflects his post-learning curve experience. Results A total of 100 cases (RC: 50; LC: 50) were collected. Baseline parameters such as age, sex, BMI, and comorbidities were comparable. There were no conversions from the planned procedure in either of the groups (0% vs 0%). There were no intraoperative complications such as bleeding or common bile duct injury (0% vs 0%). The rates of surgical site infections (SSIs) were numerically lower in the robotic group, 2% vs 6% (p = 0.3099). There were no postoperative complications in the robotic group, whereas one patient in the laparoscopic group experienced port side bleeding (0% vs 2%, p = 0.3173). The mean length of hospital stay was one day in both groups. The mean pain score 24- hours after the surgery was 1.78 ± 0.68 in the robotic group and 3.3 ± 1.2 in the laparoscopic group (p = <0.001). None of the patients required opioid analgesics in the robotic group, whereas 20% of patients in the laparoscopic group needed at least one dose of opioid analgesics (p = 0.0009). There were no reoperations reported in the robotic group, whereas the laparoscopic group reported 1 case. The 30-day mortality was nil in both groups. Conclusion RC is feasible in Indian settings. Compared to LC, it does not increase morbidity. The improvement in acute postoperative pain can potentially allow early ambulation and recovery. A larger multicentric study, comparing RC to LC in India will validate our initial experience.

Comparative Analysis of Learning Curves in Robotic Versus Laparoscopic Cholecystectomy: A Systematic Review

Robotic surgery has undergone much development and increased use over the years; it has offered many benefits for the operating surgeon compared to the more restrictive nature of conventional laparoscopic surgery (CLS) which is the current standard of care. However, to the best of our knowledge, no studies have attempted to draw a comparison between the two in terms of the cases required for the learning curve to be achieved. The systematic review was performed at Barts Cancer Institute. A search of Cochrane, PubMed and Embase was made on 15 March 2024. Screening and risk of bias were done by two reviewers. Screening was done via the eligibility criteria by two reviewers. Data collection was done using Excel (Microsoft® Corp., Redmond, USA) and information was double-checked by another reviewer and transferred into a tabulated format. Seventeen studies were included, with the learning curve reported in 14 studies. The cases required to achieve the learning curve for multiport robotic cholecystectomy (MRC) ranged from 16 to 134 and for single-site robotic cholecystectomy (SSRC), it ranged from 10 to over 102 cases. Conventional laparoscopic cholecystectomy (CLC) was from 7 to 200. The improvement in operating times was measured in very different ways and was reported in 10 of the 17 studies. The studies that were available had a high level of heterogeneity making it difficult for comparisons to be made between studies. Several studies included only one surgeon resulting in the sample size of surgeons being too small and vulnerable to bias. As robotic surgery is still relatively novel, higher-quality studies have to be made in order for more conclusive conclusions to be made on the benefits of the learning curve of MRC and SSRC.

ROBOtic Care Outcomes Project for acute gallbladder pathology

BACKGROUND

Robotic cholecystectomy is being increasingly used for patients with acute gallbladder disease who present to the emergency department, but clinical evidence is limited. We aimed to compare the outcomes of emergent laparoscopic and robotic cholecystectomies in a large real-world database.

METHODS

Patients who received emergent laparoscopic or robotic cholecystectomies from 2020 to 2022 were identified from the Intuitive Custom Hospital Analytics database, based on deidentified extraction of electronic health record data from US hospitals. Conversion to open or subtotal cholecystectomy and complications were defined using ICD10 and/or CPT codes. Multivariate logistic regression with inverse probability treatment weighting (IPTW) was performed to compare clinical outcomes of laparoscopic versus robotic approach after balancing covariates. Cost analysis was performed with activity-based costing and adjustment for inflation.

RESULTS

Of 26,786 laparoscopic and 3,151 robotic emergent cholecystectomy patients being included, 64% were female, 60% were ≥45 years, and 24% were obese. Approximately 5.5% patients presented with pancreatitis, and 4% each presenting with sepsis and biliary obstruction. After IPTW, distributions of all baseline covariates were balanced. Robotic cholecystectomy decreased odds of conversion to open (odds ratio, 0.68; 95% confidence interval, 0.49-0.93; p = 0.035), but increased odds of subtotal cholecystectomy (odds ratio, 1.64; 95% confidence interval, 1.03-2.60; p = 0.037). Surgical site infection, readmission, length of stay, hospital acquired conditions, bile duct injury or leak, and hospital mortality were similar in both groups. There was no significant difference in hospital cost.

CONCLUSION

Robotic cholecystectomy has reduced odds of conversion to open and comparable complications, but increased odds of subtotal cholecystectomy compared with laparoscopic cholecystectomy for acute gallbladder diseases. Further work is required to assess the long-term implications of these differences.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Three-arm robotic cholecystectomy: a novel, cost-effective method of delivering and learning robotic surgery in upper GI surgery

Cholecystectomy is one of the commonest performed surgeries worldwide. With the introduction of robotic surgery, the numbers of robot-assisted cholecystectomies has risen over the past decade. Despite the proven use of this procedure as a training operation for those surgeons adopting robotics, the consumable cost of routine robotic cholecystectomy can be difficult to justify in the absence of evidence favouring or disputing this approach. Here, we describe a novel method for performing a robot-assisted cholecystectomy using a "three-arm" technique on the newer, 4th generation, da Vinci system. Whilst maintaining the ability to perform precision dissection, this method reduces the consumable cost by 46%. The initial series of 109 procedures proves this procedure to be safe, feasible, trainable and time efficient.