Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study

Single-surgeon training of 14 novice surgeons in robotic cholecystectomy: a study of 300 consecutive cases, assessing training outcomes and surgical performance

Robotic-assisted surgery (RAS) is a rapidly evolving field, requiring comprehensive training for widespread adoption. The aim of this study was to analyze the effectiveness of RAS cholecystectomy training in improving the technical skills and confidence of novice surgeons. Furthermore, the study examined the transferability of RAS skills to laparoscopic skills, the role of RAS cholecystectomies in reducing errors and improving patient outcomes, and identified factors that predict a successful transition from traditional laparoscopic surgery to RAS surgery. The RAST curriculum includes multimodal learning content delivered through a cloud-based platform, with three steps: basic training, simulation exercises, and structured on-patient training in the operating room. One general surgeon was trained on the Intuitive Surgical da Vinci system and assisted in performing 10 da Vinci-assisted laparoscopic cholecystectomies. In the first 300 patients who underwent robotic cholecystectomy, there were no major complications, conversions to laparoscopy, or open surgeries. The RAST curriculum demonstrates feasibility in providing a comprehensive and effective RAS training experience for surgical residents, reducing the need for extensive travel and high costs. The RAST curriculum is a promising solution for training surgical residents in RAS, with potential for widespread adoption and scalability.

Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform

BACKGROUND

The Hugo RAS™ system (Medtronic, Minneapolis, MN, USA), approved for gynaecological and urological procedures, has been recently certified for the use in few general surgeries. Only bariatric and colorectal procedures have been described so far.

METHODS

Here, we report the first worldwide experience with three cases of full-robotic cholecystectomies with the Hugo RAS™ system.

RESULTS

A description of the operative room setup, of the docking angles and details of the procedures is reported. Docking time was 12, 10, and 6 min, respectively. The total operative time was 105 min in the first case, 100 min in the second and 88 in the third case. Intra- and post-operative courses were uneventful.

CONCLUSIONS

With this pre-defined set up, the innovative conformation of Hugo RAS™ system can safely allow performing full robotic cholecystectomy avoiding the need for additional ports.

Cost-effectiveness analysis of robotic cholecystectomy in the treatment of benign gallbladder disease

BACKGROUND

Laparoscopic cholecystectomy is the current standard of care treatment for benign gallbladder disease. Robotic cholecystectomy is another approach for performing cholecystectomy that offers a surgeon better dexterity and visualization. However, robotic cholecystectomy may increase cost without sufficient evidence to suggest an improvement in clinical outcomes. The purpose of this study was to construct a decision tree model to compare cost-effectiveness of laparoscopic cholecystectomy and robotic cholecystectomy.

METHODS

Complication rates and effectiveness associated with robotic cholecystectomy and laparoscopic cholecystectomy over a 1-year time frame were compared using a decision tree model populated with data from the published literature. Cost was calculated using Medicare data. Effectiveness was represented by quality-adjusted life-years. The primary outcome of the study was incremental cost-effectiveness ratio, which compares the cost per quality-adjusted life-year of the 2 interventions. The willingness-to-pay threshold was set at $100,000/quality-adjusted life-year. Results were confirmed with 1-way, 2-way, and probabilistic sensitivity analyses varying branch-point probabilities.

RESULTS

The studies used in our analysis included 3,498 patients who underwent laparoscopic cholecystectomy, 1,833 patients who underwent robotic cholecystectomy, and 392 patients who required conversion to open cholecystectomy. Laparoscopic cholecystectomy produced 0.9722 quality-adjusted life-years, costing $9,370.06. Robotic cholecystectomy produced an additional 0.0017 quality-adjusted life-years at an additional $3,013.64. These results equate to an incremental cost-effectiveness ratio of $1,795,735.21/quality-adjusted life-year. This exceeds the willingness-to-pay threshold, making laparoscopic cholecystectomy the more cost-effective strategy. Sensitivity analyses did not alter results.

CONCLUSION

Traditional laparoscopic cholecystectomy is the more cost-effective treatment modality for benign gallbladder disease. At present, robotic cholecystectomy is not able to improve clinical outcomes enough to justify its added cost.

Intraoperative and postoperative outcomes of robot-assisted cholecystectomy: a systematic review

BACKGROUND

Rapid adoption of robotic-assisted general surgery procedures, particularly for cholecystectomy, continues while questions remain about its benefits and utility. The objective of this study was to compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach.

METHODS

A literature search was performed from January 2010 to March 2020, and a narrative analysis was performed as studies were heterogeneous.

RESULTS

Of 887 articles screened, 44 met the inclusion criteria (range 20-735,537 patients). Four were randomized controlled trials, and four used propensity-matching. There were variable comparisons between operative techniques with only 19 out of 44 studies comparing techniques using the same number of ports. Operating room time was longer for the robot-assisted technique in the majority of studies (range 11-55 min for 22 studies, p < 0.05; 15 studies showed no difference; two studies showed shorter laparoscopic times), while conversion rates and intraoperative complications were not different. No differences were detected for the length of stay, surgical site infection, or readmissions. Across studies comparing single-port robot-assisted to multi-port laparoscopic cholecystectomy, there was a higher rate of incisional hernia; however, no differences were noted when comparing single-port robot-assisted to single-port laparoscopic cholecystectomy.

CONCLUSIONS

Clinical outcomes were similar for benign, elective gallbladder disease for robot-assisted compared with laparoscopic cholecystectomy. Overall, the rates of complications were low. More high-quality studies are needed as the robot-assisted technique expands to more complex gallbladder disease, where its utility may prove increasingly beneficial.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020156945.

Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9 years, men = 77.9%, BMI = 31.2 ± 6.3 kg/m²) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2 years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3 kg/m²; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9 days, p < 0.001), EBL (32.3 ± 52.3 vs. 17.0 ± 43.1; p = 0.001), and conversion to open (6.6% vs. 0.6%, p = 0.001) were all superior with the robotic platform. Thirty-day overall morbidity (9.8% vs. 12.3%, p = 0.4), skin-to-skin OR time (84.5 ± 33.5 vs. 88.0 ± 35.3 min, p = 0.2), and total OR time (129.2 ± 36.8 vs. 129.7 ± 39.7, p = 0.9) were similar between the LC and RC groups. Despite being older and having more comorbidities, Veteran patients undergoing robotic cholecystectomy experienced equivalent OR time and a moderate improvement in conversion rate, EBL, and hospital LOS compared to those undergoing conventional laparoscopy, therein demonstrating the safety and efficacy of the robotic platform for this patient population.