Performance of a predictive weight loss model in terms of rapid detection of inadequate weight loss after Roux-en-Y gastric bypass.

BACKGROUND: Predictive weight loss models can help patients meet their expectations after bariatric surgery and assist physicians in responding to deviations from the predicted weight. A model published by Seyssel et al. appears to accurately predict postoperative body mass index. OBJECTIVES: We aimed to demonstrate this model's performance in terms of rapid detection of insufficient weight loss (surgical nonresponse). SETTING: Cantonal Hospital, Switzerland. METHODS: We retrospectively analyzed weight and body mass index deviations at 2 years postoperatively, based on values predicted by the model of Seyssel et al. The primary outcome was the timing of detection of surgical nonresponse. The secondary outcome was how patients' weight loss expectations influenced their real weight loss. RESULTS: Between 2016 and 2019, 190 patients underwent Roux-en-Y gastric bypass. Of these patients, 36 were lost to follow-up and 154 were included in this study. At 24 months, 16 patients had surgical nonresponse, defined as a real weight of +1 standard deviation higher than that predicted. Among these patients, 44% had a weight of ≥+1 standard deviation higher than predicted at 3 months, and 63% at 12 months. The positive and negative predictive values at 12 months were 59% and 95%, respectively. Patients with a lower hypothetically wanted weight (38.5%) exhibited greater weight loss (P < .05). CONCLUSIONS: The predictive weight loss model of Seyssel et al. enables rapid detection of surgical nonresponse, allowing physicians to react as early as 3 months postsurgery. Patients' overestimation of postoperative weight loss was positively correlated with the actual weight loss achieved.

An effect of the COVID-19 pandemic: Significantly more complicated appendicitis due to delayed presentation of patients!

AIMS OF THE STUDY: The novel coronavirus pandemic has affected emergency department consultations for surgical pathologies. The aim of our study was to compare the number of acute appendicitis cases and the proportion of complicated appendicitis before and during the COVID-19 pandemic. METHODS: We retrospectively analyzed all data collected from a multi-center database of patients presenting to the emergency department for acute appendicitis during the COVID-19 pandemic from March 12 to June 6, 2020, and compared these data with those from the same periods in 2017, 2018, and 2019. The number of acute appendicitis cases, proportion of complicated appendicitis, and pre- and postoperative patient characteristics were evaluated. RESULTS: A total of 306 patients were included in this evaluation. Sixty-five patients presented during the 2020 COVID-19 pandemic lockdown (group A), and 241 patients in previous years (group B: 2017-2019). The number of consultations for acute appendicitis decreased by almost 20 percent during the pandemic compared with previous periods, with a significant increase in complicated appendicitis (52% in group A versus 20% in group B, p < 0,001.). Comparing the two groups, significant differences were also noted in the duration of symptoms (symptoms > 48h in 61% and 26%, p < 0,001), the intervention time (77 vs 61 minutes, p = 0,002), length of hospital stay (hospitalization of > 2 days in 63% and 32%, p < 0.001) and duration of antibiotic treatment (antibiotics > 3 days in 36% and 24% p = 0.001). CONCLUSIONS: The COVID-19 pandemic resulted in a decreased number of consultations for acute appendicitis, with a higher proportion of complicated appendicitis, most likely due to patient delay in consulting the emergency department at symptom onset. Patients and general practitioners should be aware of this problem to avoid a time delay from initial symptoms to consultation.

Perforated Meckel's Diverticulitis in a Patient with Unknown Intestinal Malrotation: Clinical Pitfall.

Symptomatic Meckel's diverticulum is rare in adults. The most frequent complications are intestinal obstruction and diverticulitis. Diagnosis of Meckel's diverticulitis can be challenging due to nonspecific clinical manifestation of pain in the right lower abdominal quadrant, mimicking acute appendicitis. If associated with congenital malformation, such as intestinal malrotation, the anomalous anatomy makes the diagnosis even more challenging. In such cases, radiological imaging is essential to guide further management. We present a case of Meckel's diverticulitis in which physicians were initially misguided because of the atypical clinical presentation. Yet, anamnestic details directed to a potential underlying malformation, leading to supplementary radiological examination and the final diagnosis.

Endometriotic Mass After Hysterectomy in a 61 Year Old Post-menopausal Woman: A Case Report and Update.

Endometriosis is a common, hormone-dependent gynecologic disease. Undiagnosed in large proportion of women, managing therapies depend on the impact of quality of life and includes hormonal treatment and pelvic surgery. Less likely endometriosis can occur in post-menopausal women. Malignant transformation of endometriosis is a rare but well-described process, most of time occurring in the ovary, and justifies the practitioner not to underestimate this pathology. We present a case of a 61 year old woman with a symptomatic endometriotic pelvic mass, status post hysterectomy, with no history of endometriosis diagnosed beforehand.

Pseudomyxoma Peritonei: A Case Report Diagnosed in a 47-Year-Old Woman with Chronic Pelvic Abdominal Pain and Appendicular Origin: Review of the Literature and Management.

The authors report a case of pseudomyxoma peritonei with gelatinous peritoneum in a 47-year-old-woman. The main symptom for discovery was a chronic pelvic abdominal pain. This disease is particularly rare. The gelatinous substance is often associated with a malignant ovarian tumor or appendicitis perforated. Currently, on the whole, an exploratory laparoscopy allows diagnosis, biopsies, and appendectomy. The treatment is essentially surgical. The prognosis depends on grade (1/3) and response to chemotherapy. This case was presented to the tumor board.

Roux-en-Y gastric bypass for super obese patients: what approach?

BACKGROUND: Super obese (SO) patients with a Body Mass Index (BMI) ≥ 50 kg/m(2) still represent a real anesthesiological and surgical challenge. While the best procedure to perform in this population remains unclear, robotic technology has been proposed to accomplish Roux-en-Y gastric bypass (RYGB). The study aim is to report our experience of robotic RYGB for SO patients and to compare it with open and laparoscopic surgery. METHODS: From July 1997 to March 2014, all consecutive RYGB cases for SO patients were collected in a dedicated database and reviewed retrospectively. Two hundred and fourteen SO patients were operated on: 65 by a robotic approach (30.4%), 54 by a laparoscopic approach (25.2%), and 95 using an open approach (44.4%). Peri- and post-operative data were compared between the three approaches. RESULTS: There were more male patients in the robotic group, but with a slightly lower BMI. The operative time was longer for the robotic (+27 min) and laparoscopic (+21 min) groups in comparison with the open group (P < 0.05). Overall, there were less reoperations (P < 0.05) and a shorter hospital stay (P < 0.05) in the robotic group in comparison with other groups. Of note there was also a trend in favor of robotics with less conversions (P = 0.08) and less postoperative complications (P ≥ 0.05). CONCLUSIONS: Robotic RYGB can be performed safely in super obese patients with results that compare favorably with laparoscopic and open surgery. However, the robotic approach has a longer operative time. The exact role of robotics for super obese population needs to be clarified in larger and randomized trials before drawing definitive conclusions. Copyright © 2015 John Wiley & Sons, Ltd.

Laparoscopic versus robotic Roux-en-Y gastric bypass: lessons and long-term follow-up learned from a large prospective monocentric study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) has become the procedure of choice for the treatment of morbid obesity. Recently, several reports have shown the potential advantages of the robotic approach, notably by reducing complications. The aim of this study is to report our long-term experience with robotic Roux-en-Y gastric bypass (RYGB) and to compare outcomes with the laparoscopic approach. METHODS: From January 2003 to September 2013, 777 consecutive minimally invasive RYGB have been performed in our institution: 389 laparoscopically (50.1 %) and 388 robotically (49.9 %). During the study period, all the data regarding these consecutive RYGB has been prospectively collected in a dedicated database. RESULTS: While longer in duration compared to laparoscopy (+30 min; p=0.0001), the robotic approach had a lower conversion rate (0.8 vs. 4.9 %; p=0.0007), and less complications (11.6 % vs. 16.7 %; p=0.05), in particular, less gastrointestinal leaks (0.3 vs. 3.6 %; p=0.0009). There were also less early reoperations (1 vs. 3.3 %; p=0.05) and a shorter hospital stay in the robotic group (6.2 vs. 10.4 days; p=0.0001). There were no statistical differences between the early and the current robotic experience, except in operative time and hospital stay, which were shorter for the last 100 cases. Finally, the BMI loss was significantly higher in the laparoscopic group starting at the first post-operative year. CONCLUSIONS: Robotic RYGB is not only safe and feasible, but also a valid option in comparison to laparoscopy. At the cost of a longer operative time, we observed better short-term outcomes with the robotic approach.

Perirenal fat surface area as a risk factor for morbidity after elective colorectal surgery.

BACKGROUND: Visceral obesity appears to be an emerging parameter affecting postoperative outcome after abdominal surgery. However, total visceral fat remains time consuming to calculate, and there is still a lack of data about its value as an independent risk factor in colorectal surgery. OBJECTIVES: The aim of this study was to validate the simple measurement of perirenal fat surface as a surrogate of visceral obesity, and to test the value of perirenal fat surface as a risk factor for morbidity in colorectal surgery and to compare it with the predictive value of other obesity parameters such as BMI and waist-hip ratio. DESIGN: This is a prospective observational cohort study. SETTING: The study was conducted at a tertiary university hospital. PATIENTS: Two hundred twenty-four consecutive patients (130 male) undergoing elective colorectal surgery with a mean age of 65.2 years (SD, ±12.9) were identified. INTERVENTION: Elective colorectal resections were performed. MAIN OUTCOME MEASURES: We assessed complications as the primary outcome measure. Secondary outcome measures were the conversion rates, duration of operation, and length of hospital stay. RESULTS: Perirenal fat surface was validated as a surrogate of visceral fat and a strong correlation between the 2 was confirmed (Spearman correlation coefficient ρ = 0.96). The overall postoperative complication rate was 22.8% (51/224) with 14.7% moderate complications (grade I and II) and 7.6% severe complications (grade III-IV), with a mortality rate of 0.5%. Multivariate analysis confirmed perirenal fat surface as an independent risk factor for postoperative complications (OR, 3.87; 95% CI, 1.73-8.64; p = 0.001), whereas BMI and waist-hip ratio were not statistically associated with postoperative complications (OR, 1.16; 95% CI, 0.51-2.66; p = 0.72). LIMITATIONS: This study was limited by its sample size. CONCLUSION: Perirenal fat surface is an excellent and easy-to-reproduce indicator of visceral fat volume. Furthermore, perirenal fat surface is an independent risk factor for postoperative outcome in colorectal surgery that appears to be of higher predictive value than BMI and waist-hip ratio.

Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery.

BACKGROUND: Revisional bariatric procedures (RBP) can be technically challenging. While robotics might provide help for complex procedures, the study aim was to report our experience with robotic RBP. METHODS: From March 2000 to June 2013, 60 consecutive RBP (11 robotic, 21 laparoscopic, 28 open) have been prospectively entered into a dedicated database and reviewed retrospectively. Outcomes have been compared between the three approaches. RESULTS: The robotic group had fewer complications (0 vs. 14.3% for laparoscopy, vs. 10.7% for open; P > 0.05), but took longer than the other approaches (352 vs. 270 vs. 250 minutes respectively; P < 0.05). There were fewer conversions in the robotic group (0 vs. 14.3% for laparoscopy; P > 0.05), and a significantly shorter hospital stay (6 vs. 8 vs. 9 days, respectively). CONCLUSIONS: Robotic RBP is feasible and safe, but at the price of a longer operative time. The exact role of robotics remains yet to be defined for this indication in larger studies.

Reliability of robotic system during general surgical procedures in a university hospital.

BACKGROUND: Data concerning the reliability of robotic systems are scarce, especially for general surgery. The aim of this study was to assess the incidence and consequences of robotic malfunction in a teaching institution. METHODS: From January 2006 to September 2012, 526 consecutive robotic general surgical procedures were performed. All failures were prospectively recorded in a computerized database and reviewed retrospectively. RESULTS: Robotic malfunctions occurred in 18 cases (3.4%). These dysfunctions concerned the robotic instruments in 9 cases, the robotic arms in 4 cases, the surgical console in 3 cases, and the optical system in 2 cases. Two malfunctions were considered critical, and 1 led to a laparoscopic conversion (conversion rate due to malfunction, .2%). Overall, there were more dysfunctions at the beginning of the study period (2006 to 2010) than more recently (2011 to 2012) (4.2% vs 2.6%, P = .35). CONCLUSIONS: The robotic system malfunction rate was low. Most malfunctions could be resolved during surgery, allowing the procedures to be completed safely. With increased experience, the system malfunction rate seems to be reduced.

Robotic single-site cholecystectomy.

BACKGROUND: Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy. METHODS: From February 2011 to February 2013, all consecutive robotic single site cholecystectomies (RSSC) were prospectively collected in a dedicated database. Demographic, intra- and postoperative data of all patients that underwent RSSC at our institution were analyzed. Data were evaluated for the overall patient cohort as well as after stratification according to patient BMI (body mass index) and surgeon's experience. RESULTS: During the study period, 82 patients underwent robotic single site cholecystectomy at our institution. The dominating preoperative diagnosis was cholelithiasis. Mean overall operative time was 91 min. Intraoperative complications occurred in 2.4% of cases. One conversion to open surgery due to the intraoperative finding of a gallbladder carcinoma was observed and two patients needed an additional laparoscopic trocar. The rate of postoperative complications was 4.9% with a mean length of stay of 2.4 days. No significant differences were observed when comparing results between robotic novices and robotic experts. Patients with higher BMI trended towards longer surgical console and overall operative time, but resulted in similar rates of conversions and complications when compared to normal weight patients. CONCLUSIONS: Robotic Single-Site cholecystectomy can be performed safely and effectively with low rates of complications and conversions in patients with differing BMI and by surgeons with varying levels of experience.

Robotic transanal endoscopic microsurgery: technical details for the lateral approach.

BACKGROUND: Transanal endoscopic microsurgery is a minimally invasive approach reserved for the resection of selected rectal tumors. However, this approach is technically demanding. Although robotic technology may overcome the limitations of this approach, the system can be difficult to dock, especially in the lithotomy position. OBJECTIVE: The study aim is thus to report the technical details of robotic transanal endoscopic microsurgery with the use of a lateral approach. DESIGN AND SETTINGS: This study is a prospective evaluation of robotic transanal endoscopic microsurgery in a single tertiary institution, under a protocol approved by our local ethics committee. INTERVENTION: Patients underwent a routine mechanical bowel preparation and were placed in the left or right lateral position according to the tumor location. A circular anal dilatator was used together with the glove port technique. The robotic system was then docked over the hip. A 30° optic and 2 articulated instruments were used with an additional assistant trocar. The tumor excision was realized with an atraumatic grasper and an articulated cautery hook, and the defect was closed with barbed continuous stiches in each case. MAIN OUTCOME MEASURE: The primary outcome was the safety and feasibility of the procedure. RESULTS: Three patients underwent a robotic transanal endoscopic microsurgery with the use of the lateral approach. Mean operative time was 110 minutes, including 20 minutes for the docking of the robot. There was 1 intraoperative complication (a pneumoperitoneum without intraabdominal lesion) and no postoperative complications. Mean hospital stay was 3 days. Margins were negative in all the cases. LIMITATIONS: The study was limited by the small number of patients. CONCLUSION: Robotic transanal endoscopic microsurgery with use of the lateral approach is feasible and may facilitate the local resection of small lesions of the mid and lower rectum. It might assume an important place in sphincter-preserving surgery, especially for selected and early rectal cancer (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A114).

[Robotic general surgery: where do we stand in 2013?]. / Chirurgie générale robotique: où en sommes-nous en 2013?

While the number of publications concerning robotic surgery is increasing, the level of evidence remains to be improved. The safety of robotic approach has been largely demonstrated, even for complex procedures. Yet, the objective advantages of this technology are still lacking in several fields, notably in comparison to laparoscopy. On the other hand, the development of robotic surgery is on its way, as the enthusiasm of the public and the surgical community can testify. Still, clear clinical indications remain to be determined in the field of general surgery. The study aim is to review the current literature on robotic general surgery and to give the reader an overview in 2013.

Early experience with robotic rectopexy.

BACKGROUND: The introduction of robotics in colorectal surgery has been gaining increasing acceptance. However, experience remains still limited for pelvic floor disorders. We report herein our first cases of fully robotic rectopexy and promontofixation for rectal prolapse. METHODS: From October 2011 to June 2012, five female patients underwent a robotic rectopexy at our institution. The patients were selected according to their primary pathology and their medical history for this preliminary experience. Four of them presented a rectal prolapse associated or not with a vaginal prolapse and the last patient presented a recurrent rectal prolapse 5 years after a laparoscopic repair. The study was approved by our local ethics committee. The robot da Vinci Si (Intuitive Surgical Inc, Sunnyvale, CA) was used with a 4-port setting in all cases. RESULTS: The mean operative time was 170 minutes (range: 120-270). There was no conversion. The blood loss was minimal. One patient presented a retrorectal hematoma, treated conservatively with success. There was no other complication. The mean hospital stay was 3.6 days (range: 2-7). At 2 months, there was neither recurrence nor readmission. In comparison with the laparoscopic approach, there were no statistically significant differences. CONCLUSIONS: Robotic rectopexy and promontofixation are feasible and safe. The outcomes are encouraging, but functional results and long-term outcomes are required to evaluate the exact role of robotics for rectal prolapse.

Learning tools and simulation in robotic surgery: state of the art.

Robotic surgery has emerged as a new technology over the last decade and has brought with it new challenges, particularly in terms of teaching and training. To overcome these challenges, robotic courses, virtual simulation, and dual consoles have been successfully introduced. In fact, there are several simulators currently on the market that have proven to be a valid option for training, especially for the novice trainee. Robotic courses have also found success around the world, allowing participants to implement robotic programs at their institution, typically with the help of a proctor. More recently, the dual console has enabled two surgeons to be operating at the same time. Having one experienced surgeon and one trainee each at his or her own console has made it an obvious choice for training. Although these methods have been successfully introduced, the data remain relatively scarce concerning their role in training. The aim of this article was to review the various methods and tools involved in the training of surgeons in robotic surgery.

Real-time near-infrared fluorescent cholangiography could shorten operative time during robotic single-site cholecystectomy.

BACKGROUND: With the introduction of a new platform, robotic single-site cholecystectomy (RSSC) has been reported as feasible and safe for selected cases. In parallel, the development of real-time near-infrared fluorescent cholangiography using indocyanine green (ICG) has been seen as a help during the dissection, even if the data are still preliminary. The study purpose is to report our experience with ICG RSSC and compare the outcomes to standard RSSC. METHODS: From February 2011 to December 2011, 44 selected patients underwent RSSC for symptomatic cholelithiasis. Among them, 23 (52.3%) were included in an experimental protocol using the ICG, and the remainder (47.7%) underwent standard RSSC. There was no randomization. The endpoints were the perioperative outcomes. This is a prospective study, approved by our local Ethics Committee. RESULTS: There were no differences in terms of patients' characteristics, except that there were more male patients in the ICG group (47.8 vs. 9.5%; p = 0.008). Regarding the surgical data, the overall operative time was shorter for the ICG group, especially for patients with a body mass index (BMI) ≤25 (-24 min) but without reaching statistical significance (p = 0.06). For BMI >25, no differences were observed. Otherwise, there were no differences in terms of conversion, complications, or length of stay between both groups. CONCLUSIONS: A RSSC with a real-time near-infrared fluorescent cholangiography can be performed safely. In addition, for selected patients with a low BMI, ICG could shorten the operative time during RSSC. Larger studies are still required before drawing definitive conclusions.

Augmented environments for the targeting of hepatic lesions during image-guided robotic liver surgery.

BACKGROUND: Stereotactic navigation technology can enhance guidance during surgery and enable the precise reproduction of planned surgical strategies. Currently, specific systems (such as the CAS-One system) are available for instrument guidance in open liver surgery. This study aims to evaluate the implementation of such a system for the targeting of hepatic tumors during robotic liver surgery. MATERIAL AND METHODS: Optical tracking references were attached to one of the robotic instruments and to the robotic endoscopic camera. After instrument and video calibration and patient-to-image registration, a virtual model of the tracked instrument and the available three-dimensional images of the liver were displayed directly within the robotic console, superimposed onto the endoscopic video image. An additional superimposed targeting viewer allowed for the visualization of the target tumor, relative to the tip of the instrument, for an assessment of the distance between the tumor and the tool for the realization of safe resection margins. RESULTS: Two cirrhotic patients underwent robotic navigated atypical hepatic resections for hepatocellular carcinoma. The augmented endoscopic view allowed for the definition of an accurate resection margin around the tumor. The overlay of reconstructed three-dimensional models was also used during parenchymal transection for the identification of vascular and biliary structures. Operative times were 240 min in the first case and 300 min in the second. There were no intraoperative complications. CONCLUSIONS: The da Vinci Surgical System provided an excellent platform for image-guided liver surgery with a stable optic and instrumentation. Robotic image guidance might improve the surgeon's orientation during the operation and increase accuracy in tumor resection. Further developments of this technological combination are needed to deal with organ deformation during surgery.

Stereoscopic augmented reality for da Vincii™ robotic biliary surgery.

INTRODUCTION: New laparoscopic techniques put distance between the surgeon and his patient. PRESENTATION OF CASE: 3D volume rendered images directly displayed in the da Vinci surgeon's console fill this gap by allowing the surgeon to fully immerse in its intervention. DISCUSSION: During the robotic operation the surgeon has a greater control on the procedure because he can stay more focused not being obliged to turn is sight out of his operative field. Moreover, thanks to depth perception of the rendered images he had a precise view of important anatomical structures. CONCLUSION: We describe our preliminary experience in the quest of computer-assisted robotic surgery.

Impact of robotic general surgery course on participants' surgical practice.

BACKGROUND: Courses, including lectures, live surgery, and hands-on session, are part of the recommended curriculum for robotic surgery. However, for general surgery, this approach is poorly reported. The study purpose was to evaluate the impact of robotic general surgery course on the practice of participants. METHODS: Between 2007 and 2011, 101 participants attended the Geneva International Robotic Surgery Course, held at the University Hospital of Geneva, Switzerland. This 2-day course included theory lectures, dry lab, live surgery, and hands-on session on cadavers. After a mean of 30.1 months (range, 2-48), a retrospective review of the participants' surgical practice was performed using online research and surveys. RESULTS: Among the 101 participants, there was a majority of general (58.4 %) and colorectal surgeons (10.9 %). Other specialties included urologists (7.9 %), gynecologists (6.9 %), pediatric surgeons (2 %), surgical oncologists (1 %), engineers (6.9 %), and others (5.9 %). Data were fully recorded in 99 % of cases; 46 % of participants started to perform robotic procedures after the course, whereas only 6.9 % were already familiar with the system before the course. In addition, 53 % of the attendees worked at an institution where a robotic system was already available. All (100 %) of participants who started a robotic program after the course had an available robotic system at their institution. CONCLUSIONS: A course that includes lectures, live surgery, and hands-on session with cadavers is an effective educational method for spreading robotic skills. However, this is especially true for participants whose institution already has a robotic system available.

Docking of the da Vinci Si Surgical System® with single-site technology.

BACKGROUND: Strategies to spare operating room (OR) times are crucial to limiting the costs involved in robotic surgery. Among other factors, the pre-operative set-up and docking phases have been incriminated at first to be time consuming. The docking process on the standard multiport da Vinci Surgical System has not been shown to significantly prolong the overall OR time. This study aims to analyse whether the length of the docking process on the new da Vinci Si Surgical System with Single-Site™ technology remains acceptable. METHODS: We prospectively analysed all of the robotic single-incision cholecystectomies performed at our institution for docking and operating times during 2011-2012. The docking task load was assessed each time in a self-administered fashion by the docking surgeon using the NASA TLX visual scale. RESULTS: Sixty-four robotic single-incision cholecystectomies were included and analysed. The mean operative time was 78 min. Two surgeons with previous robotic surgery experience and a group of three less experienced robotic surgeons were responsible for docking the system. They performed 45, 10 and nine dockings, respectively. The overall mean docking time was 6.4 min with no significant difference between the groups. The docking process represented approximately 8% of the operating time. The surgeon with the most procedures showed significant progress in his docking times. The different task load parameters did not show a statistical difference between the three groups, with the exception of the frustration parameter, which was higher in the group of less experienced surgeons. There were significant correlations between docking times and the assessment of the various task load parameters. CONCLUSION: The docking process for a robotic single-incision cholecystectomy is learned rapidly and does not significantly increase the overall OR time.