Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up.

Objectives: We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution. Methods: A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2. Results: Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8. Conclusion: TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.

Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis.

BACKGROUND: With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis. METHODS: This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed. RESULTS: All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery. CONCLUSIONS: Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.

[Expert consensus on the laparoscopic radical resection of gallbladder cancer(2023)].

The incidence of gallbladder cancer has been increasing. Radial resection is still the most promising curable treatment for patients with gallbladder cancer. Although the techniques required for laparoscopic radical resection of gallbladder cancer have matured, the number of reports is also on the rise, and laparoscopic radical resection of gallbladder cancer is still controversial. To standardize laparoscopic radical resection of gallbladder cancer, the Biliary Surgery Branch, Chinese Society of Surgery, Chinese Medical Association, together with the Chinese Medical Doctor Association in Chinese Committee of Biliary Surgeons, gathered experts to formulate recommendations and consensus on laparoscopic radical resection of gallbladder cancer. This consensus includes several parts: safety, preoperative evaluation, indications, surgical team, positioning of patient and trocars, intraoperative frozen examination, lymph node dissection, liver resection,bile duct resection, etc. Furthermore, suggestions on the principle of treatment, surgical procedures, and precautions were also provided for patients with delayed diagnoses of gallbladder cancer undergoing resection. This consensus aims to offer valuable suggestions for the standardization of laparoscopic radical resection of gallbladder cancer.

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.

BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS.

BACKGROUND: Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy. AIMS: To report a case of bile duct injury in a patient with situs inversus totalis. METHODS: A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis. RESULTS: The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis. CONCLUSIONS: Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

Advancing laparoscopy in resource-limited settings.

BACKGROUND: Although laparoscopic surgery has made remarkable progress and become the standard approach for various surgical procedures worldwide over the past 30 years, its establishment in low-resource settings, particularly in public hospitals, has been challenging. The lack of equipment and trained expertise has hindered its widespread adoption in these settings. Cholecystectomy is one of the most commonly performed procedures using laparoscopy world wide AIM: The aim of the study is to determine whether laparoscopic cholecystectomy is feasible in a resource challenged setting METHODS: The research focused on individuals who underwent laparoscopic or open cholecystectomies at Yekatit 12 Hospital in Addis Ababa, Ethiopia, over a one-year period. Comprehensive data collection was conducted prospectively, encompassing both intraoperative and postoperative parameters. Follow-up was carried out via phone calls. The surgical procedures employed innovative techniques, including the reuse of sterilized single-use equipment and the utilization of local resources. The evaluation involved a comparison of demographic information, intraoperative details (such as critical view determination and operative duration), and postoperative complications, including assessments of pain and wound infections RESULTS: From August 2021 to September 2022, 119 patients were assessed. Among these patients, 65 (54.6%) underwent open cholecystectomies, while the remaining 54 (45.4%) underwent laparoscopic cholecystectomies. The average duration of the laparoscopic cholecystectomies was 90.7 min, which is 17.7 min behind the open. Patients in the laparoscopy group had significantly shorter hospital stays than the open group, and 94% were discharged by post operative day 2. The conversion rate from laparoscopic to open surgery was determined to be 3.3% CONCLUSION: To sum up, the safe execution of laparoscopic cholecystectomies is feasible in public hospitals and settings with limited resources, given adequate training and resource distribution. The study findings showcased superior outcomes, including reduced hospitalization duration and fewer complications, while maintaining comparable levels of operative duration and patient satisfaction in both groups.

[Can laparoscopic surgery be the preferred strategy for gallbladder cancer?]

Gallbladder cancer, notoriously known for its high malignancy, predominantly requires radical surgery as the treatment of choice. Although laparoscopic techniques have become increasingly prevalent in abdominal surgeries in recent years, the progress of laparoscopic techniques in gallbladder cancer is relatively slow. Due to the anatomical complexity, technical difficulty, and biological features of gallbladder cancer that is prone to metastasis and dissemination, traditional open surgery is still the main surgical approach. This study aims to reappraisal the current state of laparoscopic surgery for gallbladder cancer by appraising clinical practice and research evidence. Laparoscopic surgery for various stages of gallbladder cancer, including early, advanced, incidental, and unresectable gallbladder cancer were discussed. The promise and limitations of laparoscopic techniques are systematically explored.

Operative efficiency: a comparative analysis of Versius and da Vinci robotic systems in abdominal surgery.

Robotic-assisted surgery has gained momentum in the pursuit of improved minimally invasive procedures. The adoption of new robotic platforms, such as the Versius, raises concerns about safety, efficacy, and learning curves. This study compares the Versius to the well-established da Vinci in terms of operative time and patient population. Retrospective data collection was conducted on patient data from inguinal hernia surgery, ventral hernia surgery, and cholecystectomies performed between February 2022 and March 2023 at the American Hospital of Dubai. Only experienced cases were included, ensuring proficiency with robotic technology. Versius had longer procedure times in inguinal and ventral hernia surgeries but not in cholecystectomy. No intraoperative complications were observed in either system. This study demonstrates that Versius can provide comparable outcomes to the da Vinci in abdominal surgery, with no observed intraoperative complications.

Comparative analysis of robotic single-site cholecystectomy outcomes between novice and expert surgeons.

Single-incision laparoscopic cholecystectomy (SILC) has declined in popularity, posing a challenge for novice surgeons. However, robotic single-site cholecystectomy (RSSC) has gained popularity in hepatopancreatic surgery, suggesting a paradigm shift in minimally invasive procedures due to the advantages of robotic platforms. The purpose of this study was to compare the surgical outcomes and learning curves between experts and novices without SILC experience, and discuss the utility and potential of RSSC for novice surgeons. A total of 235 patients underwent RSSC between April 2019 and June 2023 at the OOO University Hospital. Among them, 31 cases from novice and expert surgeons were selected to compare their initial experience. Comprehensive demographic and perioperative factors were analyzed and statistical comparisons were made, including cumulative sum analysis (CUSUM) for learning curves. The demographic factors showed no statistically significant differences between the two groups. Although the docking time (P < 0.001) and hospital stay (P = 0.014) were statistically significant, the total operative time and other perioperative factors were comparable. Novice surgeons demonstrated a shorter absolute total operative time, primarily attributed to differences in docking time. The CUSUM analysis indicated a shorter learning curve for novice surgeons. This study shows that the inherent benefits of the robotic platform make it an accessible and reproducible technique for novices. The benefits of integrating observational learning into robotic surgery training programs and the intrinsic advantages of the robotic platform in minimizing the learning curve for RSSC were also highlighted.

Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital.

BACKGROUND: We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle. METHODS: This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype. RESULTS: The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries. CONCLUSION: Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.

Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis.

INTRODUCTION: With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders. METHODS: Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality. RESULTS: Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 â€‹% vs. 1.6 â€‹%, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47). CONCLUSION: SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis.

OBJECTIVE: To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC). PATIENTS AND METHODS: A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching. RESULTS: Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor. CONCLUSION: EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

Acute cholecystitis: how to avoid subtotal cholecystectomy-preliminary results.

BACKGROUND: The aim of this manuscript is to illustrate a new method permitting safe cholecystectomy in terms of complications with respect to the common bile duct (CBD). METHODS: The core of this new technique is identification of the continuity of the cystic duct with the infundibulum. The cystic duct can be identified between the inner gallbladder wall and inflamed outer wall. RESULTS: In the last 2 years, from January 2019 until December 2021, 3 patients have been treated with the reported technique without complications. CONCLUSIONS: Among the various cholecystectomy procedures, this is a new approach that ensures the safety of the structures of Calot's triangle while providing the advantages gained from total removal of the gallbladder.

Retrospective multi-center study of robotic-assisted cholecystectomy: after-hours surgery and business-hours surgery outcomes.

The effect of robotic-assisted cholecystectomy (RAC), when performed after hours, on perioperative outcomes has not been evaluated against outcomes achieved during normal business hours. Subjects 18-80 years old who underwent da Vinci robotic-assisted cholecystectomy from August 2018 to February 2021 were included. Baseline and 30-day perioperative outcomes were retrospectively and consecutively collected and analyzed. Inverse probability treatment weighting (IPTW) was performed to balance patient characteristics between groups. A weighted comparative analysis was followed. Outcomes from 505 patients (after hours, n = 169; business hours, n = 336) undergoing RAC across 5 U.S. medical institutions were analyzed. The higher rates of acute cholecystitis and gallbladder inflammation, gangrene, and intraoperative abnormalities in the after-hours group were associated with higher rates of urgent cases and longer operative times-but not increased complication rates-compared to the business-hours group. There were no significant differences in rates of intraoperative or postoperative complications, readmissions, or reoperations. Integrated da Vinci Firefly fluorescence imaging system was used extensively, and the critical view of safety was achieved in > 96% of cases in both groups. No conversions occurred in the after-hours group compared to four conversions in the business-hours group (p = 0.0266). After-hours patients had shorter outpatient lengths of stay. No mortalities were reported for either group (p = 0.0139). After-hours RAC with integrated da Vinci Firefly imaging performed by surgeons experienced in RAC is associated with similar or improved outcomes than the same procedures during business hours in terms of complications, conversions, readmissions, reoperations, and length of stay. ClinicalTrials.gov identifier: NCT04551820; August 5, 2020.

Meta-analysis of fenestrating versus reconstituting subtotal cholecystectomy in the management of difficult gallbladder.

AIMS: To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder. METHODS: A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool. RESULTS: Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n = 353) or reconstituting (n = 237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR: 2.47, p = 0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD: -0.02, p = 0.86) or with (OR: 1.84, p = 0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD: -0.02, p = 0.16), need for postoperative ERCP (OR: 1.36, p = 0.49), wound infection (RD: 0.03, p = 0.27), re-operation (OR: 0.95, p = 0.95), gallbladder remnant cholecystitis (OR: 0.21, p = 0.09) or need for completion cholecystectomy (RD: 0.01, p = 0.59) between two groups. CONCLUSIONS: Fenestrating STC is associated with a higher risk of bile leak than the reconstructing technique. This issue can be mitigated by routine use of drains, delayed drain removal, and in selected cases endoscopic therapy. We encourage the fenestrating approach considering trends in improved short- and long-term outcomes.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION: Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC. METHODS: A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed. RESULTS: Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy. CONCLUSIONS: LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

Double cholecystectomy of duplex gallbladder associated with chronic cholecystitis in a cat.

A 6-year-old female neutered Persian cat presented with hyporexia and gradual weight loss over 6 months. Physical examination revealed cranial abdominal pain. Haematology and serum biochemistry were within normal limits. Abdominal ultrasonography and a computed tomography scan suggested a non-neoplastic mass compressing the gallbladder. During an exploratory laparotomy, a duplex gallbladder with two separate cystic ducts was diagnosed intraoperatively. The mass identified using the imaging techniques was an abnormal right gallbladder which was distended with immobile mucoid bile and a thickened wall. The left gallbladder and cystic duct were grossly normal. A cholecystectomy of both gallbladders was performed. Histopathology of the right gallbladder identified chronic cholecystitis. The cat made a good recovery from surgery and reported complete resolution of its hyporexia and a return to normal body weight. This is the first report of a successful cholecystectomy of a duplex gallbladder with chronic cholecystitis of a single gallbladder.

A rare case of urothelial carcinoma metastasizing to the gallbladder wall with manifestations as acute cholecystitis.

BACKGROUND: Metastasis to the gallbladder is very rare. This case report highlights a rare cause of acute cholecystitis, which should be considered by the surgeon and other treating physicians in the differential diagnosis of patients with urothelial carcinoma. CASE: We report the case of a 73 year-old man with follow-up oncology care. He was diagnosed with infiltrating urothelial carcinoma in 2019, received neoadjuvant chemotherapy, and subsequently underwent radical cystectomy with ureteroileostomy in April 2020. Histology confirmed complete regression of bladder cancer, the lymphonodes were also free of tumour infiltration. In July 2021, the patient was examined for intermittent abdominal pain, predominantly of the right upper quadrant. On clinical examination, the gallbladder hydrops was palpable and a positive Murphy's sign was present. Due to the signs of acute cholecystitis, the patient was indicated for acute cholecystectomy. Gallbladder histology revealed metastatic involvement of the gallbladder wall by urothelial carcinoma. CONCLUSION: If patients with bladder cancer present with intermittent right subcostal pain or signs of acute cholecystitis and diagnostic imaging shows a thickened gallbladder wall, clinicians and radiologists should consider the possibility of metastatic origin of lesion.

Patient outcomes and cost in robotic emergency general surgery.

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Oncologic safety of robotic extended cholecystectomy for gallbladder cancer.

BACKGROUND: Although laparoscopic cholecystectomy is applicable for the treatment of early gallbladder cancer (GBC), minimally invasive surgery is not widely used for advanced GBC. This is because advanced GBCs necessitate complicated surgical techniques, including lymph node dissection and liver resection. Robotic extended cholecystectomy (REC) is thought to overcome the limitations of laparoscopic surgery, but oncological safety studies are lacking. Therefore, in this study, we aimed to evaluate the oncologic outcomes of REC compared with those of open extended cholecystectomy (OEC). METHODS: A total of 125 patients, who underwent extended cholecystectomy for GBC with tentative T2 or higher stage between 2018 and 2021, were included and stratified by surgical methods. To minimize the confounding factors, 1:1 propensity-score matching was performed between the patients who underwent REC and those who underwent OEC. RESULTS: Regarding short-term outcomes, the REC group showed significantly lower estimated blood loss (382.7 vs. 717.2 mL, P = 0.020) and shorter hospital stay (6.9 vs. 8.5 days, P = 0.042) than the OEC group. In addition, the REC group had significantly lower subjective pain scores than the OEC group from the day of surgery through the 5th postoperative day (P = 0.006). Regarding long-term outcomes, there were no significant differences in the 3-year [5-year] overall survival (OS) and disease-free survival (DFS) rates between the REC group [OS, 92.3% (92.3%); DFS, 84.6% (72.5%)] and the OEC group [OS, 96.8% (96.8%); DFS, 78.2% (78.2%)] (P = 0.807 for OS and 0.991 for DFS). CONCLUSIONS: In this study, REC showed superior short-term outcomes to OEC and no difference in long-term survival outcomes. Additionally, REC was superior to OEC in terms of postoperative pain. Therefore, REC may be a feasible option with early recovery compared with OEC for patients with advanced GBC.