By Suzanne A. Law, D.O., General and Breast Surgery
Since the 1990s, the standard treatment for gallbladder disease has been Laparoscopic Cholecystectomy. As the overall skill level of laparoscopic surgeons has increased, the conversion rate to open cholecystectomy has plummeted, now currently on the order of 2-10%, depending on the study. With the advent and widening use of robotic surgery, a debate has opened up regarding which minimally invasive surgery (MIS) method is best for cholecystectomy, or if there is any difference at all.
From the standpoint of the patient, there really is not any difference in terms of their immediate experience. Both procedures are done under general anesthesia, with 3 or 4 access ports, insufflation of the abdomen, and removal of the gallbladder through a small incision, usually at the umbilicus, typically with same day discharge for elective cases. Both procedures are amenable to single port surgery, although most MIS surgeons would say that robotic surgery is a far superior method for single port surgery due to the improved flexibility of the instrumentation. The only real difference in the immediate experience of the patient is the positioning of the access ports.
From the standpoint of the surgeon, however, the experience is quite different. Robotic surgery offers improved visualization of the anatomy with 3D optics, improved dexterity and precision with wristed instruments that offer enhanced articulation compared to “straight stick” laparoscopic technology, improved accuracy in identifying abnormal anatomy with real-time fluorescence imaging of the biliary tract, and greater control over the surgery with the ability to drive the camera as well as 2-3 instruments at the same time.
So why not do all cholecystectomies robotically? Critics of this approach cite the reported longer operative times and increased cost of robotic surgery over traditional laparoscopic cholecystectomy. Many early studies highlighted these disadvantages of robotic surgery. More recent studies, however, are showing that the gap in operative times between laparoscopic and robotic cholecystectomy is closing as robotic surgeons progress along the learning curve and dedicated robotic operative teams become much more efficient at setting up the operative field, positioning the patient, and docking the robot. Unfortunately, cost is still a factor, as the increased complexity of the instrumentation naturally translates into a higher cost per instrument. This can be offset slightly with more experienced surgeons who can accomplish more tasks with fewer instruments, but overall the instrumentation cost remains a little higher for robotics.
Early comparison studies suggested that there was no overall difference in outcomes for robotic vs. laparoscopic cholecystectomy, however, some studies have been able to demonstrate advantages of robotic surgery in terms of length of stay, 60-90 day readmission rate, blood loss, and conversion to open procedure. As the biliary system is one of the most variable organ systems in the human body, the ability to delineate the biliary tree with indocyanine green using fluorescence imaging technology offers a unique advantage toward avoiding the pitfalls in navigating the bile ducts over traditional laparoscopic cholecystectomy. Given this improved visualization and the increased precision of dissection with robotic surgery, it stands to reason that more serious complications such as bile duct injury would be lower, however, as the rate is already fairly low, about 1-5/1000, it is very difficult to reach enough power in a comparison study to statistically prove an advantage. Thankfully, in most elective cases, that advantage is not wholly necessary and most laparoscopic cholecystectomies proceed without incident, but, as any robotic surgeon can tell you, when you do see a biliary anomaly under fluorescence imaging and have that heart-stopping realization of what could have happened without it, that improved technology becomes indispensable in that moment. Unfortunately, you don’t know you’re going to need it until you need it, which is why many robotic surgeons prefer to do their elective cholecystectomies on the robot.
One of the biggest practical barriers to being able to do robotic assisted laparoscopic cholecystectomy can be availability of the robot. As the indications for robotic surgery expand, more surgeons are competing for time on the robot in each hospital, which is limited by the number of robots (usually 1-2 per hospital) and the availability of robotically-trained staff. Only hospitals with large robotic programs and multiple teams of trained robotic staff allow use of the robot outside of elective surgery hours. Because robotic time is limited, many surgeons default to laparoscopic cholecystectomy to be able to get those cases on the schedule in a timely fashion and save their robotic time for more complex cases, where the advantage is even bigger. In urgent or emergent cholecystectomies, where the improved visualization and precision may have an even greater advantage, the likelihood that the cases will be scheduled outside of elective operating hours decreases the likelihood that the robot will be available for use and many of these cases default to laparoscopic, as well. Thankfully, our track record with laparoscopic cholecystectomy is long and reassuring. Overall complications rates are relatively low, even in complex cases. A combined review of eight large studies of laparoscopic cholecystectomies reported the following types and frequencies of major complications: bleeding (0.11 to 1.97 percent), abscess (0.14 to 0.3 percent), bile leak (0.3 to 0.9 percent), biliary injury (0.26 to 0.6 percent), and bowel injury (0.14 to 0.35 percent). As robotic surgery continues to gain in surgeon experience and widespread use, its advantages may start to outweigh those of traditional laparoscopic cholecystectomy, but as of now, they are both considered safe and reliable options.
(Citations available upon request)