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292
C. Benlice et al.
Fig. 22.4 Images of recurrent incisional hernia after prior rectus abdominus ap. Highlighting the
integrated previous mesh, large defect width of 20cm and the absence of rectus muscle
Hybrid Robotic Ventral Hernia Repair
The hybrid approach has become a preferred method for managing the complexities associated with recurrent incisional hernias, particularly those presenting
challenges such as closing massive hernia defects in various clinical scenarios,
including recurrence after rectus abdominis muscle ap, retrorectus repair, TAR,
and in conjunction with excision of massive skin and soft tissue necrosis
(Figs.22.5 and 22.6). Additionally, it optimizes operative times, particularly in
prolonged procedures involving extensive enterolysis and mesh removal. This
hybrid approach combines the precision of robotic dissection and component
separation with the efcacy of open fascial defect closure and mesh deployment.
Comparative studies with open repair have shown that hybrid robotic ventral hernia repair results in a shorter length of hospital stay while maintaining similar
rates of complication and wound morbidity.
22 Complex Robotic Abdominal Wall Reconstruction
293
Fig. 22.5 Pre, intra, and post images of hybrid TAR for a complex incisional hernia after an open
abdomen and hernia defect width of 24cm
294
C. Benlice et al.
Fig. 22.6 Pre- and postoperative images of hybrid robotic TAR for lateral incisional hernia
Conclusion
The utilization of robotic technology in retromuscular ventral hernia repair, with or
without the incorporation of transversus abdominis release, offers a distinctive advantage in restoring the functional integrity of the abdominal wall. This advanced surgical
22 Complex Robotic Abdominal Wall Reconstruction
295
approach allows for the precise reestablishment of the anatomical structure, ensuring
a robust closure. A key component of this procedure involves strategically placing
mesh in an extraperitoneal sublay position. By reinforcing the abdominal wall in this
manner, the mesh provides essential support and stability, contributing to the longterm durability of the repair. The robotic platform, with its enhanced dexterity and
three-dimensional optics, facilitates meticulous execution of these steps, enabling surgeons to achieve a comprehensive restoration of the abdominal wall’s functional anatomy. The integration of a comprehensive robotic approach in the management of
complex ventral hernia surgery aims to tackle technical challenges while enhancing
ergonomics. The distinctive feature of the fully robotic approach lies in overcoming
technical difculties, resulting in a streamlined surgical process and empowering surgeons to navigate the intricacies of complex abdominal wall anatomy with heightened
precision. The superior ergonomics offered by robotic systems alleviate physical
strain on the surgeon, ensuring sustained focus and dexterity throughout the procedure. As the realm of surgical innovation progresses, continuous scientic exploration
is expected to unveil further insights into the advantages of such advancements.
Despite inherent limitations concerning cost and potential operative time, optimism
surrounds the potential of complex ventral hernia surgery. Ongoing learning and
renement within the eld are anticipated to effectively address these challenges.
Conicts of Interest and Source of Funding Dr. Kudsi have received consultancy fees from
Intuitive Surgical and W.L.Gore outside the submitted work. Dr. Benlice and Dr. Baca have no
conicts of interest including relevant nancial interests, activities, relationships, and afliations.
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Robotic Cholecystectomy
23
SamuelCass, JenniferMoffett, andSarahSamreen
Introduction
Cholecystectomy repeatedly ranks as one of the most common procedures performed by general surgeons annually. With the evolution of robotic platforms, cholecystectomy has similarly risen as one of the most common robotic-assisted
surgeries performed by both trainees and surgeons in the United States [1–3]. The
advent of minimally invasive cholecystectomy began in the late 1980s with Mühe’s
description of the laparoscopic approach [4]. While initially met with hesitance,
laparoscopic cholecystectomy gained traction over the next decade, supported by
studies showing a reduction in postoperative pain, length of hospital stay, and
shorter recovery time, and ultimately became the standard of care approach [5, 6].
In the same way, robotic cholecystectomy has been increasingly adopted over the
past two decades following FDA approval in 2000 and the rapid evolution of robotic
platforms since this time.
As with other surgeries described in this manual, the high-denition 3-D optics
and wristed dexterity of robotic instruments aid dissection in patients with challenging biliary anatomy. Fluorescence cholangiography can additionally be utilized to
assist in visualization of the biliary tree in complex cases. Multiport robotic cholecystectomy (MPRC) has been shown to be safe, and when compared to the laparoscopic approach, it has demonstrated similar short-term surgical outcomes, as well
as similar operative times and hospital length of stay [7–10]. In a recent, widely
circulated retrospective study from 2010 to 2019, the robotic approach was found to
be associated with a slightly higher rate of bile duct injury compared to the laparoscopic approach (0.7% vs 0.2%, RR 3.2) [11]. However, this study had several limitations including an inability to account for surgical complexity as well as the
surgeon learning curve. As the experience with robotic cholecystectomy increases
S. Cass · J. Moffett · S. Samreen (*)
Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
e-mail: sasamree@UTMB.EDU
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_23
299
300
over time, prospective analyses of short- and long-term outcomes as well as costeffectiveness analyses will be needed.
This chapter serves to describe the perioperative management and intraoperative
techniques required for the safe application of multiport robotic cholecystectomy
for biliary disease.
S. Cass et al.
Indications
Overall, indications for cholecystectomy include symptomatic cholelithiasis, both calculous and acalculous cholecystitis, biliary dyskinesia, symptomatic gallbladder polyp
greater than 1cm, and gallstones >3cm. Additionally, complicated biliary diseases
including gallstone pancreatitis and choledocholithiasis warrant cholecystectomy with
intraoperative cholangiography [12]. Ultimately, robotic systems and laparoscopic
equipment are tools used to assist with cholecystectomy, and therefore, both approaches
can be utilized for similar indications. However, many favor the robotic platform for
patients with complex surgical or biliary anatomy due to the benets of increased visualization and the use of uorescence cholangiography. Contraindications are few and
relative but include signicant right upper quadrant abdominal surgery, end-stage cirrhosis, and complex cholecystoenteric stula. For single-port surgery, relative contraindications include BMI>50, need for cholangiography, or complex biliary pathology.
Robotic Equipment andtheOperative Team
The most utilized robotic systems are the da Vinci Xi and Si surgical systems
(Intuitive Surgical Inc., Sunnyvale, Ca) and will serve as the focus of the technical
descriptions herein. However, the details from this chapter can be extrapolated for
application of other systems that are either available or are currently in development.
The sterile component of the da Vinci system is the patient-side cart (PC) which
is draped in sterile fashion and docked at the operating table. The PSC has four
articulating robotic arms which control the endoscope and surgical instruments that
are docked to the ports. Away from the operating table, the surgeon console (SC)
serves as the working hub for the surgeon, equipped with high-denition, threedimensional visualization and the technical controls for surgical equipment on the
operative eld. The visual cart (VC) is the processing center communicating
between consoles, supporting hardware and software such as the optical light
source, electrosurgical unit, and optical integration.
A coordinated operating room team is needed for efcient and safe robotic cholecystectomy. Reasonable docking and anesthesia times are achieved when operating
teams consist of organized, well-trained personnel. In the OR, a circulating nurse and
scrub nurse who are trained in robotic systems assist with setup, robotic docking,
instrument exchange, and bedside assistance. Additionally, robotic equipment technicians assist with setup, troubleshooting, and locating robotic equipment, while a charge
nurse assists with supervising and coordinating cases between multiple robotic ORs.
23 Robotic Cholecystectomy
Fig. 23.1 Room layout
301
Room Setup andPatient Positioning
Patients are placed on the operating table in a supine position with all pressure
points padded. The instrument table and scrub nurse are at the feet, opposite of the
PC.For the da Vinci Xi, the rotating boom allows more freedom for the PC to be
positioned on either side of the patient. The patient’s arm on the side of the PC may
be tucked. The location of the SC and VC depends on the OR layout; however, we
recommend that SC placement allows for easy and direct visualization of the operative eld (Fig.23.1).
Port Placement andRobotic Docking
As with any minimally invasive case, the strategy for peritoneal entry depends on
patient factors including body habitus and prior surgical history. Generally, it is our
practice to obtain pneumoperitoneum with a Veress needle at Palmer’s point. The
abdomen is insufated to as low as 8mmHg, though standard pressure (12–15mmHg)
can be used if improved visualization is needed, and the patient’s hemodynamics
can tolerate the pressure. Next, we insert an 8mm robotic trocar in the supraumbilical region under direct visualization with a laparoscope. Note, we ensure to place
this port 15cm from the operative eld in the upper right quadrant. Alternatively,
entry can be achieved through an open technique or the Veress technique at this
supraumbilical site. Two 8mm ports are placed in the upper right quadrant at the
midclavicular and anterior axillary line. One 8mm port is placed in the upper left
quadrant at the midclavicular line, at the same level or slightly cephalad to the rightsided ports. We measure 8cm between ports to avoid instrument collision (Fig.23.2).
302
Fig. 23.2 Port placement
for cholecystectomy. The
camera is introduced into
arm 2, a ProGrasp is used
in arm 4 for gallbladder
retraction, and arms 1 and
3 are used for dissection of
the critical view with a
fenestrated bipolar
and hook
S. Cass et al.
The patient is placed in the reverse Trendelenburg position (10–15 degrees) and
tilted to the left side (3–5 degrees). After the pneumoperitoneum has been achieved
and robotic ports placed, the PC is driven to the patient and docked to the supraumbilical port. A 30 degree, downward-facing endoscope is introduced in arm 3 and
PC is targeted to the gallbladder. The remaining 8mm ports are docked with appropriate spacing and clearance to prevent arm collision and patient injury.
We typically use the following instruments: bipolar in the right lateral arm, camera in the mid-right port, permanent cautery hook at the umbilical port, ProGrasp in
the left upper quadrant, and a large clip applier exchanged at the umbilicus when
clipping the cystic duct and artery. A Maryland bipolar forceps can be added if ner,
blunt dissection is required. Monopolar curved scissors can be used for the sharp
division of adhesions or cystic structures if needed. A suction irrigator can be utilized for bleeding and gallbladder spillage.
Robotic Dissection
After identifying the gallbladder, the fundus is grasped and retracted cephalad over
the liver (ProGrasp). If any adhesions are encountered, these can be lysed with hook
cautery. The infundibulum of the gallbladder is then retracted laterally (f). In doing
so, the triangle of Calot is splayed open for better visualization of cystic structures.
Active manipulation of the infundibulum throughout the case provides dynamic
exposure and tension throughout the dissection.