Cholecystectomy is one of the most commonly performed abdominal procedures with more than 600,000 performed annually in the United States. Laparoscopic cholecystectomy, first introduced in the 1980s, offered faster recovery time and a more cosmetic result making it the more favorable approach.
Since the introduction of the da Vinci surgical system in the early 2000s, robotic surgery has exhibited remarkable growth. The amount of robotic procedures performed worldwide has tripled since 2007. Despite the established superiority in operative precision via 3D visualization and increased dexterity, robotic surgery has faced criticism owing to reports of unfavorable cost implications.
Landmarks of Cholecystectomy
In 1882, Carl Langenbuch performed the first cholecystectomy in a patient concluding that the gallbladder should be removed “not because it contains stones, but because it forms them.” Cholecystectomy then became a standard surgery for gallbladder disease .
The next landmark in gallbladder surgery was in 1985, when the first laparoscopic gallbladder surgery was performed by Dr. Erich Mühe in Germany. Immediately he saw advantages over the traditional open approach with the immediate recovery stating “the approach was like magic.” Unfortunately, he was met with much skepticism by colleagues who rejected this novel approach .
It was not until laparoscopic cholecystectomy was performed in France that it began to spread globally. Dr Philippe Mouret of Lyon in France was a private surgeon who shared his practice with a gynecologist, who was performing laparoscopy.
He too never published his achievement, stating “I did not see any chance for publishing in a surgical journal.” Unlike Mühe, news of Mouret’s success spread throughout France.
Francois Dubois, a surgeon in Paris also performed a successful laparoscopic cholecystectomy and together with Jacques Perissat circulated news of this technique to the world. Laparoscopic cholecystectomy gradually became an attractive alternative to open cholecystectomy with its superior outcomes and is now the gold standard.
The next decade saw the introduction of single site laparoscopic cholecystectomy, with the first reports published in 1995. This approach hoped to achieve even more enhanced cosmesis and decreased post-operative pain.
Early versions of the technique utilized standard laparoscopic equipment via two 10 mm port incisions in the umbilicus. At the end of the procedure, the bridge of skin between the two incisions was cut to permit extraction of the gallbladder.
In 1997, this evolved to a single incision surgery technique where multiple ports could be placed through a single incision. In order to perform this type of surgery, surgeons use end articulating instruments and specialized ports.
In 2000, the FDA approved the first robotic surgery system. The first robotic cholecystectomy was performed on a human the following day.
The first series of robotic cholecystectomies soon followed in the last 15 years, and robotic cholecystectomy has become increasingly popular and has been established as a safe approach.
The robotic single site platform was introduced in December 2011 as a counterpart for multiport robotic surgery with an intention to reduce invasiveness of this procedure and to overcome some of the technical limitations of laparoscopy.
Advantages of Robotic Cholecystectomy
Some advantages of robotic platform are the 3D view, better instrument dexterity, improved ergonomics for the surgeon, enhanced stability, magnification, and electronic implementations that provide microsurgical precision and safety.
As compared to traditional surgical techniques, some potential benefits of laparoscopic or robotic cholecystectomy procedures include:
- A reduced risk of surgical complications
- Less pain
- A shorter hospital stay
- Faster recovery
- Minimal scarring
Significant benefits have resulted from the incorporation of specifically designed technology to the field of surgery. The implementation of robotics into this area is a clear example.
Robotic cholecystectomy may be considered equivalent to laparoscopic cholecystectomy in many aspects, but it is also more costly and, in some instances, lengthy.
A greater value of the robotic system for this operation may be found when performed as a single-site procedure.
The use of flexible curved instruments eliminates the phenomenon of coaxiality, thus avoiding external collisions and restoring triangulation, while the software reversal feature enables the surgeon to proceed without the awkward “mirror like” sensation.
Moreover, the learning curve associated with this procedure seems to be shorter than for LESS cholecystectomy.
The increased cost in robotic surgery, however, may be a related to it being a relatively new technology with limited competition. In hospitals with an established infrastructure for robotic surgery, there is potential for cost efficacy.
In a review from one institution, overall savings from supplies and instruments and shortened operating room times resulted in robotic cholecystectomy being more cost effective than laparoscopic cholecystectomy.
When comparing cost margin only at a private community hospital, there was no difference in cost between robotic and laparoscopic cholecystectomy.
A similar concern regarding cost existed when laparoscopic cholecystectomy was first introduced. Although laparoscopic surgery had increased costs, the savings resulted from decreased hospital stays.
Today, cholecystectomy is performed routinely as an outpatient procedure, and those that are hospitalized are able to be discharged after 1 day.
A possible area where robotic surgery can present a cost benefit is in the use of ICG vs. cholangiography and reduction in biliary injuries and subsequent surgeries and hospitalization.