Invited Commentary <\/p>\n\n\n\n
September 20, 2023<\/p>\n\n\n\n
Thirty-five years ago, the rapid adoption of laparoscopic cholecystectomy ushered in the minimally invasive surgical revolution. Combining 2 preexisting and safe operations, this transformative innovation nonetheless resulted in unexpected patient harms: a significant increase in bile duct injuries during the learning curve.1<\/a><\/sup><\/a><\/p>\n\n\n\n Is history repeating itself with the introduction of robotic approaches? The advanced visualization, dexterity, and data analytics of robotic platforms may extend the benefits of minimally invasive surgery to highly complex procedures and perhaps enhance safety through future innovations like task automation, molecular imaging, and artificial intelligence\u2013driven decision support. However, the rapid growth of robotic surgery in the United States is occurring in such common general surgical procedures as inguinal hernia and cholecystectomy, where traditional laparoscopic approaches already have excellent results.<\/a><\/p>\n\n\n\n Kalata et al2<\/a><\/sup> now raise safety concerns about robotic compared with laparoscopic cholecystectomy. In an elegant study of Medicare administrative claims, robotic cholecystectomy was associated with a higher rate of severe bile duct injuries (0.72% vs 0.23%), postoperative biliary interventions (7.4% vs 6.0%), and serious complications (9.3% vs 8.6%). This pattern was consistent across sensitivity analyses and was mitigated in hospitals with a higher volume of robotic procedures, suggesting a learning-curve effect rather than selection of more difficult cases.<\/a><\/p>\n\n\n\n The concern about increased complications associated with the learning curve for robotic cholecystectomy has been raised in previous studies.3<\/a><\/sup>,4<\/a><\/sup> This important observation should be considered in light of some limitations in the current study. The cohort is a selected population of older patients with a high proportion undergoing nonelective surgery. Despite rapid growth, the number of robotic cases remained low (~25\u202f000 robotic cases vs approximately 1 million laparoscopic cases). When compared with other contemporary cohorts, their population had a very high proportion of open cases (26%), with the highest rate of bile duct injuries and complications. This likely includes conversions but could not account for all cases. The authors argue against the hypothesis that more difficult cases were done robotically, pointing to the higher proportion of elective cases in the robotic group, yet the highest proportion of elective cases was in the open group (41% open vs 34% robotic vs 15% laparoscopic).<\/a><\/p>\n\n\n\n Regardless of approach, this study highlights the need to adhere to principles of safe cholecystectomy.5<\/a><\/sup> These include understanding the critical view of safety and applying it to every case, making liberal use of techniques to image the biliary tree, taking a momentary pause to confirm the anatomy before clipping and cutting structures, and applying bail-out maneuvers when the hepatocystic triangle is too inflamed or fibrotic for safe dissection.6<\/a><\/sup> Some relevant questions about the increasing use of the robotic approach are how frequently cholangiography is used and whether near-infrared technology, integrated into every robotic system, is being sufficiently leveraged. As surgeons integrate new technologies into practice and other robotic platforms become available, using the multiple available adjuncts to minimize the risk of bile duct injuries during the learning curve must be embraced to avoid repeating the mistakes of the past.<\/p>\n","protected":false},"excerpt":{"rendered":" Invited Commentary September 20, 2023 N […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24725"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=24725"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24725\/revisions"}],"predecessor-version":[{"id":24726,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24725\/revisions\/24726"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=24725"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=24725"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=24725"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}