title: Laparoscopic robot-assisted completion cholecystectomy: a report of three cases.
abstract: BACKGROUND
  Gangrenous cholecystitis remains a serious, life-threatening, surgical emergency. Surgeons are occasionally forced to perform a subtotal cholecystectomy and forego formal dissection of the cystic duct and artery, in an attempt to avoid iatrogenic injury to the common bile duct. Not infrequently, a patient may develop a persistent biliary fistula or symptomatic gall bladder remnant, which may ultimately require operative intervention.
  
  
  METHODS
  Three patients were referred to the University of North Carolina Hospitals for evaluation and treatment. All patients initially presented with gangrenous cholecystitis and had undergone open cholecystectomies and placement of surgical drains at outside medical facilities. All three patients had subsequently developed persistent biliary leaks or had significant gall bladder remnants. Due to the anticipated difficulty and complexity of performing a laparoscopic completion cholecystectomy in this setting, the DaVinci robot (Intuitive Surgical, Sunnyvale, CA, USA) was utilized for these three consecutive patients. Dissection was performed using two robotic instrument arms, as well as assistant ports for suction/irrigation devices, clips and endostaplers.
  
  
  RESULTS
  All three patients were found to have significant gall bladder and cystic duct remnants, some with sizeable retained stones in the infundibulum. All procedures were completed laparoscopically with robotic assistance, with no complications. At follow-up, all patients were without biliary leaks or symptoms.
  
  
  CONCLUSIONS
  Laparoscopic robot-assisted completion cholecystectomy is a feasible option in the setting of a reoperative, hostile abdomen following gangrenous cholecystitis.
authors.affiliation: Department of Surgery, University of North Carolina at Chapel Hill, NC 27599-7081, USA. geoffKohn@gmail.com
authors.forename: Geoffrey P
authors.initials: GP
authors.lastname: Kohn
authors.forename: John B
authors.initials: JB
authors.lastname: Martinie
mesh_terms: D000328:Adult; D017081:Cholecystectomy, Laparoscopic / Q000295:instrumentation* / Q000379:methods*; D002764:Cholecystitis / Q000601:surgery*; D004867:Equipment Design; D019544:Equipment Failure Analysis; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012371:Robotics / Q000295:instrumentation* / Q000379:methods*; D025321:Surgery, Computer-Assisted / Q000295:instrumentation* / Q000379:methods*; D016896:Treatment Outcome