Perioperative management - Cholecystectomy, Robotic-Assisted

• Symptomatic cholecystolithiasis or gallbladder sludge with typical biliary colicky pain, often postprandial.
• Asymptomatic cholecystolithiasis with stones >3 cm, gallbladder polyps >1 cm, or porcelain gallbladder (significantly increased gallbladder carcinoma risk).
• Gallstone colic during the first trimester of pregnancy due to the high risk of recurrence later in pregnancy (recommend early elective surgery).
• Acute cholecystitis requiring early laparoscopic surgery within 24 hours of admission.
• Post-ERCP bile duct clearance for concurrent cholecystolithiasis (preferably within 72 hours, “therapeutic splitting”).
• Acute biliary pancreatitis with resolving cholestasis/pancreatitis and no ERCP; early elective surgery is advised due to high recurrence risk of pancreatitis.

Note: Robotic surgery significantly expands the boundaries of minimally invasive procedures, especially for cases that were previously contraindicated.

Contraindications for minimally invasive robot-assisted cholecystectomy include:

• Malignant tumors of the gallbladder or bile ducts requiring extensive resection (though robotic approaches may be feasible).
• Frozen/hostile abdomen.
• Acute florid pancreatitis.
• Portal vein thrombosis or conditions with severe venous collateralization (e.g., cirrhosis).
• Cirrhosis (Child B and C).
• Severe cardiovascular comorbidities posing an anesthetic risk (e.g., NYHA III with critical carotid stenoses).

Other contraindications to conventional laparoscopic cholecystectomy, such as biliodigestive fistulas or Mirizzi syndrome, may still be approached robotically in expert centers.

• History: Colicky pain (>15 minutes) in the right upper quadrant/epigastrium, jaundice, and fever are main symptoms of inflammatory gallbladder or bile duct disease.
• Clinical Examination: Typical signs of acute cholecystitis include right upper quadrant pain, Murphy’s sign (localized tenderness over the gallbladder on direct pressure), elevated inflammatory markers, and fever.
• Laboratory Workup: Includes complete blood count, CRP, liver enzymes (transaminases), bilirubin, amylase, lipase, coagulation parameters, electrolytes, creatinine, and tumor marker CA 19-9 if malignancy is suspected.
• Abdominal Ultrasound: Detects stones, wall thickening, triple-layered gallbladder wall, and Murphy’s sign in acute cholecystitis.
• Imaging: Avoid additional imaging if no evidence of choledocholithiasis (clinical, lab, or ultrasound) is found.
• ERCP: Therapeutic intent only for choledocholithiasis; use endosonography or MRCP as a diagnostic precursor if necessary.
• Endosonography: Highest sensitivity for detecting common bile duct stones.
• CT/MRCP/MRI: For unclear ultrasound findings or tumor suspicion.
• Gastroscopy: If unclear clinical presentation suggests gastric pathology despite cholecystolithiasis.

General Preparation:

• Previous evening shower.
• Shave from jugular notch to symphysis pubis.
• Apply Octenisept swab to the navel.
• Premedication and single-shot prophylactic antibiotics (e.g., Cefuroxime 1.5 g) in the operating room.
  • Perioperative antibiotic therapy is required for acute cholecystitis or choledocholithiasis.
  • Single-shot antibiotic prophylaxis is optional in other cases.
• Thromboprophylaxis with enoxaparin (“Clexane 40”) and anti-thrombosis stockings per VTE prevention guidelines.

Anticoagulation Management:

• Continue aspirin therapy perioperatively.
• Discontinue clopidogrel (ADP inhibitor) at least 5 days prior.
• Pause vitamin K antagonists for 7 - 10 days, monitoring INR.
• Pause NOACs (new oral anticoagulants) 2 - 3 days before surgery. Consult cardiologist if needed.

Bridging:

• Vitamin K antagonists: Bridge with short-acting heparins if INR is outside the target range.
• NOACs: Generally, bridging is unnecessary due to their short half-life, except in high thrombotic risk cases (use UFH in a monitored setting).

Preoperative Functional Diagnostics

• ECG: For patients > 40 years or with pre-existing conditions.
• Elevated Cardiac/Pulmonary Risk: Evaluate operability with further diagnostics (chest X-ray, lung function tests, stress ECG, echocardiography, coronary angiography).
• Additional tests depend on comorbidities.

• Conversion to open cholecystectomy
• Bile duct injury
• Gallbladder perforation
• Intra-abdominal loss of stones
• Open or minimally invasive bile duct revision
• Intraoperative cholangiography
• Vascular injury (hepatic artery, portal vein)
• Injury of nearby organs (duodenum, small intestine, colon, liver)
• Peritonitis
• Abscess formation
• Follow-up interventions