PMC6664601_01
CT scan: (a) sagittal plane; (b) coronal plane; (c) axial plane. Dotted line circle shows the site of the gallbladder. Unique lithiasis is observed in (a) and (c).
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Abdominal and pelvic CT scans showed a dilated GB with large (5.4 cm) stone without signs of cholecystitis (Figure 1).
US scan.
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RUQ ultrasound (US) reported a GB with marked wall thickening, pericholecystic fluid, and positive sonographic Murphy's sign (Figure 2).
Comparison of bright vs. near-infrared images: (a) twisted GB in bright light view; (b) twisted GB in near-infrared view; (c) untwisted GB in bright light view; (d) untwisted GB in near-infrared view. TP: torsion point.
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The torsion of the GB hilum was identified, accompanied with a distended and gangrenous GB (Figure 3). The fundus was grasped with the 3rd arm; the organ was untwisted (Figure 3) and then pulled cranially towards the diaphragm in order to expose the GB neck and also lift up the liver. After the cystic duct was identified, intravenous indocyanine green fluorescence (ICG) was used to facilitate the assessment of the biliary anatomy as shown in Figure 3 (IV ICG was previously injected at induction of general anesthesia).
Hilar element dissection.
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The cystic artery was then identified and dissected, and Calot's triangle was exposed adequately (Figure 4); the cystic duct and artery were transected in between Hem-o-loks with robotic scissors (Figure 5).
Clipped hilar elements before transection.
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The cystic artery was then identified and dissected, and Calot's triangle was exposed adequately (Figure 4); the cystic duct and artery were transected in between Hem-o-loks with robotic scissors (Figure 5).