Complications - Cholecystectomy, Robotic-Assisted

• Liver Capsule Tear (including the area of the ligamentum teres hepatis):
  •  Manage with fibrin glue or fibrin-coated collagen fleece
• Gallbladder Hydrops or Severe Wall Thickening (Difficult Handling):
  • Initiate cholecystectomy by puncturing the gallbladder
• Accidental Gallbladder Perforation:
  • Aspirate bile and irrigate the surgical field
  • Administer antibiotics
  • Close the perforation with a clip, ligature, or grasping forceps
  • Check for and recover any lost stones
• Lost Stones or Clips:
  • Search for and retrieve lost items, possibly using a retrieval bag
• Injury or Partial Ligation of the Common Bile Duct (DHC):
  • Remove all clips
  • Redissect to expose the confluence and DHC
  • Place the first clip close to the gallbladder neck
  • Insert a drain
  • If DHC is injured, suture with PDS 5-0. Consider conversion or intra-/postoperative ERCP with stent placement
• Transection of the Common Hepatic Duct (DHC):
  • Perform laparotomy
  • Attempt reanastomosis or create a biliodigestive anastomosis
• Uncertain Clip Closure:
  • Use a Roeder loop for secure closure
  • Guide the pre-fabricated loop with forceps, grasp the cystic stump, place the loop near the base, and cut it 5-7 mm above the knot
• Bleeding in the Common Hepatic Duct Bifurcation Area:
  • Use careful bipolar high-frequency (HF) coagulation
  • Compress and control bleeding with fibrin-coated collagen fleece
  • For larger vessels: Apply clips or perform ligation
  • For uncontrolled laparoscopic bleeding: Convert to laparotomy
• Bleeding from the Cystic Artery:
  • Suction blood and position the suction tip at the perforation site
  • Place a blind clip if the bleeding site is unclear, then aspirate and rinse to identify the site
  • Apply a new targeted clip and remove the old one
  • Ensure definitive identification of the cystic artery
  • If identified, circumferentially dissect the vessel and place clips proximally and distally
• Bleeding from the Liver Bed:
  • Use bipolar HF coagulation, compression, or ligation sutures
  • Place a hemostatic agent (e.g., fibrin-coated collagen fleece), possibly combined with fibrin glue
• Diaphragm Perforation:
  • Repair with sutures
  • If necessary, perform laparotomy and place a Bülow drain

Biliary leakage: Biliary Secretion

• If bile secretion is observed from the subhepatic drain or an incision site:
  • Perform ERCP.
  • If a bile duct leak is confirmed:
  • Perform papillotomy and, if necessary, place an endoscopic transpapillary stent for three weeks or longer.
     
• If ERCP confirms free bile flow and bile duct integrity, with adequate drainage:
  • Adopt a wait-and-see approach.
     
• If the fistula persists:
  • Conduct diagnostic laparoscopy, and if needed, convert to laparotomy.

Peritonitis: Exploratory Laparoscopy

• Perform exploratory laparoscopy with:
  • Swab collection for microbiological analysis.
  • Lavage and focus control (e.g., closure of a bile duct leak or intestinal perforation).
  • Irrigation and placement of a targeted drainage system.
  • Initiate antibiotic therapy.
     
• If necessary:
  • Convert to laparotomy in cases of extensive findings
  • For septic multiorgan failure, consider staged lavage or relaparotomy on demand combined with intensive care management

Subhepatic abscess: Initial Step:

• Perform CT-guided puncture and drainage placement
• If this is not feasible or unsuccessful:
  • Proceed with laparoscopy or laparotomy
  • Collect swabs for microbiological analysis
  • Perform lavage and identify and address the source of infection (e.g., retained stone, intestinal injury)
  • Place a targeted drainage system

Bleeding: 

Perform relaparoscopy for targeted hemostasis. If the bleeding source cannot be clearly identified, convert to laparotomy.

Elevation of Laboratory Parameters: 

If transaminases or bilirubin levels increase, conduct an ERCP and perform color duplex imaging of liver vessels to determine the cause. If necessary, perform an abdominal angiographic CT.

Jaundice: 

Investigate with labs and imaging; resolve obstruction with stenting or stone removal.

Wound infection: 

Open, irrigate, and manage with open wound care.