A 56-year-old patient with upper right quadrant discomfort for 2 months was admitted to our department. She had already been diagnosed with gallstone disease at a local hospital. She had no unusual medical history of past illness. She weighted 75kg and was 160cm tall (Body Mass Index = 29.3). Other laboratory evaluations including complete blood count, SGPT, SGOT, total/direct bilirubin, alkaline phosphatase, and GGT were all within normal limits. An abdominal ultrasound scan performed at the local hospital showed multiple gallbladder stones ranging in size from 0.5cm to 1.5cm. She underwent laparoscopic cholecystectomy using a da Vinci robotic surgical system on the second day after admission.

The da Vinci robotic surgical system has three components. The first is the vision cart that holds the dual light source and image processors for the dual three-chip cameras. The dual cameras are mounted on an endoscope which is placed in the camera arm, and provide three-dimensional images. The second component is the surgical console (Fig. 1), where the operating surgeon sits and manipulates the robotic arms. This console contains image processing computers that combine the images into a true 3-D image with depth of field, and the view port screening through which the surgeon can view the 3-D operative field. There are two control grips and several foot pedals to control the movement of robotic arms at the patient's side, other robotic laparoscopic instruments, camera focus and instrument/camera arm clutches. The last component is the surgical robotic cart (Fig. 2). The three instrument arms and one camera arm are mounted on this robotic cart. The laparoscopic instruments with uniquely designed instrument tips can be equipped to the three instrument arms, thereby creating flexible movement with seven degrees of freedom like that of a human hand. Each arm has several articulates by which it is controlled to adjust its location appropriate to respective trocar sites.

In this time, only three robotic arms including camera arm were used. The da Vinci system was prepared behind sterile drapes before the patient arrived at the operating room. The patient was placed in the supine position on the operating table and underwent general endotracheal anesthesia. The abdomen was prepared and draped in the usual sterile fashion. The 12-mm subumblical camera port① was placed through mini-laparotomy and pneumoperitoneum was achieved by CO₂ insufflation. Under direct vision, the two 8-mm robotic instrument ports were placed in the standard position for laparoscopic cholecystectomy; one② at the right midclavicular line in the subcostal region and the other③ in the epigastric region. Another 5-mm accessory port④ was placed lateral and inferior to the robot's right instrument arm port (Fig. 3). The patient was placed in the steep reverse Trendelenburg position with her left side tilted. The da Vinci system was rolled into position, 40˚-45˚ off of the right head of the table. The robotic camera arm and instrument arms were then connected to their respective ports. The right accessory port was used to place the grasper that would retract the gallbladder upward and outward, operated by the patient-side assistant surgeon. At this point, the surgeon sat down at the surgical console located about 3m from the operating table. The patient-side assistant surgeon was positioned on the patient's right to retract the gallbladder using a 5-mm grasper and then change the robotic instrument. The operating surgeon controlled the da Vinci robotic surgical system in the dissection of the gallbladder, including Calot's triangle, and its complete removal (Fig. 4 and 5)

Total operation time (beginning with minilaparotomy for robotic port insertion and ending with completion of wound dressing) was 110 minutes. Total robot time (beginning when the surgeon sat at the console and ending when the surgeon completed robotic manipulation) took 45 minutes. The dissection time of Calot's triangle (measured as starting when the grasping forcep and hook cautery were introduced and concluding when cystic artery and cystic duct were completely ligated) was 14 minutes. Gallbladder dissection time (beginning when the hook cautery and grasping forcep were in place to dissect the gallbladder out of the liver bed and ending when the gallbladder was put into an Endopouch bag) was 14 minutes. After inspection of the liver bed and dissected area to confirm no injuries, the abdomen was desufflated. The portside incision was closed by several stitches with a skin stapler. The patient was able to have an oral diet on the first postoperative day, and was discharged without problems on the second postoperative day. The delivered gallbladder had the appearance of chronic cholecystitis with wall thickening and several cholesterol stones reaching up to 2.5cm in size.