Telepresence-assisted robotic common bile duct exploration using the da Vinci 5 platform: a novel application of real-time intraoperative telementoring

Abstract Background Single-stage management of choledocholithiasis with intraoperative cholangiography (IOC) and concomitant common bile duct exploration (CBDE) is supported by reduced length of stay, fewer anesthetic events, and high stone-clearance rates. However, broad adoption is limited by surgeon experience and the technical demands of transcystic exploration. The fourth-generation da Vinci 5 (DV5) surgical platform (Intuitive Surgical, Sunnyvale, CA) integrates a native Telepresence module that enables a remote expert to view the operative field and the surgeon console feed in real time and to communicate with the operating surgeon through bidirectional audio and video. We describe what we believe to be the first reported use of DV5 Telepresence to assist intraoperative decision-making and execution during robotic CBDE for choledocholithiasis discovered on IOC. Methods A surgeon with early experience in common bile duct exploration while performing a robotic cholecystectomy with routine fluoroscopic IOC encountered a filling defect at the distal common bile duct consistent with an obstructing stone. A DV5 Telepresence session was activated, connecting an experienced surgeon in common bile duct exploration. The picture-in-picture (PiP) feature on the surgeon console displayed the intraoperative view and the live fluoroscopic image simultaneously, allowing both surgeons to review the cholangiogram in real time. Verbal-only guidance was provided through bidirectional audio while the operating surgeon performed transcystic flushing and balloon sphincteroplasty. Results Total Telepresence connection time was 19 min. Complete duct clearance was achieved during the index operation, confirmed by completion cholangiogram. The patient was discharged from the post-anesthesia care unit with no complications. The PiP feature facilitated simultaneous interpretation of the cholangiogram and operative anatomy by both surgeons without exiting the console or duplicating monitors. Conclusions Native robotic Telepresence on the DV5 is feasible, safe, and clinically useful for time-sensitive intraoperative consultation during CBDE. By collapsing the latency between identification of choledocholithiasis and expert-guided definitive management, this approach may broaden access to single-stage biliary clearance for surgeons earlier in their learning curve and warrants prospective evaluation. This feature may allow for surgical advice/mentoring in a variety of settings/cases.