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Sullivan et al. Mini-invasive Surg 2023;7:15 https://dx.doi.org/10.20517/2574-1225.2022.106 Page 5 of 11

[36]
oncologically safe and that disease biology, rather than time to reoperation, is more significant in
[37]
determining the overall outcome .
Minimally invasive surgery for gallbladder polyps
The historical method of gallbladder resection was open cholecystectomy (OC), usually with a subcostal
[38]
incision. Laparoscopic cholecystectomy (LC) was first reported in 1987 and was subsequently shown to
have lower complication rate and faster recovery compared to OC for benign gallbladder disease, including
cholelithiasis and acute cholecystitis [39-41] . The laparoscopic approach for cholecystectomy was then
expanded to include gallbladder polyps as the majority are in fact benign. The laparoscopic approach was
initially utilized for gallbladder polyps with caution, given their malignant potential, as a 1998 study
[42]
reported 2 cases of disseminated gallbladder cancer after LC, including one for a gallbladder polyp .
However, other early case series of laparoscopic cholecystectomies for gallbladder polyps [Table 2] [43-46] each
concluded that laparoscopic resection of even early T1 malignant lesions arising in gallbladder polyps was
safe. More recently, advances in laparoscopic technique have reported the utilization of a single port
laparoscopic approach to LC. While multiple studies have evaluated single port LC (SP-LC), Choi et al.
[47]
compared 56 SP-LC specifically for gallbladder polyps to an equal number of conventional LC and found no
difference in complication rate, bile spillage, postoperative pain, or hospital stay, and all conversions to open
were in the conventional LC cohort. The findings suggest SP-LC is a safe minimally invasive surgical
approach to the management of gallbladder polyps in addition to standard LC.

In the mid-1990s, the robotic approach to cholecystectomy was first described [48,49] . The United States Food
and Drug Administration (FDA) approved the da Vinci robotic surgical system in 2000. The robotic
technique allows for several advantages over laparoscopy, including 3D camera visualization and wrist
articulation of the instruments. Early series of robotic cholecystectomy (RC) for benign disease included
small percentages of cholecystectomies performed for polyps and showed that RC was safe without
[50]
complications or conversions to open [Table 2] . In general, systematic reviews and meta-analyses of LC
vs. RC show that LC has shorter operative times, but there are no significant differences in complications,
hospital length of stay, or readmission rate for RC or LC [51,52] . A recent retrospective study compared
outcomes of 612 LC and RC that included a total of 19 gallbladder polyps (3.1% of the cholecystectomies
were for gallbladder polyps). Amongst all cases, the authors found that RC had improved hospital length of
stay, blood loss, and conversion to open compared to LC, with no difference in grade 3 or higher Clavien-
Dindo complications . A randomized controlled trial of single incision RC (SI-RC) vs. LC with
[53]
conventional 4 ports included gallbladder polyps as inclusion criteria for cholecystectomy and
demonstrated no statistically significant differences between SI-RC and LC in postoperative pain or adverse
[54]
events including bile spillage and bleeding, while SI-RC had improved cosmesis . Therefore, for those with
experience and comfort with robotic surgery, RC can be a viable alternative to LC for minimally invasive
treatment of gallbladder polyps.

Minimally invasive surgery for incidentally discovered gallbladder cancer
A minimally invasive approach for radical resection of gallbladder cancer using laparoscopy was shown in
institutional case series to have low blood loss, minimal morbidity, and negative margins . A retrospective
[55]
institutional series comparing laparoscopic management of patients with known gallbladder cancer to those
with incidentally discovered gallbladder cancer showed that the conversion rate was higher without
statistical significance in known cancer vs. incidentally discovered cancer groups (29% vs. 9%, respectively).
73% of the procedures had at least 7 lymph nodes retrieved during the lymphadenectomy . In comparing
[56]
laparoscopic radical resection vs. open, another retrospective study showed lower blood loss and hospital
stay with laparoscopy with similar 1-year overall survival . Mayo reported institutional data showing less
[57]
blood loss and shorter length of stay for laparoscopic vs. open liver resection for intrahepatic