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

Table 3. Retrospective studies comparing minimally invasive vs. open radical resection for gallbladder cancer
LOS,
Authors Patients EBL, days Complication/Morbidity rate Oncologic outcome
mL
[64]
Agarwal et al. Open: 123 Open: Open: 5 Open: 17% No difference in R0 rate or number of
Lap: 24 275 Lap: 5 Lap: 13% lymph nodes resected
Lap: 200
Feng et al. [65] Open: 61 Open: Open: 11 Open: 9.8% 5-year OS
Lap: 41 386 Lap: 5 Lap: 7.3% Open: 56%
Lap: 358 Lap: 52%
Vega et al. [66] Open: 190 Open: Open: 6 Open: 20% 3-year OS
Lap: 65 200 Lap 4 Lap: 18% Open: 62%
Lap: 300 Lap: 87%
[57]
Dou et al. Open: 31 Open: Open: 14 No difference in the rate of Clavien-Dindo grade 1-year OS
Lap: 32 503 Lap: 11 0-2 or 3-4 events Open: 48%
Lap: 267 Lap: 73%
(P = 0.09)
[67]
Navarro et al. Open: 43 Open: Open: 13 Open: 4 Clavien-Dindo ≥ 2 5-year OS
Lap: 43 208 Lap 6 Lap: 0 Clavien-Dindo ≥ 2 Open: 64%
Lap: 72 Lap: 80%
(P = 0.21)
[68]
Yang et al. Open: 56 Open: Open: 13 Open: 21% 3-year OS
Rob: 28 156 Rob: 10 Rob: 10% Open: 63%
Rob: 99 Rob: 75%
[69]
Lee et al. Open: 24 Open: Open: 12 Open: 21% 5-year OS
Lap: 20 594 Lap: 11 Lap: 10% Open: 54%
Lap: 320 Lap: 80%
Cho et al. [70] Open: 19 NR Open: 14 Open: 10% 5-year OS
Lap: 19 Lap: 8 Lap: 21% Open: 82%
Lap: 78%
[71]
Dou et al. Open: 30 Open: Open: 14 Open: 7% 3-year OS
Lap: 30 484 Lap: 10 Lap: 10% Open: 30%
Lap: 257 Lap: 40%
EBL: estimated blood loss; LOS: length of stay; Lap, laparoscopic; NR: not reported; OS: overall survival; Rob: robotic.

Another technique aimed to use endoscopy alone and was first described for the treatment of gallstones.
One study uses endoscopic ultrasound-guided cholecystostomy (either via cholecystoduodenostomy or
cholecystogastrostomy) to place a metal stent for access to the gallbladder. Several days later, the patient
returns for endoscopic per oral gallbladder polypectomy. Shen et al. report their experience with 4
[74]
patients with multiple polyps using this technique (3 cholecystoduodenostomy and 1
cholecystogastrostomy) and found that 1 patient developed significant pancreatitis and another later
underwent LC for cholelithiasis, but none of the 4 patients developed gallbladder polyp recurrence at 3-15
months and all eventually had the stent removed. Another group reported on 22 patients who underwent a
similar technique of endoscopic gallbladder polypectomy, but as one procedure without metal stent
placement. Zhang et al. describe an endoscopic anterior gastrotomy and introduction of the endoscope
[75]
into the peritoneal cavity, followed by identification and incision into the gallbladder. After suctioning bile,
polypectomy is performed with snare, biopsy forceps, or argon beam coagulation. The cholecystotomy is
closed with clips and the gastrotomy is closed with endoloop and clips. This study reports a median hospital
stay of 5 days and 4 (18.2%) patients with complications of localized peritonitis. One patient developed
recurrent gallstones but wished not to undergo LC as he was asymptomatic. Another endoscopic strategy
employed is embryonic-natural orifice transumbilical endoscopic surgery (E-NOTES), which uses a 10 mm
trochar placed through the umbilicus, followed by gallbladder incision with an endoscope, polypectomy,
and gallbladder closure with clips. He et al. report their experience of 12 patients who underwent E-
[76]
NOTES and describe minimal post-procedural pain and satisfactory cosmetic outcome with no recurrence
of polyps at 12 months. As the current literature is retrospective, subject to publication bias, and includes
less than 100 total patients, additional data is needed to confirm the safety and efficacy of these approaches,