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Belli et al. Mini-invasive Surg 2020;4:77 I http://dx.doi.org/10.20517/2574-1225.2020.70 Page 3 of 12

who refused the minimally invasive approach were offered a standard open operation. In case of a
previous cholecystectomy, operative notes of the index gallbladder resection were carefully reviewed,
and the surgeons who performed the operations were contacted whenever possible. Clinicopathological
features of the patients were prospectively recorded in a dedicated electronic database and included age,
sex, American Society of Anesthesiology score, previous abdominal surgery, tumour dimensions and T
stage at preoperative imaging. Intraoperative variables analysed included operative time (divided into
robotic system docking time and skin incision to skin closure time), occurrence and type of intraoperative
complications, need and cause of conversion to laparoscopy or to laparotomy, blood loss, need for
intraoperative transfusions, and occurrence of bile spillage. Surgery-related mortality was defined as death
occurring during hospital admission or within 90 days of the operation. Occurrence of postoperative
[14]
complications with 90 days were graded by the Clavien-Dindo classification . Specific morbidity related to
lymphadenectomy was assessed in terms of biliary or vascular injuries, postoperative pancreatitis, bleeding
and the occurrence of lymphatic fistula (defined as the presence of triglycerides in drain fluid > 110 mg/dL),
[15]
bile leaks were graded by the definition of the International Study Group of Liver Surgery . Postoperative
recorded variables included length of hospital stay, radicality of the resection (R1 resection defined as any
microscopically positive margin or a cancer-free margin < 1 mm), T stage and number of retrieved and
positive nodes at final pathology, M status, need for and accomplishment of postoperative chemotherapy.
Oncologic follow-up included blood tests, tumour markers and a total-body CT scan at 40 days after the
operation and at 3 and 6 months thereafter. Type and location of recurrence were prospectively recorded as
well as the type of treatment administered when needed.

Surgical technique
Step 1
The patient is placed supine and legs apart in a slight reverse Trendelenburg and tilted to the left. A
periumbilical incision is made, and the pneumoperitoneum is created by the open technique. Once the
abdomen is insufflated, a staging laparoscopy is performed to exclude any sign of peritoneal carcinomatosis
or diffuse hepatic involvement. In case of no contraindications to the procedure, 3 additional robotic
trocars and one service 12-mm port for the assistant surgeon are inserted under direct view [Figure 1], and
the robotic da Vinci Xi Surgical System® (Intuitive Surgical Inc. Sunnyvale, CA, USA) is docked. The first
surgeon is at the robotic console while the assistant surgeon stands between the patient’s legs.

Step 2
Intraoperative liver ultrasound is performed to assess the presence of liver invasion and its depth,
and to exclude any other intrahepatic metastasis as well. In case of re-intervention after a previous
cholecystectomy, any fatty or omental adhesions to the gallbladder bed are left in place with the aim of
being resected en bloc with the liver resection specimen. The right colonic flexure is then mobilized and
a wide Kocker manoeuvre is carried out to greatly expose the inferior vena cava and aorta. The lymph
nodes of station 16 (aortocaval nodes) are excised from the gonadic vein caudally up to the left renal vein
cranially by the aid of robotic scissors and robotic Maryland bipolar forceps and sent for frozen section
analysis [Figure 2]. In case of node involvement the procedure is abandoned.

Step 3
Retropancreatic lymph nodes (i.e., station 13) are carefully excised avoiding injuries to the duodenum or
the pancreatic head. This manoeuvre is facilitated by the 3D high-definition view of the surgical area and by
the articulated robotic scissors and Maryland bipolar forceps [Figure 3]. The lymphadenectomy continues
on the right lateral border of the hepatic pedicle (i.e., station 12). In case of re-intervention for revision
post-cholecystectomy surgery at this level, even in the presence of inflammatory tissue, which can make
the dissection difficult, an effort is made to isolate and resect the stump of the clipped cystic duct for frozen
section analysis. In case of no previous cholecystectomy, Calot’s triangle is dissected and the cystic duct