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Page 8 of 12 Belli et al. Mini-invasive Surg 2020;4:77 I http://dx.doi.org/10.20517/2574-1225.2020.70

Table 2. Pre- and postoperative tumour characteristics
Incidental GBC (3 patients) Suspected GBC (5 patients)
Preoperative tumour size
No evidence of liver mass 19.6 mm (range 12-31 mm)
Preoperative T stage
T1b 2/3 (66.6%) 1/5 (20%)
T2a 1/3 (33.3%) 0/5 (0%)
T2b 0/3 (0%) 2/5 (40%)
T3 0/3 (0%) 2/5 (40%)
Postoperative T stage
T1b 2/3 (66.6%) 1/5 (20%)
T2a 1/3 (33.3%) 0/5 (0%)
T2b 0/3 (0%) 1/5 (20%)
T3 0/3 (0%) 3/5 (60%)
Lymph node status
N0 2/3 (66.6%) 4/5 (80%)
N+ 1/3 (33.3%) 1/5 (20%)
Total lymph nodes
1-6 0/3 (0%) 0/5 (0%)
7-12 1/3 (33.3%) 1/5 (20%)
> 12 2/3 (66.6%) 4/5 (80%)
Mean 22.35 ± 1.75 25.75 ± 2.25

GBC: gallbladder cancer

or open surgery. In one case, minor intraoperative bleeding from the inferior vena cava occurred during
lymphadenectomy and was effectively managed by robotic suturing with prolene 3/0 stiches. Operative
time was 46.25 min (range 30-70 min) for robot docking time and adhesiolysis (5 patients having extensive
adhesions due to previous laparotomic abdominal surgery) and 147.5 min (range 110-220 min) for robotic
accomplishment of radical cholecystectomy. Mean blood loss was 198.75 mL (range 50-600 mL) and no
intraoperative transfusions were needed. No bile leaks nor lymphatic fistula occurred. Mean postoperative
stay was 6 days (range 5-11 days). Postoperative morbidity included one postoperative bleeding treated
with a transfusion of packed red blood cell (Clavien-Dindo grade II complication) and one re-intervention
for a strangulated bowel loop herniated at one of the trocar site (Clavien-Dindo grade IIIb complication).
All patients had an R0 liver resection and 2 patients had N positive disease at final pathology. Mean lymph
nodes yield was 25.75 ± 2.25, and all patients had more than 6 retrieved lymph nodes. Intraoperative and
postoperative information is provided in Table 3. The cystic duct margin was negative in all patients as well
as the station 16 sampling for frozen section analysis. With a mean follow-up of 17.5 months (range 29.3-
7.3 months), all patients are alive and all but one, who experienced a peritoneal recurrence and is currently
undergoing chemotherapy, are free from disease and under clinical follow-up. No port site metastases were
observed during the follow-up period.

DISCUSSION
The current study is one of the very few reported series on the robotic approach to the surgical treatment of
GBC. We presented a prospective series of eight consecutive patients operated for GBC by a robotic
approach with results comparable to those reported in the recent literature and showed the feasibility and
the safety of this minimally invasive approach. Despite that cholecystectomy was the first surgical
intervention widely performed by laparoscopy, a strong reluctance accompanied the adoption of the
minimally invasive approach for the treatment of GBC, which is one of the most aggressive cancers of the
biliary tract and is generally associated with a poor prognosis. One of the major concerns related to the
adoption of the minimally invasive approach for GBC has been the fear of port site recurrence, which has
[16]
been historically reported to occur in up to 18.6% of cases in the case of incidental GBC . Tumour cell
implantation at the port sites is postulated to occur by extraction of surgical specimen without protective