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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 9 of 12

Table 3. Intraoperative and postoperative information
Robot docking time + adhesiolysis 46.25 min (range 30-70)
Robotic radical cholecystectomy operative time 147.5 min (range 110-220)
Intraoperative blood loss 198.75 mL (range 50-600)
Intraoperative complications
Bleeding 1/8 (12.5%)
Conversion rate 0/8 (0%)
Postoperative complications
Bleeding 1/8 (12.5%)
Ventral hernia on port defect 1/8 (12.5%)
Hospital stay 6 days (range 5-11)
Follow-up
Mean 17.5 months (range 29.3-7.3)

bag, contact with contaminated instruments (especially in case of bile spillage) or by nidation of exfoliated
tumour cells brought to the port site by a sort of aerosol effect created by desufflation of the
pneumoperitoneum. The historically reported data are perhaps related to an inappropriate surgical
technique carried out in the early years of the learning curve of laparoscopic cholecystectomy for presumed
benign disease and were probably associated with gallbladder perforation, bile spillage and no use of
protective bag for specimen extraction. The key role of bile spillage during index cholecystectomy for
[17]
incidentally diagnosed GBC has been addressed in a population-based study by Horkoff et al. who
highlighted in a retrospective cohort comparison the negative prognostic impact of bile spillage and its role
in the development of peritoneal carcinomatosis. The occurrence of incidentally diagnosed GBC after
cholecystectomy is assumed to vary between 0.19% and 3.3% with a slight increase after the advent of
[18]
laparoscopic cholecystectomy. Generally, simple cholecystectomy is considered an adequate treatment for
Tis and T1a cancers while a re-intervention consisting in a radical cholecystectomy as first described by
[19]
Glenn and Hays (which includes locoregional lymphadenectomy and gallbladder bed liver resection) is
suggested to resect any potential residual disease and obtain an adequate staging. Since cholecystectomy
has already been performed, revision surgery for incidentally diagnosed GBC is not at risk of tumour
seeding associated with bile spillage. Full-thickness resection of the port insertion sites at index
[20]
cholecystectomy has been advocated to minimize the incidence of port site recurrence , but as
[21]
demonstrated by Maker et al. port site resection is not associated with improved survival or disease
recurrence and should not be considered mandatory. Nevertheless, radical revision surgery can be very
technically demanding because of the presence of fibrosis and inflammatory adhesions often present in the
gallbladder bed and at the hepatodudoenal ligament, thus complicating the identification of the vasculo-
biliary structures and the risk of bile duct injury during radical lymphadenectomy. Only in the last decade,
some authors have advocated the minimally invasive surgical treatment of clinically suspected or
incidentally diagnosed GBC, highlighting the feasibility and apparent safety of this approach in terms of
[8]
oncologic outcomes. In 2011, Belli et al. published their initial series of patients with incidental GBC who
underwent a revision procedure by a totally laparoscopic approach, reporting satisfactory clinical outcomes
[9]
in terms of perioperative and middle term oncologic results. Recently, Vega et al. reported the results of a
multicentre retrospective study of patients with incidental GBC who underwent re-resection with curative
intent at four centres (including 65 patients operated by a laparoscopic approach) and concluded that a
laparoscopic approach for radical re-resection has similar morbidity and oncologic outcomes as open
[10]
radical re-resection. Feng et al. conducted a comparative analysis of open (61 patients) versus
laparoscopic (41 patients) cholecystectomy and radical cholecystectomy for Tis-T3 GBC and found no
differences between the two approaches in terms of lymph node retrieval and survival outcomes. Similar
results were reported in the retrospective comparative series (open vs. laparoscopic approach) published by
[12]
[13]
[11]
Jang et al. and Dou et al. In the study by Agarwal et al. , also analysed in a retrospective comparative
design were the outcomes of GBC patients (with limited liver infiltration or incidental diagnosis) who
underwent laparoscopic radical resection versus those of patients who underwent open radical