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Page 10 of 12 Belli et al. Mini-invasive Surg 2020;4:77 I http://dx.doi.org/10.20517/2574-1225.2020.70

cholecystectomy during the same period. They concluded that laparoscopic radical cholecystectomy is safe
and feasible in selected patients with GBC and can offer similar results as open approach. An expert
consensus statement published in 2019 recognises that the laparoscopic approach to GBC seems to have
[22]
favourable outcomes in selected cases operated by expert teams but also highlights that the minimally
invasive approach for GBC is still in the early phase of the adoption curve, and more data are needed to
assess the outcomes of the procedure. Only anecdotal reports on the surgical treatment of GBC by a robotic
[23]
approach are currently available in the literature. Byun et al. described their robotic technique for the
resection of 13 patients with T2 or greater stage GBC and highlighted the feasibility and safety of the
[24]
robotic approach and adequate lymph node retrieval. Goel et al. compared the operative outcomes of 23
patients submitted to robotic radical cholecystectomy to those of 70 patients submitted to open procedure
and reported a 14.8% conversion rate and equivalent oncologic and perioperative outcomes between the
two approaches. There is no consensus on the extent of optimal lymphadenectomy for GBC, but in the
authors’ opinion, a full locoregional node clearance including retro-pancreatic nodes should be performed
together with interaortocaval sampling (station 16b1). In fact, as demonstrated by Agarwal et al. , routine
[25]
sampling at this level prevents non-therapeutic radical resection in 18.6% of patients deemed resectable on
preoperative imaging and staging laparoscopy. The minimum number of harvested nodes for GBC is still a
[26]
matter of debate, where the 8th edition of the AJCC recommends a cut-off of six retrieved nodes for
GBC. In our series, all patients had more than 6 lymph nodes retrieved, which is in line with the results of
reported open series and fulfil the benchmarks proposed by the AJCC. Radical extended cholecystectomy
or radicalisation of incidentally GBC can be technically demanding procedures consisting in a liver
resection and an accurate lymphadenectomy, including the retropancreatic nodes and a full clearance of the
hepatoduodenal ligament, which requires a high grade of dexterity when performed by unidirectional
instruments as in laparoscopy. Appropriate lymphadenectomy can be performed safely and effectively by
[27]
laparoscopy as demonstrated by Ratti et al. , but it deserves advanced laparoscopic skills and a suitable
learning curve. In our opinion, the application of the robotic platform in this settings, thanks to higher
dexterity achievable with the robotic instruments, which with the endowrist system have seven degrees of
freedom, can facilitate adequate surgical manipulation and the achievement of an appropriate lymph node
clearance in a confined space such as the hepatic pedicle. The magnified high-resolution 3D stereoscopic
view offered by the robotic platform is also an added value in defining the anatomical structures. As regards
to the extent of liver resection for GBC, there is still no broad consensus, and parenchymal resection is
generally tailored on T stage and tumour size and location [28,29] . While for T1b and T2 cancers, an extended
cholecystectomy (atypical resection of segment IVb-V or a formal bisegmentectomy) is generally
considered adequate, but the optimal extent of liver resection for T3 tumours is still unclear. Since GBC is
staged as T3 by the AJCC for any infiltration of liver parenchyma, regardless of the location and size of the
tumour, the surgical treatment can vary widely from an ultrasound-guided atypical resection (for liver bed
type tumours located at the gallbladder fundus) to up a formal extended hemi-hepatectomy (generally
reserved for T3 gallbladder neck and hepatic hilum type tumours). In our series, we decided on a robotic
approach only in patients with liver bed type lesions of the gallbladder fundus and a limited liver
involvement [mean tumour size of 19.6 mm (range 12-31 mm)], and therefore we considered appropriate
an atypical resection of segments IVb-V with a an ultrasound-checked free margin of at least 2-3 cm .
[30]
Such as for laparoscopy, the robotic approach when compared to the standard open approach, which
requires a wide bilateral subcostal incision, can promote a faster recovery, as demonstrated by the short
postoperative stay of our series, and a fast access to adjuvant chemotherapy when appropriate. This an
important issue in a biologically aggressive disease such as GBC and could play a role in prolonging
survival. As regards to early oncologic outcomes, no port site metastases were observed during the follow-
up period in the current series. One of our patients experienced an early peritoneal recurrence, but this is
more likely to be related to the advanced stage of the disease (T2 N1) and to the adenosquamous
histological type of the cancer than to any factor related to the surgical approach. This is one of the very
few reports currently available in the literature on the robotic treatment of GBC. Our series is limited and