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Page 8 of 10 Lee et al. Mini-invasive Surg 2021;5:57 https://dx.doi.org/10.20517/2574-1225.2021.139

robot-assisted surgery can be chosen depending on each surgeon’s preference. But in relatively simple
surgery, the issue of cost-effectiveness matters.

Due to the monopoly of Da Vinci robotics, the cost of robotic surgery is still high. Many patients in Korea
do not have insurance coverages for robotic surgery, forcing them to pay the high cost of robotic surgery
out-of-pocket. For pancreas and liver surgery, the operative type is planned preoperatively. In contrast, in
the treatment of GBC, the decision to proceed with a radical operation is often decided according to the
results of the intraoperative frozen section pathology. Therefore, routine use of robots for any stage of GBC
can be too expensive. Another demerit of robot-assisted surgery is the lack of proper instruments. When
liver resection is required, parenchymal transection may be difficult, as there is no cavitron ultrasonic
surgical aspirator in robotic surgery. Harmonic scalpel is frequently used as well for parenchymal
transection in liver surgery. However, a robotic harmonic scalpel with endo-wrist movement has yet to be
developed, diminishing the advantage of robotic surgery. In many cases of GBC, lymphadenectomy can be
the only necessary procedure for an extended cholecystectomy. This procedure can be performed superbly
with laparoscopic surgery. The benefits of choosing the robotic system for just the lymphadenectomy are
questionable.

The dissemination of robotic surgery may be different from the dissemination of laparoscopic surgery.
When laparoscopic surgery was first introduced, there was the very definite, obvious benefit of reduced
scars and faster recovery compared to open surgery. The only concern was to ensure the oncologic safety.
However, robotic surgery has no obvious benefits over laparoscopic surgery, which makes adoption of the
procedure still a matter of debate, even decades after the introduction of robotic surgery.

Breakthrough innovations in the field of surgery are constantly happening. We are currently debating the
pros and cons of laparoscopic and robotic surgery, but as is outlined in this editorial by professor
Gumbs et al. , artificial intelligence surgery is already here, albeit in limited ways. Refusing to accept new
[21]
methods without any reason would slow down these advances in the field of surgery. But we must be critical
in appraising the feasibility and safety of new methods, so that core values such as patient safety, oncologic
feasibility, and cost-effectiveness are ensured. Perhaps with future developments of cheaper robotic systems
with better surgical techniques, the benefit of robotic surgery may be shown later. But to date, there is
insufficient evidence of benefit of the robotic system over laparoscopic surgery, in terms of extended
cholecystectomy.

CONCLUSION
Laparoscopic surgery is a safe, effective alternative for open surgery in the treatment of gallbladder cancer.
The benefits of robotic surgery should be proven with further research.

DECLARATIONS
Authors’ contributions
Manuscript drafting: Lee JS
Made substantial contributions to conception and design of the study, editing, and administrative support:
Han HS
Provided administrative, technical, and material support: Yoon YS, Cho JY, Lee HW, Lee BR, Kim MW,
Jo YS