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Page 2 of 12 Belli et al. Mini-invasive Surg 2020;4:77 I http://dx.doi.org/10.20517/2574-1225.2020.70

needed to confirm our results and to assess the oncologic outcomes of the robotic approach.

Keywords: Gallbladder cancer, robotic surgery, radical cholecystectomy, incidental gallbladder cancer,
lymphadenectomy, minimally invasive surgery

INTRODUCTION
Minimally invasive approaches are gradually becoming a standard of care in abdominal surgical oncology.
Several high-quality studies including randomized controlled trials demonstrated non-inferiority in terms
of oncologic outcomes of the laparoscopic approach for the treatment of colorectal and gastric cancer
and confirmed the advantages of minimal invasiveness in terms of perioperative outcomes and length of
[1-3]
postoperative stay . The feasibility, safety and oncologic non-inferiority of laparoscopic liver resection
have already been established as well as the advantages of the minimally invasive approach in terms of
[4-7]
intraoperative bleeding and short-term outcomes . The minimally invasive approach to liver neoplasms
is more and more applied worldwide and is becoming a routine approach in dedicated centres in selected
patients for the surgical treatment of colorectal liver metastases and hepatocellular carcinoma [4-7] .
However, there is a strong reluctance to the adoption of the minimally invasive approach for the treatment
of gallbladder cancer (GBC), which is one of the most aggressive cancers of the biliary tract and is
generally associated with a poor prognosis. This scepticism is historically related to the fear of tumour
dissemination due to bile spillage, tumour manipulation during laparoscopy, possible tumour peritoneal
implantation due to the pneumoperitoneum as well as to technical difficulties related to liver resection and
to the achievement of an adequate clearance of lymph nodes. Recently, some reports have advocated the
minimally invasive surgical treatment of clinically suspected or incidentally diagnosed GBC, highlighting
the feasibility and apparent safety of this approach [8-13] . Nevertheless, only few authors have reported on the
feasibility and outcomes of the surgical treatment of GBC by a robotic approach, which has the potential to
facilitate, by the articulated instrumentations and magnified 3D view, the accomplishment of the procedure
and the locoregional lymphadenectomy needed to obtain a radical resection and an accurate staging of
the resected patients. The aim of this study was to report the outcomes of our initial experience with the
robotic treatment of clinically suspected or incidentally diagnosed GBC and to highlight the technical
details related to the robotic approach.

METHODS
This was a retrospective observational study including consecutive patients operated by a robotic approach
for the surgical treatment of clinically suspected or incidentally diagnosed GBC (with the intent of radical
re-resection after index cholecystectomy) at the National Cancer Institute - G. Pascale - IRCCS of Naples,
Italy. Patients without relevant comorbidities precluding a minimally invasive approach were considered for
robotic resection in case of the following.

(1) A suspected preoperative diagnosis of GBC without massive liver involvement and/or suspicion of bile
duct invasion (T stage > 1b and < T4) and no suspicion of peritoneal carcinomatosis.

(2) Patients already submitted to cholecystectomy for presumed benign disease and an incidental diagnosis
of GBC (T stage > 1b) without massive liver involvement and/or suspicion of bile duct invasion and no
suspicion of peritoneal carcinomatosis.

The preoperative staging protocol included standard blood tests including carcinoembryonic antigen,
carbohydrate antigen (CA) 19.9 and CA 125, a total-body CT scan and an abdominal MRI. An FDG-PET
was used selectively in case of suspected advanced disease. Informed consent was obtained and patients