Use of minimally invasive surgery for gallbladder cancer (GBC) has been uncertain, mainly due to a potential risk of tumor cell dissemination during surgery [1], difficulty in liver resection, and suboptimal lymph node clearance in laparoscopic surgery [2]. Laparoscopic liver resection has gained technical proficiency during the last decades [3,4]. A previous study showed that laparoscopic lymphadenectomy did not decrease the oncologic success with accumulated experience of laparoscopic surgery and improved instruments [5,6]. Nevertheless, conventional straight laparoscopic instruments have limitations in accessing the posterior portal and pancreatic structures during radical lymphadenectomy for biliary malignancy. Therefore, laparoscopic nodal dissection for primary biliary malignancy is recommended for experienced surgeons [5]. Recently, the robotic system has been applied to overcome the limitations of the laparoscopic approach in GBC surgery, especially for radical lymphadenectomy around the hepatoduodenal ligament [7]. However, few cases have been reported, and the technical differences or advantages of robotic extended cholecystectomy compared to the laparoscopic approach have not been determined. The current study aimed to present the technical views of both laparoscopic and robotic extended cholecystectomy including nonanatomical partial liver resection with lymphadenectomy.

A 69-year-old male patient presented with right upper quadrant abdominal pain due to mild acute cholecystitis. Preoperative computed tomography scan, endoscopic ultrasonography, and magnetic resonance imaging revealed suspicious cT1 or 2 GBC with outlet obstruction of the gallbladder. There was no evidence of serosal invasion or metastasis. The patient underwent laparoscopic extended cholecystectomy (Supplementary Video 1). For the laparoscopic approach, the patient was placed in the reverse Trendelenburg position angled slightly up to the right side. Trocar placements were identical to the conventional four ports in laparoscopic cholecystectomy, and a 12-mm trocar was used at the subxiphoid area for access to the laparoscopic Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab). Nonanatomical partial hepatectomy for en bloc resection of the gallbladder and associated lymphadenectomy were performed. A rubber-band liver retraction technique was applied for stable and effective liver retraction during liver resection, which was described in detail in our previous publication [8]. Liver parenchymal transection was performed using CUSA and ultrasonic shears, and Pringle’s maneuver using a homemade device was applied. After liver resection, lymphadenectomy around the hepatoduodenal ligament proceeded to obtain lymph nodes, skeletonizing the portal triads to clear the lymphatic tissues. The specimen was retrieved through a small extension of the umbilical wound.

A 55-year-old male was diagnosed with cT2 GBC with biopsy-proven lymph node metastasis. He underwent chemotherapy with gemcitabine, cisplatin, and nanoparticle albumin-bound paclitaxel and was assessed as a partial response after four cycles of chemotherapy. The multidisciplinary team decided to perform robotic surgery (Supplementary Video 1). For the robotic approach, the patient position and extent of surgery were identical to those in the laparoscopic approach except for trocar placements and instruments. Four 8-mm trocars were placed (one at the umbilicus for the robotic camera and two at the right and one at the left abdomen) and one 5-mm assistant port was inserted at the subxiphoid area for suture application and access of the suction tube. The performance of robotic liver resection including the rubber band retraction method and Pringle’s maneuver was the same as for laparoscopic surgery. Liver parenchymal dissection was carried out using a combination of a Maryland bipolar dissector and a Harmonic scalpel (Intuitive Surgical, Inc.), and the third robotic arm was used for traction with Cadiere forceps (Intuitive Surgical, Inc.). Lymphadenectomy was performed using the Maryland bipolar dissector and monopolar curved scissors (Intuitive Surgical, Inc.), which had an Endowrist function for delicate dissections.

The total operative times were 180 and 220 minutes, and the respective estimated blood loss amounts were 140 and 130 mL without transfusion in both laparoscopic and robotic extended cholecystectomy. The patients showed uneventful postoperative courses and were discharged on the 5th and 4th postoperative days in good condition. Final pathology results were gallbladder adenocarcinoma with free surgical margins and pathologic stages of pT1bN0 and pT2aN1, respectively. No perineural or lymphovascular infiltration was identified in either case. The patient who underwent laparoscopic surgery was followed with routine surveillance without adjuvant therapy, and the other received four cycles of adjuvant chemotherapy. There was no evidence of recurrence at 33 and 18 months after the operations.

This multimedia article aimed to demonstrate the techniques of both laparoscopic and robotic approaches for extended cholecystectomy. The technical videos showed that both approaches are feasible and safe.

Both laparoscopic and robotic approaches have advantages and disadvantages for specific procedures [9,10]. The authors prefer the laparoscopic approach for liver resection because of the many options of laparoscopic instruments for effective liver parenchymal transection. However, lymphadenectomy in extended cholecystectomy is a challenge when using laparoscopic surgery. In extended cholecystectomy, lymphadenectomy should be performed over the structures while the duodenum and pancreas remain in place. This is different from pancreaticoduodenectomy where lymphadenectomy can be performed after removal of the duodenum and pancreas, resulting in easier access. With accumulated experience in robotic liver resection and a growing volume of literature on oncologic safety of laparoscopic surgery for GBC, robotic surgery has been attempted for GBC [7,8]. Byun et al. [7] advocated the strength of the EndoWrist system of the robotic instruments for performing complete lymphadenectomy. The robotic surgical system would be helpful in the connective tissues and obtaining an optimal number of lymph nodes while minimizing tissue destruction during surgery due to the enhanced dexterity and fidelity of the robotic instruments.

In conclusion, both robotic and laparoscopic extended cholecystectomies can be safely performed. The robotic surgical system seems to be helpful for effective lymphadenectomy. However, further studies are required to investigate the real benefits of robotic surgery in extended cholecystectomy for malignant diseases of gallbladder.

Ethical statements

This study was approved by the Institutional Review Board of CHA University (No. 2022-10-043) and performed in accordance with the ethical standards of institutional research and the Declaration of Helsinki. The need for informed consent in this study was waived, as Korean regulations do not require consent for retrospective analyses.

Authors’ contributions

Conceptualization, Investigation, Methodology: KHK, SHC

Writing–original draft: All authors

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.