Robotic extended cholecystectomy in gallbladder cancer

Exploring the Potential of Robotic Single-Port Surgery for Gallbladder Cancer: Initial Insights and Future Prospects

BACKGROUND

Robotic surgery has demonstrated outcomes comparable or superior to open and laparoscopic surgeries for extended cholecystectomy.1-8 Despite its advantages, the minimally invasive robotic single-port (SP) system remains underutilized in complex hepatobiliary pancreatic surgery due to instrument limitations and retraction issues.9,10 This study evaluated the feasibility, safety, and effectiveness of the da Vinci SP system in gallbladder cancer surgery. The study was approved by the Ethics Committee of OOO University Hospital (IRB no. DAUH IRB-24-081) and conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the study's retrospective design.

METHODS

A 62-year-old woman with a diagnosis of gallbladder cancer was referred for surgery. Preoperative computed tomography (CT) scans showed no evidence of metastasis (T2N0). Therefore, a robotic SP extended cholecystectomy was planned. Figure 1 shows a 30-mm SP port and a 1-mm assistant port inserted for the procedure. Due to the absence of an energy device for the liver wedge resection, Maryland bipolar forceps were used, mimicking the Kelly clamp crushing technique. A monopolar cautery hook was used for lymph node resection of stations 7, 8, 12, and 13 (Fig. 2). Fig. 1 Port placement for robotic extended cholecystectomy using the da Vinci Xi system Fig. 2 Demonstration of full lymph node dissection RESULTS: The total duration of the operation was 226 min, with an estimated blood loss of 200 ml. The CT scan on day 5 showed no abnormalities, and the patient was discharged routinely on day 7 (Fig. 3). The pathologic examination confirmed adenocarcinoma (T2a) with clear resection, and all six lymph nodes tested negative for malignancy. Fig. 3 The wound 2 weeks after surgery CONCLUSIONS: This study underscores the adequacy of robotic surgeries and emphasizes the potential of the da Vinci SP system in hepatobiliary surgery. Despite current challenges related to instrument limitations, the authors are confident that the SP system will evolve into a crucial asset for hepatobiliary surgical practices in the foreseeable future.

Evolution from laparoscopic to robotic radical resection for gallbladder cancer: a propensity score-matched comparative study

BACKGROUND

The use of robotic or laparoscopic surgery for gallbladder cancer (GBC) is increasing, with reported advantages over conventional open surgery. The purpose of this study was to compare the perioperative outcomes and postoperative overall survival (OS) associated with robotic radical resection (RRR) and laparoscopic radical resection (LRR) for GBC.

METHOD

A total of 109 patients with GBC who underwent radical resection with the same surgical team between January 2015 and December 2023 were enrolled, with 21 patients in the RRR group and 88 cases in the LRR group. A 1:1 propensity score matching (PSM) algorithm was used to compare the surgical outcomes and postoperative prognosis between the RRR and LRR groups. Logistic regression analysis was used to identify the risk factors of postoperative overall survival (OS) and complications of Clavien-Dindo (C-D) Grades III-IV.

RESULTS

The median follow-up time was 46 (inter-quartile range, IQR 29-70) months for the LRR group and 16 (IQR 12-34) months for the RRR group. After PSM, the baseline characteristics of the RRR and LRR groups were generally well balanced, with 21 patients in each group. RRR was associated with significantly decreased intraoperative bleeding [100.00 (50.00, 200.00) mL vs 200.00 (100.00, 300.00) mL] and higher number of lymph nodes (LNs) yield [12.00 (9.00, 15.50) vs 8.00 (6.00, 12.00)]. The two groups showed comparable outcomes in terms of the incidence of biliary reconstruction, the range of liver resection, the length of operation, the incidence of postoperative morbidity, the incidence of C-D Grades III-IV complications, number of the days of drainage tubes indwelling and postoperative hospital stay, and mortality by postoperative days 30 and 90. After PSM, the 1-, 2-, and 3-year overall survival rates were 78, 70, and 37%, respectively, in the RRR group, and 71, 59, and 48%, respectively, in the LRR group (P = 0.593). Multivariate analysis showed that the preoperative TB level ≥ 72 µmol/L and biliary reconstruction were found to be the independent risk factors of C-D Grades III-IV complications. T3 stage was identified to be the risk factor for postoperative OS.

CONCLUSION

Compared with LRR, RRR showed comparable perioperative outcomes in terms of length of operation, and postoperative complications, recovery, and OS. In our case series, RRR of GBC can be accomplished safely and tends to show less intraoperative bleeding and higher LNs yield.

Evolution of minimally invasive cholecystectomy: a narrative review

BACKGROUND

Laparoscopic cholecystectomy, being a prevalent abdominal surgical procedure, has transitioned through various innovative stages aimed at reducing the procedure's invasiveness. These stages encompass Single-Incision Laparoscopic Cholecystectomy (SILC), Mini Laparoscopic Cholecystectomy (MLC), Natural Orifice Transluminal Endoscopic Surgery (NOTES), and Robotic-Assisted Laparoscopic Cholecystectomy (RALC). The purpose of this review is to trace the evolution of minimally invasive cholecystectomy techniques, assess their status, and identify emerging trends and challenges in the field.

METHOD

An extensive review was performed to explore the evolution and characteristics of SILC, MLC, NOTES, and RALC. The approach involved an in-depth examination of literature available on PubMed, coupled with a critical assessment of surgical outcomes, associated complications, and technical hurdles posed by these methods.

RESULTS

SILC, despite its potential for reduced scarring, exhibits an elevated risk of bile duct damage and incisional hernia occurrences. MLC, mirroring the standard technique closely, presents minor benefits without amplifying postoperative complications, hence, positing itself as a feasible choice for routine elective cholecystectomy. NOTES, although still facing technical challenges, the hybrid transvaginal procedure is gaining clinical interest. RALC, heralded for its augmented precision and dexterity, emerges as a potential future avenue, although necessitating further exploration to ascertain its efficacy and safety.

CONCLUSION

The progression of laparoscopic cholecystectomy methodologies embodies the surgical society's aspiration to minimize invasiveness whilst enhancing patient outcomes. This review endeavors to offer a structured discourse on SILC, MLC, NOTES, and RALC, aspiring to aid the ongoing deliberation on the judicious selection of surgical techniques in clinical practice.

Robotic, laparoscopic and open surgery for gallbladder cancer: a systematic review and network meta-analysis

INTRODUCTION

Minimally invasive oncological resections have become increasingly widespread in the surgical management of cancers. However, the role of minimally invasive surgery (MIS) for gallbladder cancer (GBC) remains unclear. We aim to perform a systematic review and network meta-analysis of existing literature to evaluate the safety and feasibility of laparoscopic and robotic surgery in the management of GBC compared to open surgery (OS) by comparing outcomes.

METHODS

A literature search of the PubMed/MEDLINE (2000 to December 2021) and EMBASE (2000 to December 2021) databases was conducted. The primary outcome studied was overall survival, and secondary outcomes studied were postoperative morbidity, severe complications, incidence of bile leak, length of hospital stay, operation time, R0 resection rate, local recurrence and lymph node yield.

RESULTS

Thirty-two full-text articles met the eligibility criteria and were included in the final analysis with a total of 5883 patients undergoing either OS or MIS (laparoscopic or robotic) for GBC. 1- and 2-stage meta-analyses did not reveal any significant differences between OS, laparoscopic and robotic surgery in terms of overall survival, R0 resection, lymph node harvest, local recurrence and post-operative complications. Patients who underwent OS had significantly longer hospitalization stay and intra-operative blood loss compared to those who underwent laparoscopic or robotic surgery. Network meta-analysis did not reveal any significant differences between post-operative and survival outcomes of laparoscopic vs robotic surgery groups.

CONCLUSION

This network meta-analysis suggests that both laparoscopic and robotic surgery are safe and effective approaches in the surgical management of GBC, with post-operative and survival outcomes comparable to OS. An MIS approach may also lead to shorter hospitalization stay, less intraoperative blood loss and post-operative complications compared to OS. There was no obvious benefit of either MIS approach (laparoscopic versus robotic) over the other.

Innovations in surgery for gallbladder cancer: A review of robotic surgery as a feasible and safe option

BACKGROUND

This study evaluates the efficacy and safety of robotic-assisted surgical techniques in the treatment of gallbladder cancer, comparing it with traditional open and laparoscopic methods.

METHODS

A systematic review of the literature searched for comparative analyses of patient outcomes following robotic, open, and laparoscopic surgeries, focusing on oncological results and perioperative benefits.

RESULTS

Five total studies published between 2019 and 2023 were identified. Findings indicate that robotic-assisted surgery for gallbladder cancer is as effective as traditional methods in terms of oncological outcomes, with potential advantages in precision and perioperative recovery.

CONCLUSIONS

Robotic surgery offers a viable and potentially advantageous alternative for gallbladder cancer treatment, warranting further research to confirm its benefits and establish comprehensive surgical guidelines.

SOAT1 in gallbladder cancer: Clinicopathological significance and avasimibe therapeutics

The aim of this investigation was to evaluate the differential expression of the sterol O-acyltransferase 1 (SOAT1) protein in gallbladder cancer tissues and cells, investigate the impact of Avastin on the proliferation, migration, invasion capabilities of gallbladder cancer cells, and its potential to induce cell apoptosis. Immunohistochemical analysis of samples from 145 gallbladder cancer patients was conducted, along with analysis of SOAT1 protein, mRNA expression levels, and cholesterol content in gallbladder cancer cell lines SGC-996, NOZ, and gallbladder cancer (GBC)-SD using Western blot and q-PCR techniques. Furthermore, the effects of Avastin on the proliferation, migration, and invasion capabilities of these gallbladder cancer cell lines were studied, and its ability to induce cell apoptosis was evaluated using flow cytometry, Western blot, and immunohistochemical methods. Additionally, gene expression and pathway analysis were performed, and the synergistic therapeutic effects of Avastin combined with gemcitabine were tested in a gallbladder cancer xenograft model. The study found that SOAT1 expression was significantly upregulated in GBC tissues and positively correlated with lymph node metastasis and TNM staging. In vitro experiments demonstrated that Avastin significantly inhibited the proliferation, migration, and invasion capabilities of SGC-996 and GBC-SD cell lines and induced apoptosis. RNA sequencing analysis revealed multiple differentially expressed genes in cells treated with Avastin, primarily enriched in biological pathways such as signaling transduction, malignant tumors, and the immune system. In vivo, experiments confirmed that Avastin could effectively suppress tumor growth in a gallbladder cancer xenograft model and enhanced the treatment efficacy when used in combination with gemcitabine. Overall, these findings provide new insights and strategies for targeted therapy in gallbladder cancer.

Gallbladder cancer: surgical treatment, immunotherapy, and targeted therapy

Gallbladder cancer is a common type of biliary tract tumor. Optimal management for early stage cases typically involves radical excision as the primary treatment modality. Various surgical techniques, including laparoscopic, robotic, and navigational surgery, have demonstrated favorable clinical outcomes in radical gallbladder excision. Unfortunately, most patients are ineligible for surgical intervention because of the advanced stage of the disease upon diagnosis. Consequently, non-surgical interventions, such as chemotherapy, radiotherapy, immunotherapy, and targeted therapy, have become the mainstay of treatment for patients in advanced stages. This review focuses on elucidating various surgical techniques as well as advancements in immunotherapy and targeted therapy in the context of recent advancements in gallbladder cancer research.

Clinical outcomes of minimally invasive (laparoscopic and robotic) versus open extended cholecystectomy: A multicenter propensity score matched study

BACKGROUND

This multicenter study aimed to compare the clinical outcomes of minimally invasive extended cholecystectomy (MI-EC) versus open EC (O-EC) for patients with gallbladder cancer (GBC).

METHODS

Patients who underwent EC (cholecystectomy, wedge resection of the liver bed, and regional lymphadenectomy) for GBC between 2010 and 2020 in three centers were included in the study. The clinicopathological data were compared after propensity score matching. Additional subgroup analysis on laparoscopic and robotic EC (L-EC and R-EC) was performed.

RESULTS

A total of 377 patients were included: 308 for O-EC and 69 for MI-EC, respectively. The MI-EC group had a longer operative time (188.9 vs. 238.1 min, p < .001) and shorter hospital stay (9.0 vs. 7.2 days, p = .007), although no differences were found in operative blood loss, complication rate and survival outcome. In subgroup analysis, L-EC patients had a longer operative time (264.4 vs. 202.0 min, p = .001), compared to R-EC patients with comparable perioperative and survival outcomes.

CONCLUSION

Although patients with MI-EC had a longer operation time and higher medical costs, the advantages were enhanced recovery with comparable short- and long-term outcomes. The operation time was less for R-EC patients than for L-EC patients, though the high cost still remains. The surgery type for EC can be selected according to the patient's condition, social status and surgeon's preference.

Application of laparoscopic surgery in gallbladder carcinoma

Gallbladder carcinoma (GC) is a rare type of cancer of the digestive system, with an incidence that varies by region. Surgery plays a primary role in the comprehensive treatment of GC and is the only known cure. Compared with traditional open surgery, laparoscopic surgery has the advantages of convenient operation and magnified field of view. Laparoscopic surgery has been successful in many fields, including gastrointestinal medicine and gynecology. The gallbladder was one of the first organs to be treated by laparoscopic surgery, and laparoscopic cholecystectomy has become the gold standard surgical treatment for benign gallbladder diseases. However, the safety and feasibility of laparoscopic surgery for patients with GC remain controversial. Over the past several decades, research has focused on laparoscopic surgery for GC. The disadvantages of laparoscopic surgery include a high incidence of gallbladder perforation, possible port site metastasis, and potential tumor seeding. The advantages of laparoscopic surgery include less intraoperative blood loss, shorter postoperative hospital stay, and fewer complications. Nevertheless, studies have provided contrasting conclusions over time. In general, recent research has tended to support laparoscopic surgery. However, the application of laparoscopic surgery in GC is still in the exploratory stage. Here, we provide an overview of previous studies, with the aim of introducing the application of laparoscopy in GC.

The technique of laparoscopic and robotic extended cholecystectomy for gallbladder cancer

The application of minimally invasive surgery for gallbladder cancer (GBC) is yet controversial. This article discusses the techniques of laparoscopic and robotic extended cholecystectomy. A 69-year-old male diagnosed with cT1-2N0 GBC underwent laparoscopic surgery, and a 55-year-old male with cT2N1 GBC underwent robotic surgery after preoperative chemotherapy. Nonanatomical partial hepatectomy with lymphadenectomy was performed. Liver parenchymal dissection was performed using Cavitron Ultrasonic Surgical Aspirator laparoscopically and Maryland bipolar dissector and Harmonic scalpel robotically. The operation time was 180 and 220 minutes, and the estimated blood loss was 140 and 130 mL, respectively. The final pathologies were pT1bN0 and pT2aN1, for which patients received adjuvant chemotherapy. There was no evidence of recurrence at 33 and 18 months without complications. Both laparoscopic and robotic extended cholecystectomy can be safely performed with the robotic surgical system as an effective alternative for GBC requiring liver resection with radical lymphadenectomy.

Target nursing care on anxiety and depression in patients with gallbladder cancer during perioperative period

BACKGROUND

This study retrospectively investigated the effects of target nursing care (TNC) on anxiety and depression in patients with gallbladder cancer (GBC) during the perioperative period.

METHODS

This retrospective study analyzed the data of 80 patients with GBC during perioperative period. These records were divided into an intervention group (n = 40) or a control group (n = 40). All 80 patient records in both groups were administered routine nursing care (RNC). The patients in the intervention group also underwent TNC. The primary outcomes were depression (measured using the Hamilton Depression Scale, HAMD) and anxiety (assessed using the Hamilton Anxiety Scale, HAMA). The secondary outcomes were quality of life (assessed using the 36-Item Short Form Health Survey, SF-36) and adverse events. We collected and analyzed the outcome data before and after treatment.

RESULTS

After treatment, patients in the intervention group showed more promising effects on depression (HAMD, P < .01) and anxiety (HAMA, P < .01) than those in the control group did. However, there were no significant differences in the quality of life before and after treatment. No TNC- or RNC-associated adverse events were reported in patient records.

CONCLUSION

This study found that TNC was more effective than RNC in relieving depression and anxiety. Future studies should be conducted to validate the present findings.

Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: Report of an international multicenter cohort study with propensity score matching

BACKGROUND

Intrahepatic cholangiocarcinoma is a rare disease with a poor prognosis. In patients where surgical resection is possible, outcome is influenced by perioperative morbidity and lymph node status. Laparoscopic liver resection is associated with improved clinical and oncological outcomes in primary and metastatic liver cancer compared with open liver resection, but evidence on intrahepatic cholangiocarcinoma is still insufficient. The primary aim of this study was to compare overall survival for a large series of patients treated for intrahepatic cholangiocarcinoma by open or laparoscopic approach. Secondary objectives were to compare disease-free survival, predictors of death, and recurrence.

METHODS

Patients treated with laparoscopic or open liver resection for intrahepatic cholangiocarcinoma from 2000 to 2018 from 3 large international databases were analyzed retrospectively. Each patient in the laparoscopic resection group (case) was matched with 1 open resection control (1:1 ratio), through a propensity score calculated on clinically relevant preoperative covariates. Overall and disease-free survival were compared between the matched groups. Predictors of mortality and recurrence were analyzed with Cox regression, and the Textbook Outcomes were described.

RESULTS

During the study period, 855 patients met the inclusion criteria (open liver resection = 709, 82.9%; laparoscopic liver resection = 146, 17.1%). Two groups of 89 patients each were analyzed after propensity score matching, with no significant difference regarding pre- and postoperative variables. Overall survival at 1, 3, and 5 years was 92%, 75%, and 63% in the laparoscopic liver resection group versus 92%, 58%, and 49% in the open liver resection group (P = .0043). Adjusted Cox regression revealed severe postoperative complications (hazard ratio: 10.5, 95% confidence interval [1.01-109] P = .049) and steatosis (hazard ratio: 13.8, 95% confidence interval [1.23-154] P = .033) as predictors of death, and transfusion (hazard ratio: 19.2, 95% confidence interval [4.04-91.4] P < .001) and severe postoperative complications (hazard ratio: 4.07, 95% confidence interval [1.15-14.4] P = .030) as predictors of recurrence.

CONCLUSION

The survival advantage of laparoscopic liver resection over open liver resection for intrahepatic cholangiocarcinoma is equivocal, given historical bias and missing data.

Treatment of Resectable Gallbladder Cancer

Gallbladder cancer (GBC) is the most common biliary tract cancer worldwide and its incidence has significant geographic variation. A unique combination of predisposing factors includes genetic predisposition, geographic distribution, female gender, chronic inflammation, and congenital developmental abnormalities. Today, incidental GBC is the most common presentation of resectable gallbladder cancer, and surgery (minimally invasive or open) remains the only curative treatment available. Encouragingly, there is an important emerging role for systemic treatment for patients who have R1 resection or present with stage III-IV. In this article, we describe the pathogenesis, surgical and systemic treatment, and prognosis.

Robotic Surgery for Biliary Tract Cancer

Biliary tract cancer consists of cholangiocarcinoma (CC) and gallbladder cancer (GBC). When resectable, surgery provides the best chance at long-term survival. Unfortunately, surgery for these tumors is associated with long operative times, high morbidities, and prolonged hospital stays. Minimally invasive surgery has been shown to impact selected outcomes, including length of stay, in other diseases, and robotic surgery may offer additional advantages compared to laparoscopic surgery in treating bile duct cancers. This is a systematic review of robotic surgery for biliary tract cancer. Predetermined selection criteria were used to appraise the literature. The PRISMA guidelines were followed. In total, 20 unique articles with a total of 259 patients with biliary tract cancer undergoing robotic surgery met the inclusion criteria. For CC and GBC, respectively, the weighted average operative time was 401 and 277 min, the estimated blood loss was 348 and 260 mL, the conversion rate to open was 7 and 3.5%, the all-cause morbidity was 52 and 9.7%, the major morbidity was 12 and 4.4%, the perioperative mortality was 1.4 and 0%, the length of stay was 15 and 4.8 days, the positive margin rate was 27 and 9%, and the number of lymph nodes retrieved was 4.2 and 8. Robotic surgery for biliary tract cancer appears non-inferior to open surgery when compared to the published contemporary data. However, the current literature on the topic is of low quality, and future prospective/randomized studies are needed.

Robotic Central Hepatectomy for the Treatment of Gallbladder Carcinoma. Outcomes of Minimally Invasive Approach

Gallbladder cancer (GBC) is an uncommon but very aggressive malignancy with poor prognosis. Concerns for oncological inferiority related to the technical difficulties in performing laparoscopic portal lymphadenectomy discourage many surgeons to undertake this operation minimally invasively. With wide application of robotic technology to solve limitations of conventional laparoscopy, we describe our initial outcomes of robotic central hepatectomy and portal lymphadenectomy for gallbladder carcinoma in 15 consecutive patients. Data were presented as median (mean ± SD). Patients were 70 (73 ± 10.9) years old with BMI of 26 (26 ± 3.6) kg/m². Tumor size was 3(4 ± 1.9) cm. Operative duration was 222 (237 ± 85.7) minutes and estimated blood loss was 200 (222 ± 135.4) mL. There were no intraoperative complications and complete resection (R0) was obtained in nearly all patients. Postoperative complications were seen in two patients (bile leak (n = 1) and respiratory failure (n = 1)). Length of stay was 3 (4 ± 4.0) days without 30-day mortality. Robotic approach is safe and effective for the treatment of GBC.

Essential updates 2019/2020: Surgical treatment of gallbladder cancer

Gallbladder cancer is a biliary tract cancer that originates in the gallbladder and cystic ducts and is recognized worldwide as a refractory cancer with early involvement of the surrounding area because of its anatomical characteristics. Although the number of cases is increasing steadily worldwide, the frequency of this disease remains low, making it difficult to plan large-scale clinical studies, and there is still much discussion about the indications for surgical resection and the introduction of multidisciplinary treatment. Articles published between 2019 and 2020 were reviewed, focusing mainly on the indications for surgical resection for each tumor stage, the treatment of incidental gallbladder cancer, and current trends in minimally invasive surgery for gallbladder cancer.