Evolution of minimally invasive surgery in gallbladder carcinoma: maintaining oncological radicality and the enduring value of open resection

Advancements in minimally invasive surgery, including laparoscopic and robot-assisted procedures, have made it possible to achieve optimal short- and long-term outcomes for various gastrointestinal malignancies compared with the outcomes of open surgery (1,2). Gallbladder carcinoma (GBC) remains a formidable challenge in surgical oncology because of its aggressive nature and frequent diagnosis at advanced stages (3). Even after curative surgery, early and delayed recurrences frequently occur. Laparoscopic surgery for GBC is not inferior to open surgery in terms of postoperative hospital stay, intraoperative bleeding, and R0 resection (4-6). The ongoing debate surrounding the optimal surgical approach—laparoscopic versus open resection (OR)—for resectable GBC demands robust evidence to guide clinical practice and improve patient outcomes. In this context, a recent multicenter propensity score-matched comparative study by Liu et al. examining the long- and short-term outcomes of curative-intent laparoscopic resection (LR) versus OR for resectable GBC provides valuable insights (7).

Traditionally, open surgery has been the gold standard treatment for GBC, allowing for comprehensive tumor removal. According to the National Comprehensive Cancer Network guidelines, this includes extended hepatic resection, cholecystectomy, and meticulous lymphadenectomy, often with bile duct excision for lymph node metastasis (8). Liu et al. addressed these critical limitations by utilizing a multicenter database from 13 tertiary hospitals in China and employing propensity score matching (PSM) to minimize selection bias. By focusing exclusively on patients with GBC who underwent curative-intent resection between 2016 and 2020, they ensured a more homogeneous patient cohort and standardized definition of radical surgery. This rigorous methodology strengthens the credibility of the findings and offers a clearer comparison between LR and OR for this highly complex malignancy. Short-term outcomes reported by Liu et al. demonstrated clear advantages in the LR group. After PSM, patients who underwent LR had significantly lower overall morbidity rates (35.3% vs. 57.5%, P=0.01). Although the LR group had a longer operative time and more harvested lymph nodes, these factors may reflect the meticulous nature of laparoscopic dissection and improved lymph node retrieval, both of which are crucial for the accurate staging and prognosis of GBC. These findings are consistent with the growing recognition of the value of LR in hepatobiliary surgery, in which a minimally invasive approach can reduce surgical stress and accelerate recovery. The observed low morbidity rate is a significant clinical benefit, potentially leading to fewer postoperative complications and an improved quality of life for patients.

The study found no significant difference in long-term outcomes, specifically overall survival (OS) and progression-free survival (PFS), between the LR and OR groups after PSM. The 3-year OS rates were 57.4% and 55.5% in the LR and OR groups, respectively, with similar PFS rates. This parity in long-term survival is a pivotal finding, suggesting that, when selected appropriately, patients with GBC can achieve oncological outcomes comparable to those of traditional open surgery. This evidence supports the continued expansion of LR for GBC, provided that the oncological principles of radical resection are strictly adhered to, including clear margins and adequate lymphadenectomy. The conversion rate from LR to OR was 5.9%, indicating the feasibility and safety of LR in such cases. Furthermore, the number of harvested lymph nodes was seven in the LR group and five in the OR group. These differences are due to operator and institutional policies, which could be a major source of bias affecting long-term prognosis. Despite the use of PSM, potential biases such as the ‘learning curve’ effect, differences in surgeon experience across the 13 institutions and subtle selection biases when choosing candidates for LR, which are often influenced by tumor location or patient background, cannot be entirely eliminated. These factors may influence both surgical radicality and reported complication rates.

In addition to comparing surgical approaches, this study highlights the independent association between adjuvant chemotherapy (AC) and improved OS and PFS in patients with GBC after curative-intent resection. Low postoperative complications are significantly associated with long-term prognosis (9), and AC can be smoothly administered to patients with GBC. A high proportion of patients in the LR group were eligible for AC, which is a critical factor in improving the long-term survival of patients with GBC. This finding emphasizes the need for a multidisciplinary approach to GBC management, in which surgery is often complemented by systemic therapy. The JCOG1202 trial established the utility of AC with S-1 for patients with biliary cancer in the adjuvant setting, especially for patients with GBC (10). Patients’ ability to tolerate and receive AC postoperatively, particularly following a less morbid surgical approach, such as LR, is a significant advantage that can directly affect their long-term prognosis. This study identified independent risk factors for worse OS and PFS, including stage N1/N2, T2, T3/T4, poor tumor differentiation, and positive resection margins, emphasizing the importance of accurate staging and complete tumor removal. These factors are well-established prognostic indicators of GBC, and their validation in this multicenter cohort highlights the ongoing challenges in treating advanced disease.

However, the implications of this study are not fully defined. In surgical practice, it provides strong evidence to support the judicious application of LR for resectable GBC in appropriately selected patients. This approach can lead to reduced morbidity, faster recovery, and potentially better tolerance to subsequent adjuvant therapies. It offers the prospect of a less invasive treatment option with comparable long-term oncological outcomes. However, surgeons performing LR for GBC must possess advanced laparoscopic skills and strictly adhere to the principles of radical oncological resection to ensure outcomes equivalent to those of open surgery. The complexity of GBC surgery, which requires extensive lymphadenectomy and potentially hepatic or bile duct resection, necessitates a high level of surgical expertise, regardless of the approach.

Although this study provides compelling evidence, it is important to acknowledge its retrospective nature, despite its robust PSM methodology. Although challenging to conduct in rare and complex malignancies, such as GBC, prospective randomized controlled trials would provide the highest level of evidence. Future research should focus on refining patient selection criteria for LR, exploring the long-term impact of specific AC regimens after LR and investigating the role of newer technologies in optimizing laparoscopic techniques for gallbladder cancer.

In conclusion, the multicenter comparative study by Liu et al. significantly contributes to the literature on GBC management. This study provides robust evidence that for resectable GBC cases that meet the National Comprehensive Cancer Network criteria for curative intent, LR offers comparable long-term oncological outcomes to OR, with improved short-term morbidity. Furthermore, this study reinforces the critical role of AC in improving patient survival. These findings highlight a paradigm shift in the surgical management of GBC, advocating a personalized approach in which experienced surgeons can safely and effectively perform LR for suitable patients, thereby enhancing patient recovery and facilitating comprehensive adjuvant treatment. Continued refinement of patient selection, surgical techniques, and multimodal therapies is crucial to improve the prognosis of individuals with this challenging disease.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2026-1-0134/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2026-1-0134/coif). The authors have no conflicts of interest to declare.

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