Comment on “Outcomes and safety of minimally invasive surgery in gallbladder cancer: international, multicenter cohort study”

To the Editor, Law et al provide timely international multicenter data comparing minimally invasive surgery (MIS; laparoscopic/robotic) with open radical resection for gallbladder cancer (GbCa), addressing a long-standing concern that MIS might compromise oncologic adequacy in this aggressive disease[1]. Their cohort suggests MIS can deliver favorable perioperative outcomes (less blood loss, shorter length of stay) while maintaining key oncologic surrogates (margin status, nodal yield) and comparable survival endpoints to open surgery[1]. This commentary conforms to the TITAN 2025 guideline on transparency and accountable reporting[2]. Several aspects deserve emphasis. First, the reported MIS lymph node yield and R0 rate are reassuring because nodal staging quality is a persistent weakness in real-world GbCa care. Current guideline-aligned practice emphasizes adequate portal lymphadenectomy, with ≥6 nodes often cited as a minimum for accurate staging in ≥pT1b disease[3,4]. In that context, the authors’ finding of higher nodal yield in MIS than open is important, and it complements contemporary evidence that MIS radical cholecystectomy can achieve oncologic outcomes comparable to open approaches when performed in expert hepatobiliary centers[5]. Second, the lower bile-leak signal in the robotic subgroup is intriguing and biologically plausible (precision dissection, suturing, and cut-surface control), but it should be interpreted cautiously given small numbers and the likelihood of center-expertise effects[1]. The main interpretive challenge is selection and complexity confounding. As the authors note, tumor biology and extent of resection differed between groups, with more adverse features in the open cohort[1]. This mirrors real-world adoption: surgeons preferentially select MIS for earlier or technically favorable disease while reserving open surgery for bulky tumors, vascular proximity, or anticipated biliary reconstruction. Although the study’s subgroup analyses are helpful, residual confounding remains inevitable in retrospective multicenter datasets spanning evolving imaging, systemic therapy, and surgical technique. For clinical translation, the key next step is standardizing oncologic quality reporting alongside approach: nodal stations sampled, total nodes retrieved (including the ≥6 benchmark), margin definitions, and recurrence patterns by T stage and incidental vs primary presentation – elements emphasized within NCCN biliary tract guidance and related surgical quality discussions[3,4]. Overall, Law et al strengthen the case that MIS – particularly in high-volume hepatobiliary programs – can be oncologically sound for selected GbCa patients, while underscoring the need for prospective registries (or pragmatic trials) stratified by operative complexity to define where robotics and laparoscopy add consistent value[1].