Laparoscopic Approach for Large Polypoid Lesions and Cancer of the Gallbladder

Radbeh Torabi, MD, Zhi Ven Fong, MD, David W Rattner, MD, Keith D Lillemoe, MD, Cristina R Ferrone, MD. Department of Surgery, Massachusetts General Hospital.

An open cholecystectomy and partial liver resection has classically been advocated for gallbladder cancer that extends beyond the lamina propria, due to the potential of port site seeding and likelihood of liver involvement. We have previously reported that polypoid lesions of the gallbladder (PLG) greater than 9 mm, in patients older than 52 years of age are risk factors of existing cancer extending into the liver interface. We report our outcomes following laparoscopic cholecystectomy and partial segment 4b and segment 5 liver resections to analyze the safety and efficacy of the minimally invasive approach
Six patients (median age 69 years, 4 females) underwent laparoscopic cholecystectomy and partial segment 4b and segment 5 liver resection with periportal lymph node dissection, for either gallbladder cancer (n=2) or large (>9 mm) PLG (n=4). One of the patients with gallbladder cancer presented following laparoscopic cholecystectomy at an outside hospital with gallbladder cancer diagnosed on pathology, and we performed a laparoscopic partial liver resection. The second patient had CT findings suggestive of gallbladder cancer. The patients with PLG presented with lesions >9 mm on preoperative imaging including ultrasound, CT or MRI.
Pathology of the specimens from the 2 patients with gallbladder cancer revealed T3N1 adenocarcinoma with > 10 mm resection margins. Of the 4 patients with PLG, one patient presented with T2N0 adenocarcinoma, one with adenomyomatous hyperplasia forming a nodule, one with cholesterolosis polyp and one with cholelithiasis without an identified polyp. The one patient undergoing liver resection following prior cholecystectomy had a significantly higher estimated blood loss (1700mL), length of hospital stay (12 days), and was the only patient in this group that required blood transfusion and an ICU admission for monitoring. The median operative time was 155 minutes, median estimated blood loss of 150 mL and median length of hospital stay of 3 days. Median follow up was 19 months for patients diagnosed with gallbladder cancer, and 1 of these 3 patients had recurrence within 16 months following resection. There was no mortality, morbidity, or port site metastasis to report.
Our data suggests that a minimally invasive approach is a safe and effective approach for patients with gallbladder cancer and PLG. This may benefit patients as there were no operative morbidity or mortality while providing an adequate oncologic resection with negative margins. The operative time, estimated blood loss and low length of hospital stay are encouraging for wider application of this approach.

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