The majority of early gallbladder cancers are diagnosed upon final pathology after laparoscopic cholecystectomy, however, controversy exists as to what procedure should be done when gallbladder cancer is suspected preoperatively. Some authors recommend laparoscopic cholecystectomy with intra-operative frozen section analysis followed by conversion to an open approach if gallbladder cancer is confirmed. Alternatively, some centers insist on an anatomic resection of the entire right hepatic lobe although more recent studies dispute the necessity of this. At our institution, patients undergo radical cholecystectomy consisting of a removal of the gallbladder bed via en bloc wedge resections of hepatic segments IVB and V. Further controversy exists as to the role of minimally invasive techniques in the management of early gallbladder cancer. Because of our expanding laparoscopic liver program, we have begun offering patients minimally invasive radical cholecystectomies in patients with suspicion of gallbladder cancer.
Materials & Methods:
Presented here is a totally laparoscopic radical cholecystectomy performed for suspected early gallbladder cancer. This video will show the steps necessary to perform a laparoscopic radical cholecystectomy, common bile duct excision and Roux-en-Y choledochojejunostomy for a gallbladder cancer with disease in the cystic duct stump extending into the common bile duct. As with standard laparoscopic cholecystectomy, this procedure is done with 4 trocars.
The patient underwent a totally laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy and was found to have T3 N1 M0, Stage 2B gallbladder cancer with 1 out of 3 lymph nodes positive for cancer. The operation took 6 hours, the estimated blood loss was 200 cc and she was discharged home on post-operative day number 4. She has no evidence of disease on 6 months follow-up and is currently receiving 6 months of adjuvant chemoradiation. To date 6 patients have undergone laparoscopic radical cholecystectomy, 3 were found to have gallbladder cancer on final pathology. Two patients were found to have cholelithiasis and a final patient was diagnosed with autoimmune cholecystitis despite a negative preoperative serum IgG4 level within normal limits.
Of the patients found to have benign disease, one radical cholecystectomy was performed using single incision laparoscopic techniques, she was diagnosed with a porcelain gallbladder on pre-operative CT scan. For all minimally invasive radical cholecystectomies, the average operative time was 204 minutes (range= 95-360 minutes), the average estimated blood loss was 137cc (range= 50-300cc) and the average length of stay was 3.7 days (range =3-4 days). There were no intra-operative complications or morbidity or mortality at 30 and 90 days. Average lymph node retrieval for the patients with cancer was 3 (range=1-6).
Laparoscopic radical cholecystectomy may be useful in select patients with a preoperative suspicion of gallbladder cancer. Need for common bile duct excision and choledochojejunostomy is not a contraindication to the laparoscopic approach. It should be currently be done in high volume centers with expertise in surgical oncology of the Hepato-Biliary system and laparoscopy. Larger series are needed to see if there is any advantage to this approach when compared to the standard open approach.
Session: Video Channel
Program Number: V053