Laparoscopic Management of Gallbladder Cancer: A Stepwise Approach

In the era of laparoscopic cholecystectomy, incidentally discovered gallbladder cancer (IGBC) has become a common clinical presentation.1 A consensus exists that radical resection should be performed for IGBC patients with T1b or more advanced tumors.2 Although the oncologic safety of laparoscopic treatment for selected patients with gallbladder cancer (GBC) has been demonstrated, a laparoscopic approach for IGBC remains uncommonly practiced due to the technical challenge of the frequently reoperative cases.3 PATIENT: A 75-year-old man underwent laparoscopic cholecystectomy for the presumed diagnosis of chronic cholecystitis and sludge at an outside institution, and pathology showed a T3 gallbladder carcinoma with a positive margin at the cystic duct stump. Restaging computed tomography at the time of referral showed findings in the hepatoduodenal ligament and gallbladder fossa concerning residual tumor versus postoperative inflammation. After four cycles of gemcitabine and cisplatin, restaging showed interval resolution of the postoperative change, continued low tumor marker carbohydrate antigen 19-9, and no evidence of metastatic disease. Therefore, the decision was made to perform a laparoscopic radical resection TECHNIQUE: With the patient in French position, significant adhesions around the hepatoduodenal ligament had to be dissected. Lymph node stations 12 and 16 were removed after a Kocher maneuver and hepatoduodenal ligament lymphadenectomy, preserving an accessory right hepatic artery. The cystic duct stump was removed at the level of confluence with the common bile duct. The resulting defect was reconstructed with interrupted sutures. Using intraoperative ultrasonography (IOUS) guidance, an anatomic resection of segments 4b and 5 was performed. An alternative approach is a laparoscopic Glissonian approach that can facilitate a safe anatomic resection.4 An air cholangiogram detected no bile leak and confirmed biliary patency.5 The postoperative recovery was uneventful, and pathology showed residual adenocarcinoma in segments 4b, and 5 with 50 % tumor viability and negative margins.

Because laparoscopic management of IGBC involves a challenging reoperative procedure, a systematic approach using accurate preoperative anatomic assessment, meticulous IOUS-guided surgery, and air cholangiogram is recommended to minimize the morbidity of this operation.