Surgical Technique of Laparoscopic Whole-Layer Cholecystectomy for Suspected Early Gallbladder Cancer: A Safe and...

It is difficult to diagnose early gallbladder cancer (GBC) preoperatively; therefore, the surgical procedure for patients suspected of having this condition should be chosen with curability and invasiveness in mind. We herein present a standardized procedure for performing complete laparoscopic whole-layer cholecystectomy (LWLC) for suspected early GBC. Between January 2010 and January 2023, LWLC was performed on 44 patients with suspected early GBCs located on the peritoneal side. We devised and performed the following procedure to perform LWLC safely. Our procedure is based on the preservation of Laennec's capsule with an appropriate transection plane using the cystic plate as an anatomical landmark. The steps of this procedure comprise (1) isolation of the cystic duct and artery with accurate dissection of the 12c and cystic duct lymph nodes and preservation of the hilar plate; (2) preemptive ligation of the cystic duct to seal off any free cancer cells floating in bile within the gallbladder; (3) excision of the entire gallbladder starting from the S4-side of the fundus to neck with preservation of Laennec's capsule; (4) definitive visual identification and transection of the cystic plate at the neck; and (5) resection of the cystic duct after placement of the gallbladder in an organ bag to prevent intraperitoneal dissemination of bile. Pathological examination revealed 15 GBCs (34.1%), of which 13 cases were early stage (86.7%). Specifically, the depth of invasion was in situ in four cases, mucosa in four cases, muscle propria in five cases, and subserosa in two cases. Regarding lymph node metastasis, it was detected in only one case, which had tumor invasion of the subserosa. The median operation time was 138 minutes, and estimated blood loss was 27 mL (range: 0-108 mL). There was no intraoperative bile leakage and no postoperative complications requiring surgical, endoscopic, or radiological intervention. We confirmed elastic fibers covering the outer layer of subserosa at the level of dissection from the liver bed. With a median follow-up of 56 months, 14 patients remain alive without recurrence, and one has died from another disease. Our original procedure of LWLC is a reproducible and feasible means of treating early or suspected GBC located on the free peritoneal side, achieving lengthy remission, being less invasive than other currently performed procedures, and possibly being curative.