Laparoscopic extended cholecystectomy with extended left hemi-hepatectomy (left lobe & S5), after interventional...

The benefits of the use of interventional therapy and neoadjuvant chemotherapy [1] to improve post-operative outcomes and potentially reduce the rate of recurrence during a laparoscopic extended cholecystectomy with extended left hemi-hepatectomy (left lobe & S5) for a T3N1M0 (Stage IIIb) Gallbladder Cancer (GBC).

This 58-year-old female patient, diagnosed with stage IIIb GBC and left portal vein tumor thrombus (PVTT) underwent multiple cycles of transarterial chemoembolization (TACE), hepatic arterial infusion of chemotherapy (HAIC) (Chen et al., 2021) [2] and neoadjuvant systemic anti-cancer chemotherapy (SACT) prior to surgery. Tumor downstaging, left liver lobe atrophy and reduced tumor levels (especially of AFP and CA19-9) all led to safer surgical parameters for this late-staged tumor resection, that allowed for improved FLR after neoadjuvant locoregional therapies and SACT. More details on tumor size changes and other information are provided in the supplementary video file (Supplementary_Video1). Laparoscopic extended cholecystectomy with extended left hemi-hepatectomy was performed with regional lymph node skeletonization via en-bloc technique that extended from the enlarged LNs surrounding the portal vein, to the common hepatic artery. The extent of lymphadenectomy is individualized according to tumor staging and per-operative imaging findings. For late-stage GBC, extended lymphadenectomy is suggested considering the presence of skip lesions and therefore is a routine peri-operative decision that our surgical team makes given the circumstance on a case-to-case basis. Samples from gallbladder, cystic duct, liver and various regional lymph nodes were collected and sent for pathology.

This minimally invasive extended cholecystectomy with extended left hemi-hepatectomy (LHH) was successfully completed in the duration of 260 minutes with estimated blood loss of 150ml. The frozen section sample of the cystic duct stump was found to be negative. The patient's post-operative pathology results confirmed adenocarcinoma of gallbladder tissue with G2-G3 histological grading, positive perineural and lymphovascular invasion. The liver bed sample was also confirmed for infiltration. However, only the portal vein lymph nodes were found positive for metastases amongst all the lymph node samples, thereby confirming a pT3N1M0 TNM staging for this patient. The immunohistochemical results of the specimens showed: CK7(+), CK19(+), CK20(-), CDX2(+), CEA(+), MLH1(+), MSH2(+), MSH6(+), PMS2 (+), Ki-67(MIB-1)(+), HER2 (-), p53 (+). The patient was discharged Day 5 after surgery with a prescription of 1g oral capecitabine (twice a day, biweekly with one week off). The post operative 6 month and one year CT scans and MRI scans were consistent with normal post-surgical changes, and the patient didn't succumb to any complications (Supplementary_Video1 showcases the technique used for this surgery).

The use of tri-modal therapy of HAIC and TACE with neoadjuvant SACT (Lin et al., 2024) [3] showed a positive effect on the tumor by downstaging the cancer, thereby reducing the size of the tumor and in turn reducing the risk of surgery by maintaining a healthy FLR. Furthermore, adequate liver resection of Liver segments 2,3,4 and 5 lead to a lower recurrence rate. This surgical technique demonstrated the feasibility of Laparoscopic surgery for stage IIIb GBC with Liver infiltration and LN metastasis.