[Standard radical surgery for carcinoma of the gallbladder invading the subserosal layer (ss cancer)]

The postoperative survival rate is dependent on the invasive depth of cancer of the gallbladder, as shown in in our studies and in other Japanese studies detailed in questionnaires. In cases of m, mp cancer, good survival rates are achieved after simple cholecystectomy or wedge resection of the liver including the gallbladder bed with regional lymphadenectomy. However, when the cancer has invaded beyond the subserosal layer, lymph node and adjacent organ involvement is found in a large number of patients, and long-term survival cannot be achieved by wedge resection of the liver with dissection of the cystic nodes and pericholedochal lymph nodes. The poor prognosis of patients with these lesions might be due to the use of inappropriate surgical procedures. When the appropriate procedures based on the extent of subserosal (ss) invasiveness of gallbladder cancer were used, long-term survival was obtained in our patient series. The appropriate radical surgical procedures for ss cancer are as follows: When cancer is diagnosed as invading to the ss layer by intraoperative ultrasonography (IOUS), wedge resection of the liver including the gallbladder bed and D2 dissection of the lymph nodes including the paraaortic lymph nodes (16a2 inter, 16b1 inter pre) should be performed. When liver involvement (Hinf1-Hinf2) is diagnosed by IOUS or cancer is located on the liver bed, resection of segment 4a 5 in Couinaud's classification is performed. When there is involvement of the pericholedochal nodes, nodes around the common hepatic artery, and/or posterior pancreatoduodenal nodes are found at operation, pancreatoduodenectomy should be performed. Wedge resection of the liver or S4a 5 segmental resection of the liver with resection of the bile duct and D2 dissection of the lymph nodes including the paraaortic lymph nodes is considered to be the standard radical operation for many patients with ss cancer of the gallbladder.