Abstract. Patients with carcinoma of the gallbladder that is preopera- tively diagnosed by radiology do not undergo laparoscopic resection, because such ...
J Hepatobiliary Pancreat Surg (2008) 15:585–588 DOI 10.1007/s00534-008-1363-5
Total laparoscopic resection of the gallbladder together with the gallbladder bed AKIHIRO CHO, HIROSHI YAMAMOTO, MATSUO NAGATA, NOBUHIRO TAKIGUCHI, HIDEAKI SHIMADA, OSAMU KAINUMA, HIROAKI SOUDA, HISASHI GUNJI, AKINARI MIYAZAKI, ATSUSHI IKEDA, and IKUKO MATSUMOTO Division of Gastroenterological Surgery, Chiba Cancer Center Hospital, 666-2 Nitonachou, Chuo-ku, Chiba 260-8717, Japan
Abstract Patients with carcinoma of the gallbladder that is preoperatively diagnosed by radiology do not undergo laparoscopic resection, because such surgery is thought to worsen the prognosis of gallbladder carcinoma. However, the prognosis for patients with incidental T2 gallbladder carcinoma who are treated laparoscopically is reportedly no worse than that for patients undergoing conventional surgery. We successfully performed total laparoscopic resection of the gallbladder together with the gallbladder bed without any complications. We believe that this procedure represents a valid therapeutic option for carefully selected patients with T2 carcinoma of the gallbladder. Key words Laparoscopy · Gallbladder carcinoma · Gallbladder bed
Introduction In patients with T2 carcinoma of the gallbladder that invades perimuscular connective tissue without extension beyond the serosa or into the liver, only complete tumor resection enables long-term survival.1 Radical surgery, including extended cholecystectomy (resection greater than hepatic resection of the gallbladder bed), for T2 disease reportedly shows significant survival advantages compared with simple cholecystectomy.1–3 Laparoscopy for liver resection is a highly specialized field, as laparoscopic liver surgery presents severe technical difficulties. However, the recent rapid development of technological innovations, improvements in
Offprint requests to: A. Cho Received: February 1, 2008 / Accepted: March 20, 2008
surgical techniques, and the accumulation of extensive experience by surgeons have improved the feasibility and safety of laparoscopic approaches for properly selected patients.4–6 We describe herein our experience, with three patients, of total laparoscopic resection of the gallbladder together with the gallbladder bed, representing the first description of this laparoscopic procedure.
Surgical procedure The patient was placed in a supine position. A 15-mm trocar was placed 1 cm below the umbilicus, through which CO2 gas was delivered. Pneumoperitoneum was controlled electronically at a pressure of 10 mmHg. A 12-mm trocar was placed in the upper median of the abdomen, two 5-mm trocars were placed in the right subcostal area, and one 5-mm trocar was placed in the left subcostal area. The lesser omentum was sectioned and the hepatoduodenal ligament was encircled by tape to be used as a tourniquet for complete interruption of blood inflow to the liver only if necessary. The liver and gallbladder were examined using laparoscopic ultrasonography, to confirm the extension of the lesion inside the gallbladder and the absence of liver metastasis. After dissection of Calot’s triangle, the cystic duct and artery were divided. Lymph node dissection was performed around the common bile duct (the number of retrieved lymph nodes was 4, 4, and 5 in each three patients), and rapid intraoperative pathological examination of the lymph nodes was performed (Fig. 1), confirming the absence of metastasis. The gallbladder neck was dissected and separated from the gallbladder bed. Using electrocautery, a line approximately 2 cm from the attachment of the gallbladder to the liver was marked on the liver surface (Fig. 2), from which parenchymal dissection was performed using laparoscopic coagulation shears (LCS; Ethicon Endo Surgery
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Fig. 1. After lymph node dissection around the common bile duct (CBD), rapid pathological examination of the lymph nodes was performed. The CBD was exposed. GB, Gallbladder
Fig. 3. Hepatic parenchymal dissection was performed using laparoscopic coagulation shears while retracting the gallbladder neck
Fig. 4. Cut surface of the liver Fig. 2. A line approximately 2 cm from the attachment of the gallbladder to the liver was marked (arrow)
Results
Industries, Cincinnati, OH, USA) while retracting the gallbladder neck (Fig. 3). Small vessels and biliary structures that were less than 3 mm in diameter were coagulated using the LCS. Vessels of 3 mm or more in diameter were divided using endoscopic vascular clips (Endoclip; Ethicon Endo Surgery Industries). Care was taken to perform liver parenchymal dissection 2 cm or more from the gallbladder, and finally the gallbladder and liver parenchyma around the gallbladder were resected. The specimen was then extracted using an endoscopic bag retrieval system (Endo-catch; U.S. Surgical, Norwalk, CT, USA) through a minimally enlarged umbilical incision. At the cut surface of the liver, a closed drain was placed (Fig. 4).
We successfully performed the above procedures as planned in three patients with gallbladder tumor that had been diagnosed preoperatively as T2 carcinoma without lymph node metastasis. The procedure took 89–146 min (mean time, 102 min) and resulted in minor blood loss. No patients required blood transfusion. The underlying pathology was adenocarcinoma invading the subserosal layer without extension to the liver (pT2 gallbladder cancer) in two patients, and chronic cholecystitis in one patient. No lymph node metastasis was detected and all lesions were well clear of the surgical margins. The postoperative courses were uneventful in all three patients. The abdominal drain was removed and oral intake was resumed on postoperative day 1. The mean duration of hospitalization was 5 days (range,
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4–7 days). In the two patients with carcinoma, no recurrences have been observed at of the time of writing, with the follow-up period being 9 to 20 months.
Discussion Since the first descriptions of port-site metastases of gallbladder carcinoma in 1991,7 laparoscopic surgery has been considered to worsen the prognosis of gallbladder carcinoma.8 However, the prognosis for patients with incidental gallbladder carcinoma who are treated laparoscopically is reportedly no worse than that for patients undergoing conventional surgery.9 As for 5-year survival in patients with T2 tumors, no significant differences are seen between laparoscopic operation, open operation, or intraoperative conversion.9 Although perforation of the gallbladder and excessive manipulation of the organ can cause intraperitoneal spread of malignant cells, resulting in significantly worse survival,10,11 meticulous procedures and the use of isolation bags have been shown to decrease intraperitoneal dissemination and recurrences at port sites.7,12 Radical surgery, including extended cholecystectomy, for T2 disease, significantly increases survival compared with simple cholecystectomy, but no significant difference in survival is seen between extended cholecystectomy with and without extrahepatic biliary resection.13 However, the extent of liver resection, and the roles of lymph node dissection and extrahepatic bile duct resection are still controversial, and the diagnosis of the depth of mural invasion and lymph node metastasis is still difficult even with full use of imaging modalities.14 Therefore, the indication for total laparoscopic resection of the gallbladder together with the gallbladder bed should be confined to a polypoid lesion of the fundus (regardless of whether the lesion is on the peritoneal or hepatic side) in which the depth of tumor invasion is suspected to extend to the muscularis propria or possibly the subserosa (Fig. 5). In conventional laparoscopic cholecystectomy, the dissection plane on the liver side is within the subserosal layer. Therefore, laparoscopic cholecystectomy should not be employed for a lesion on the liver side, because a cancer remnant may result if the lesion has extended beyond the muscular layer.15 However, the present procedure can achieve a free margin even in a lesion on the liver side because of the en-bloc resection of the gallbladder together with the gallbladder bed. Approximately half of T2 gallbladder cancers show lymphatic, vascular, and perineural invasions and lymph node metastasis.15 In the three patients in the present study, lymph node dissection was performed around the common bile duct, and rapid intraoperative pathological examination was negative for lymph node metastasis. However, lymph node metasta-
Fig. 5. Enhanced computed tomography shows an isoenhanced sessile polypoid lesion (arrow), 3 cm in size, on the liver side of the gallbladder fundus
sis of T2 gallbladder cancer is not necessarily confined to regional lymph nodes. The recent evolution of laparoscopic surgery has allowed extended lymph node dissection for gastric cancer.16 We think that more extended lymph node dissection, including peripancreatic lymph nodes, could be necessary when total laparoscopic resection of the gallbladder together with the gallbladder bed is employed for T2 gallbladder cancer. Although our experience is limited and appropriate indications must await future studies, we believe that laparoscopic resection of the gallbladder together with the gallbladder bed and without the extrahepatic bile duct may be one of therapeutic options for carefully selected patients with T2 carcinoma of the gallbladder, if bile spillage and excessive manipulation of the gallbladder are avoided during surgery. However, an open resection would be preferred if there were any doubt that lymph node metastasis or serosal invasion had occurred.
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