Cancer of the Gallbladder and Extrahepatic Bile Ducts

Abstract

Despite the fact that laparoscopic cholecystectomy was one of the first minimally invasive gastrointestinal procedures and currently one of the most common, minimally invasive approach to gallbladder cancer has been limited to incidentally diagnosed T1a lesions. Incidentally diagnosed gallbladder cancers diagnosed on final pathology should be referred to tertiary centers and re-resection should be offered, while patients with unresectable or metastatic disease should be offered palliation. Patients diagnosed with T1b gallbladder cancers or greater are offered laparoscopic re-resection consisting of laparoscopic wedge resection of hepatic segments IVb and V and a laparoscopic hepatoduodenal lymphadenectomy. Although there is no clear survival advantage to primary resection, we have also begun offering patients with preoperatively suspected resectable gallbladder cancer laparoscopic radical cholecystectomy and laparoscopic hepatoduodenal lymph node dissection. The goals of operation are negative margins and a retrieval of, at least, three lymph nodes. When cystic duct margins are positive for malignancy, we perform laparoscopic common bile duct excision with laparoscopic creation of a Roux-en-Y choledochojejunostomy. Expertise in both hepatobiliary and laparoscopic surgery is paramount before embarking on these techniques. These procedures should probably be performed in cancer centers with specialization in minimally invasive techniques. Larger trials are needed to ascertain whether or not there are any advantages to the minimally invasive approach to T1b or greater gallbladder cancer. We describe our indications, workup, and operative technique as we practice it at Fox Chase Cancer Center.