Laparoscopic bile duct resection with lymph node dissection for GB cancer which diagnosed after simple laparoscopic cholecystectomy

Abstract

Summary: A 73-year-old female underwent laparoscopic cholecystectomy for symptomatic GB stone at other hospital 2 months ago. Unfortunately, the pathologic result revealed as 0.9x0.7cm sized T2 lesion of adenosquamous carcinoma located at cystic duct with high-grade dysplasia involving the cystic duct margin. We planned to perform laparoscopic resection of the common bile duct (CBD) with lymph node dissection (LND). Initial laparoscopic views showed severe adhesion around the falciform ligament, GB bed and duodenal bulb. After careful adhesiolysis. Kocherization was proceeded and LNs were dissected from the posterior superior portion of the pancreas. LND was extended along the right side of the CBD and the portal vein. Distal CBD was fully identified and ligated with a clip and transected, then a thinly cut end was sent for the frozen section biopsy. LND was continued along the left side of the hepatoduodenal ligament, while exposing the common and proper hepatic arteries. Dissection of proximal bile duct was proceeded and the common hepatic duct (CHD) was identified clearly. The CHD was then transected and a thinly cut end was also sent for the frozen section biopsy. Skeletonizing and en bloc LND was performed completely. The jejunum was transected by a stapler then the distal stump of the jejunum was pulled up for retrocolic choledochojejunostomy. Choledochojejunostomy was performed by multiple interrupted sutures. A side-to-side Jejunojejunostomy was done by an endo-GIA. Finally, a drain was inserted and the wounds were closed in layers. The operation time was 195 minutes and the estimated intraoperative blood loss was less than 300mL. During current operation, an intraoperative transfusion was not necessary. The postoperative pathologic report revealed that no residual tumor with negative resection margins. LN metastasis was found in one of 8 retrieved LNs. The patient was discharged on the fourth day after surgery without any complications