Hepatic Artery Dissection Research Articles

En Bloc Hilar Dissection of the Right Hepatic Artery in Continuity with the Bile Duct: a Technique to Reduce Biliary Complications After Adult Living-Donor Liver Transplantation

ObjectiveTechniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants. MethodsThis was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection. ResultsA total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3 %, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs 23.5 %., respectively, p = 0.049). ConclusionEn bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.

The computed tomographic angiography finding of hepatic artery dissection after living donor liver transplantation; what is the clinical significance?

ObjectiveTo correlate computed tomography (CT) findings of hepatic artery dissection (HAD) to clinical manifestations of arterial insufficiency and biliary stricture after living donor liver transplantation (LDLT). MethodsAmong 737 consecutive patients, we retrospectively reviewed incidence, CT findings, and complications of the HAD. ResultsHADs occurred in 43 patients, exclusively in recipient arteries. Most were resolved with recovery of true lumen without specific treatment. Five patients had insignificant hepatic arterial infarctions, and incidence of biliary stricture did not significantly differ with control group. ConclusionsHADs frequently occurred shortly after LDLT. Most HADs spontaneously improved and did not affect incidence of late biliary stricture.

Primary stent placement for hepatic artery stenosis after liver transplantation

Significant hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT) can lead to thrombosis, with subsequent liver failure in 30% of patients. Although operative intervention or retransplantation has been the traditional solution, endovascular therapy has emerged as a less invasive treatment strategy. Prior smaller studies have been conflicting in the relative efficacy of percutaneous transluminal angioplasty (PTA) vs primary stent placement for HAS. This was a single-center retrospective review of all endovascular interventions for HAS after OLT during a 54-month period (August 2009-December 2013). Patients with ultrasound imaging with evidence of severe HAS (peak systolic velocity >400-450 cm/s, resistive index <0.5) underwent endovascular treatment with primary stent placement or PTA. Outcomes calculated were technical success, primary and primary assisted patency rates, reinterventions, and complications. Sixty-two interventions for HAS were performed in 42 patients with a mean follow-up of 19.1 ± 15.2 months. During the study period, 654 OLTs were performed. Of 61 patients diagnosed with HAS, 42 underwent an endovascular intervention. The rate of endovascularly treated HAS was 6.4% (42 of 654). Primary technical success was achieved in 95% (59 of 62) of the interventions. Initial treatment was with PTA alone in 17 or primary stent in 25. Primary patency rates after initial stent placement were 87%, 76.5%, 78%, and 78% at 1, 6, 12, and 24 months, respectively, compared with initial PTA rates of 64.7%, 53.3%, 40%, and 0% (P = .19). There were 20 reinterventions in 14 patients (eight stents, six PTAs). The time to the initial reintervention was 51 days in patients with PTA alone vs 105.8 days for those with an initial stent (P = .16). Overall primary assisted patency was 93% at 24 months. Major complications were one arterial rupture and two hepatic artery dissections. The long-term risk of hepatic artery thrombosis in the entire patient cohort was 3.2%. HAS after OLT can be treated endovascularly with high technical success and excellent primary assisted patency. This series represents the largest reported cohort of endovascular interventions for HAS to date. Initial use of a stent showed a strong trend toward decreasing the need for reintervention. Avoidance of hepatic artery thrombosis is possible in >95% of patients with endovascular treatment and close follow-up.

Hepatic artery dissection with retrograde extension to the celiac trunk and splenic artery after liver transplantation: A clinical challenge

Dissection of the graft hepatic artery anastomosis with retrorade extension into the celiac trunk and splenic artery (Fig. 1) ccurred in a patient who underwent liver transplantation (OLT) or alcoholic liver cirrhosis. The patient had received an extended ight graft from a young donor split in situ (piggy-back techique); donor celiac trunk was anastomosed to the recipient ight hepatic artery. The dissection started at the level of arteial anastomosis and caused a partial occlusion of the hepatic rtery. The condition was diagnosed on postoperative day 14 y computed tomography (CT) scan, which showed sufficient raft arterial perfusion. Duplex ultrasound scan (DUS) showed ood arterial flow (peak velocity 71 cm/s, resistive index 0.77),

Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding

Objective. Transcatheter arterial embolization (TAE) is a therapeutic option for endoscopically unmanageable upper gastrointestinal (GI) bleeding. We aimed to assess the efficacy and clinical outcomes of TAE for acute non-variceal upper GI bleeding and to identify predictors of recurrent bleeding within 30 days. Materials and methods. Visceral angiography was performed in 66 patients (42 men, 24 women; mean age, 60.3 ± 12.7 years) who experienced acute non-variceal upper GI bleeding that failed to be controlled by endoscopy during a 7-year period. Clinical information was reviewed retrospectively. Outcomes included technical success rates, complications, and 30-day rebleeding and mortality rates. Results. TAE was feasible in 59 patients. The technical success rate was 98%. Rebleeding within 30 days was observed in 47% after an initial TAE and was managed with re-embolization in 8, by endoscopic intervention in 5, by surgery in 2, and by conservative care in 12 patients. The 30-day overall mortality rate was 42.4%. In the case of initial endoscopic hemostasis failure (n = 34), 31 patients underwent angiographic embolization, which was successful in 30 patients (96.8%). Rebleeding occurred in 15 patients (50%), mainly because of malignancy. Two factors were independent predictors of rebleeding within 30 days by multivariate analysis: coagulopathy (odds ratio [OR] = 4.37; 95% confidence interval [CI]: 1.25–15.29; p = 0.021) and embolization in ≥2 territories (OR = 4.93; 95% CI: 1.43–17.04; p = 0.012). Catheterization-related complications included hepatic artery dissection and splenic embolization. Conclusion. TAE controlled acute non-variceal upper GI bleeding effectively. TAE may be considered when endoscopic therapy is unavailable or unsuccessful. Correction of coagulopathy before TAE is recommended.

The changes in treatment strategies in ABOi living donor liver transplantation for acute liver failure.

Living donor liver transplantation (LDLT) using ABO-incompatible (ABOi) graft for acute liver failure (ALF) is a developing treatment modality. We reviewed the changes in our treatment strategies in applying ABOi LDLT for FH over our fourteen years of experience. Five patients with ALF received LDLT in adults using ABOi grafts, with different but gradually renewed protocols. The etiologies for acute liver failure included autoimmune hepatitis (n=3) and unknown (n=2). The desensitization protocol for ABOi barrier included Case #1; local infusion (portal vein)+plasma exchange (PE), Case #2; local infusion (hepatic artery)+rituximab+PE, Case #3 and #4; rituximab+PE, and Case #5; rituximab+PE under high-flow continuous hemodiafiltration. Local infusion was abandoned since Case #3, because Case #1 had portal vein thrombosis resulting in graft necrosis and Case #2 had hepatic artery dissection. The patients (Case #2 and #3), who received rituximab within 7 days before LDLT, experienced antibody-mediated rejection. Thus, the most recent protocol for ABOi-LDLT is that rituximab is given 2 weeks before LDLT, followed by high-flow continuous hemodiafiltration to obstacle hepatic encephalopathy until LDLT. The four patients except Case #1 are doing well with good graft function over 3.8±3.7 years. Rituximab-based ABOi-LDLT, most-recently under high-flow hemodiafiltration for treating encephalopathy, is a feasible option for applying LDLT for ALF.

TorCH manoeuver: Toronto caudate process hepatotomy for laparoscopic exposure and division of the right portal vein branch

Although formal laparoscopic hepatic lobectomies are performed routinely, concerns including the risk of major intra-operative haemorrhage remain regarding such an approach.1,2 Control of the inflow vasculature prior to parenchymal transection reduces intra-operative blood loss during major hepatectomy3, and extra-hepatic dissection, ligation and division of the right hepatic artery and right portal vein (RPV) is effective in reducing intra-parenchymal haemorrhage. Laparoscopic exposure and stapled division of the RPV is limited owing to the weight of the liver and the RPV anatomical position. Excessive tension or torque on the vein while positioning the stapler can result in catastrophic consequences. A major impediment to smooth introduction of the stapler is the caudate process posterior to the RPV. This report and accompanying video describe the author's approach to address these issues. Specific gallbladder retraction and division of the caudate process after hepatic mobilization is crucial (Fig. 1). The approach is summarized as a checklist in Fig. 2. This method (TorCH manoeuver) is readily teachable and can be included in curricula for continuing medical education or for fellows and established surgeons learning laparoscopic techniques. Figure 1 Completed TorCH manoeuver with a stapler around the right portal vein. Illustrated by: Laura Maaske Figure 2 Checklist summarizing the steps of the TorCH manoeuver

Clinical features of isolated dissections of abdominal aortic branches.

Isolated dissection of an abdominal aortic branch is a rare entity, and previous reports regarding the condition have been based only on small case-series studies. Using a national inpatient database in Japan, we describe the clinical features of patients with isolated celiac, superior mesenteric, splenic, and hepatic artery dissections (ICAD, ISMAD, ISAD, and IHAD). We extracted data on inpatients who were diagnosed with ICAD, ISMAD, ISAD, or IHAD from the Japanese diagnosis procedure combination database, including patients' age and sex, putative risk factors (smoking status and specific comorbidities), treatments (blood transfusion, transcatheter arterial embolization (TAE) and surgical procedures), and outcomes (in-hospital complications and death). Among 18.3million inpatients in the database between July 2010 and March 2013, we identified 276 ICAD, 715 ISMAD, 23 ISAD and 11 IHAD. The percentage of males was 78-92%, and the mean age was 54.7-56.8years. Hypertension was seen in 48-65, and 35-65% were smokers. Fourteen in-hospital deaths were identified in total. In the ICAD group, splenectomy was performed in one patient and TAE was performed in 26 patients. In the ISMAD group, 16 patients received surgical intervention. Most patients with isolated dissection of an abdominal aortic branch were treated conservatively, while a small percentage required TAE or open surgery. A small proportion of dissections resulted in death.

Primary Stent Placement Improves Patency After Endovascular Treatment of Hepatic Artery Stenosis Following Liver Transplantation

Significant hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT) can lead to thrombosis with subsequent liver failure in 30% of patients. Although operative intervention or retransplantation has been the traditional solution, endovascular therapy has emerged as a less invasive treatment strategy. Prior smaller studies have been conflicting in the relative efficacy of percutaneous transluminal angioplasty (PTA) vs primary stent placement for HAS. This was a single-center retrospective review of all endovascular interventions for HAS after OLT during a 54-month period (August 2009-December 2013). Patients with ultrasound evidence of severe HAS (peak systolic velocity >400 cm/s, resistive index of <0.5, tardus parvus spectral abnormalities) underwent endovascular treatment with primary stent placement or PTA. Outcomes calculated were technical success, primary and primary assisted patency rates, reinterventions, and complications. Sixty-two interventions for HAS were performed in 42 patients with a mean follow-up of 19.1 ± 15.2 months. During the study period, the rate of treated HAS was 6.4% (42 of 654). Primary technical success was achieved in 95% (59 of 62) of cases. Initial treatment was with PTA alone (n = 16) or primary stent (n = 26). Primary patency rates after initial stent placement were 91%, 81.3%, 77%, and 77% at 1, 6, 12, and 24 months, respectively, and significantly better (P = .01) compared with 68.8%, 57.1%, 44% for initial PTA (Fig). There were 20 reinterventions in 14 patients (eight stents, six PTAs) for recurrent HAS. The time to initial reintervention in patients with PTA alone vs initial stent was 51 and 105.8 days, respectively. Stent placement was required in 75% of reinterventions, of which five drug-eluting stents were placed. Overall Kaplan-Meier primary patency rates were 82%, 70%, 63%, and 50% at 1, 6, 12, and 24 months, respectively. Overall primary-assisted patency was 96% at 12 months and 93% at 24 months. Major complications were one arterial rupture treated endovascularly and two hepatic artery dissections. Long-term risk of HAT in the entire patient cohort was 4.8%. In this series, which represents the largest reported cohort of endovascular interventions for HAS to date, we demonstrate that HAS after OLT can be treated endovascularly with high initial technical success and excellent primary assisted patency. Initial stent placement significantly decreased the need for reintervention. Avoidance of HAT is possible in >95% of patients with endovascular treatment and close follow-up.

The effect of Doppler ultrasound on early vascular interventions and clinical outcomes after liver transplantation.

During the immediate postoperative period after liver transplantation (LT), postoperative bleeding and vascular complications (stenosis, thrombosis) are the two most common complications that require therapeutic decisions. Doppler ultrasound (DUS) is the established method for screening vascular patency after LT during the immediate postoperative period. The objective of our study was to evaluate the impact of DUS performed on postoperative days (POD) 1 and 2 on early vascular interventions. We studied 200 patients who had undergone living donor or deceased donor liver transplantation between January 2011 and March 2012. Postoperative liver DUS findings of up to POD 14, including patency of hepatic artery, portal vein, and hepatic vein, were retrieved. Patients with normal DUS findings on POD 1 and POD 2 were classified as the normal early DUS group. Patients with abnormal DUS findings at POD1 or POD2 were classified as the abnormal early DUS group. Frequency of vascular interventions was compared between the two groups. Risk factors that predict vascular interventions also were assessed. On POD 1 and 2, 81.5 % (163/200) had normal DUS findings and management was not altered by subsequent DUS findings. Two patients in the normal group were found to have hepatic artery dissection and hepatic vein thrombosis on routine CT on POD 7 and received vascular intervention. DUS results in the two patients were normal until POD 6, but DUS performed after the CT on POD 7 were consistent with the CT findings. Of the 37 recipients who showed abnormal DUS findings on POD 1 or 2, the DUS findings were normalized or unchanged thereafter in 33 patients and no vascular interventions were performed. Two patients underwent hepatic artery thrombectomy on POD 2, one patient required a portal vein thrombectomy on POD 1, and one patient died on POD 3 due to bleeding. The overall incidence of vascular complication requiring vascular interventions was 2.5 %. Logistic regression identified abnormal DUS findings on POD 1 or 2 as an independent risk factor of vascular complications requiring intervention. In LT recipients who demonstrate normal DUS findings in the first 2 postoperative days, additional DUS screening may have value only when clinically indicated.

Aneurysmal dissection of the common hepatic artery

ObservationM. X est un patient de 78 ans, actif et en bon etat general. Dans ses antecedents, on note une hypertension arterielle essentielle traitee, une cardiomyopathie hypertrophique moderee, un tabagisme sevre depuis 40 ans, une nephrectomie droite elargie et une nephrectomie gauche partielle pour adenocarcinome renal a cellules claires.En 2003, lors d’un bilan urologique preprostatectomie, une echographie abdominale retrouvait un anevrisme de l’artere hepatique commune, [...]

2:42 PM; Abstract No. 192 - Yttrium-90 radioembolization for hepatic breast cancer metastasis: a contemporary analysis of safety, response, and survival

(98.7%). Two cases converted to TFA due to RA loop and RA occlusion. Adjunctive embolization with coils or plugs occurred in 43/103 (42%). Repeat TRA was performed in 45/99 patients (45%). Mortality at 30 days was 0%. Minor grade 1 hematoma occurred in 8/156 (5%) cases. RA occlusion occurred in 3/156 cases (2%). Intervention was performed through the occlusion in 2/3 cases. Asymptomatic RA perforation occurred in 2/156 cases (1%). Hepatic artery dissection requiring stenting occurred in 1 case (0.6%). Conclusion: TRA is safe, feasible and well-tolerated for SIRT with rare complications and high technical success.

Partial Cholecystectomy: A Technique That Makes Hilar Dissection Easier in Recipient Hepatectomy

BackgroundIntraoperative blood loss and red blood cell transfusion requirements have a negative impact on outcome after orthotopic liver transplantation. In this study we compared blood transfusion requirements, bile duct injury, and dissection of hepatic artery rates in the patients with or without partial cholecystectomy during recipient hepatectomy. MethodsFrom December 2008 to August 2011, 100 recipient hepatectomies were performed by the same surgeon. Patients were divided into 2 groups. The first group included patients with partial cholecystectomy, and the other group patients without partial cholecystectomy. Each group consisted of 50 patients. ResultsIn recipient hepatectomy group without partial cholecystectomy, intraoperative blood transfusions were in the range of 3–11 units (mean, 6.3 units). In this group there were 4 hepatic artery dissections and 2 bile duct injuries. In the group with partial cholecystectomy, intraoperative blood transfusions were in the range of 0–7 units (mean, 3.1 units). In this group there was 1 hepatic artery dissection. There were no operative mortalities in either group. ConclusionsWe recommend partial cholecystectomy during recipient hepatectomy of cirrhotic patients, particularly with hydropic gallbladders, because bleeding from the points of adherent gallbladder during mobilization of the liver is diminished and fewer artery dissections and bile duct injuries develop, because the procedure facilitates dissection of the hilar structures.

Can the model for end-stage liver disease score replace the indocyanine green clearance test in the selection of right hemihepatectomy in Child-Pugh class A?

PurposeTo identify the correlation of the model for end-stage liver disease (MELD) scores with the assessment of the risk of hepatic function after hemihepatectomy in patients with hepatocellular carcinoma (HCC) related to hepatitis B virus (HBV).MethodsA case-control study was performed based on data for 141 consecutive patients who underwent curative right hepatic resection between January 2006 and June 2010.ResultsAll patients were Child-Pugh class A. The mean age of the patients was 50 years (range, 29-73 years). The group included 114 men (80.9%) and 27 women (19.1%). The distribution of MELD scores (median, 7; range, 6-14) and indocyanine green retention rate at 15 minutes (ICG-R15) (median, 9.2%; range, 1.1%-19.5%) showed no significant correlation (P = 0.615). Only one perioperative death (0.7%) occurred within 30 days, which was the result of liver failure by hepatic artery dissection during the Pringle maneuver. Hepatic dysfunction occurred in 25 patients (17.7%) after liver resection. In multivariate analysis, male gender, increased HBV DNA level, and elevated serum aspartate transaminase level were significantly related with hepatic dysfunction. Tumor size and satellite nodule were closely associated with tumor recurrence in HBV-related HCC after right hemihepatectomy and satellite nodule was a predisposing factor for mortality in those patients.ConclusionMELD score does not accurately predict hepatic function after right hemihepatectomy in patients with resectable HBV-related HCC. MELD scores were not correlated with the ICG-R15 values in patients with Child-Pugh class A.

Dissection of the Hepatic Artery and the Celiac Trunk After a Liver Transplant: Description of a Complication and Endovascular Management

Dissection of the common hepatic artery is a rare complication after orthotopic liver transplant. Subsequent thrombosis and occlusion of the transplant artery can result in graft failure requiring retransplant. We describe a case of hepatic artery dissection, occurring on the basis of primary vasculopathy, extending into the celiac trunk, with subtotal occlusion of the vessel through accompanying thrombosis. An attempt of endovascular rescue led to successful recanalization of the vessel and graft survival.

Adjuvant Hepatic Intra‐arterial Iodine‐131‐Lipiodol Following Curative Resection of Hepatocellular Carcinoma: A Prospective Randomized Trial

The purpose of the present study was to determine whether intrahepatic injection of (131)I-lipiodol (Lipiodol) is effective against recurrence of surgically resected hepatocellular carcinoma (HCC). From June 2001 through March 2007, this nationwide multi-center prospective randomized controlled trial enrolled 103 patients 4-6 weeks after curative resection of HCC with complete recovery (52: Lipiodol, 51: Control). Follow-up was every 3 months for 1 year, then every 6 months. Primary and secondary endpoints were recurrence-free survival (RFS) and overall survival (OS), respectively, both of which were evaluated by the Kaplan-Meier technique and summarized by the hazard ratio (HR). The design was based on information obtained from a similar trial that had been conducted in Hong Kong. The Lipiodol group showed a small, and nonsignificant, improvement over control in RFS (HR = 0.75; 95 % confidence interval [95 % CI] 0.46-1.23; p = 0.25) and OS (HR = 0.88; 95 % CI 0.51-1.51; p = 0.64). Only two serious adverse events were reported, both with hypothyroidism caused by (131)I-lipiodol and hepatic artery dissection during angiography. The randomized trial provides insufficient evidence to recommend the routine use of (131)I-lipiodol in these patients.

Ruptured hepatic artery dissection: case report

Dissections of splanchnic arteries are rare but important vascular lesions associated with high mortality. We describe a case of ruptured hepatic artery dissection in a 72-year-old woman found deceased after being unwell with diarrhoea and vomiting for 3 days. Autopsy showed haemoperitoneum of approximately 1 litre of blood and blood clot. Histological examination revealed hepatic artery dissection with medial-adventitial separation associated with a neutrophilic infiltrate, which appeared to be most likely a secondary effect rather than an underlying vasculitic process. The deceased had hypertension, which is associated with a large proportion of reported cases of hepatic artery dissection. However, no specific underlying cause was identified. Clinical features and aetiology of hepatic artery dissection will be discussed.

Arterial Abnormalities Are An Important Issue in Liver Graft Harvesting

Introduction: In the EUROTRANSPLANT region harvesting of abdominal organs in brain dead donors is usually performed by a local surgical team, contrary to thoracic grafts. Afterwards, the abdominal organs were shipped to the transplant centers if not locally used. Although harvesting procedures are widely standardized, iatrogenic organ lesions are common. The aim of the study was to analyze the quality of liver harvesting comparing liver graft description (necroliver report) of the harvesting and the transplant surgeon. Methods: A total of 89 liver grafts from brain dead donors retrieved for transplantation at our center between 09/2010 and 08/2011 were used for this study. Liver grafts for split livers or multi-visceral transplantations were excluded. Thirty (34%) livers were harvested by the local and 59 (66%) by an external team. All grafts were re-evaluated by the transplant surgeon according to the characteristics of the necroliver report. Both reports - the one of the harvesting and the one of the transplant surgeon - were then compared. Results: Beside the necroliver report, the liver transplant surgeons reported on several notable graft injuries in 29 livers (33%) following organ retrieval, such as lesions of the liver surface (n=20), cuts in accessory liver artery (n=6), very short bile duct (n=1) or portal vein (n=1), or cut into vena cava (n=1). In 79 out of 89 livers (89%) graft description was similar between both surgeons. However, relevant differences occurred in the description of the liver arterial anatomy (6/89, 7%), mostly due to non-observance of accessory right/left arteries (and others in n=4 livers). Moreover, one donor liver was not suitable for transplantation due to severe vascular lesions (dissection of accessory left hepatic artery, several large cuts into AHC and coeliac axis). Conclusion: Organ harvesting is a challenging procedure. Although well established, iatrogenic organ lesions frequently occurred, and different estimation mostly affected hepatic arterial anatomy. This may lead to organ dysfunction or severe complications after transplantation. Therefore, a quality assurance is mandatory to meet and control high standards in organ harvesting throughout the entire EUROTRANSPLANT region.

Dissection of the Proper Hepatic Artery With a Replaced Left Hepatic Artery

Dissection of the Proper Hepatic Artery With a Replaced Left Hepatic Artery

Technical description of a regional lymphadenectomy in radical surgery for gallbladder cancer

BackgroundThe guidelines for resection of gallbladder cancer include a regional lymphadenectomy; yet it is uncommonly performed in practice and inadequately described in the literature. The present study describes the technique of a regional lymphadenectomy for gallbladder cancer, as practiced by the author. Methods/TechniqueAfter confirming resectability, the duodenum is kocherized. The dissection starts from the posterior aspects of the duodenum and head of the pancreas and extends superiorly to the retroportal area. This is followed by dissection of the common hepatic artery and its branches, the bile duct and the anterior aspect of the portal vein until the hepatic hilum. Resection of the gallbladder with an appropriate liver resection completes the surgery. ResultsThis technique was used for a regional lymphadenectomy in 27 patients, of which 14 underwent radical cholecystectomy upfront, and 13 had revisional surgery for incidentally detected gallbladder cancer. The median number of lymph nodes dissected on histopathology was 8 (range 3 to 18). Eleven patients had metastatic lymph nodes on histopathological examination. There was no post-operative mortality. Two patients had a bile leak which resolved with conservative management. ConclusionA systematic approach towards a regional lymphadenectomy ensures a consistent nodal harvest in patients undergoing radical resection for gallbladder cancer.