Journal Name: International Journal of Hepatobiliary and ... · 128 gall bladder cancer. CECT...

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Early View Article: Online published version of an accepted article before publication in the

final form.

Journal Name: International Journal of Hepatobiliary and Pancreatic Diseases

Type of Article: Case Report

Title: Laparoscopic radical cholecystectomy for carcinoma gall bladder: Case report

Authors: Ashutosh Gupta, Amit Choraria , Shantanu Tiwari , Hitesh Dubey, Rajesh Kumar

Agrawal, Sourabh Nandi, Vivek Chaudhary

doi: To be assigned

Early view version published: May 31, 2017

How to cite the article: Gupta A, Choraria A, Tiwari S, Dubey H, Agrawal RK, Nandi S,

Chaudhary V. Laparoscopic radical cholecystectomy for carcinoma gall bladder: Case

report. International Journal of Hepatobiliary and Pancreatic Diseases. Forthcoming 2017.

Disclaimer: This manuscript has been accepted for publication. This is a pdf file of the

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TYPE OF ARTICLE: Case Report 1

2

TITLE: Laparoscopic radical cholecystectomy for carcinoma gall bladder: Case 3

report 4

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AUTHORS: 6

Ashutosh Gupta (MCh Surgical Oncology), Associate Professor1 7

Amit Choraria (Fellowship in Surgical Oncology), Senior Resident1 8

ShantanuTiwari (DNB General Surgery), Senior Resident1 9

Hitesh Dubey (MS General Surgery), Senior Resident1 10

Rajesh Kumar Agrawal (MS General Surgery), Senior Resident1 11

Sourabh Nandi (MS General Surgery), Senior Resident1 12

Vivek Chaudhary (MD Radiotherapy), Director1 13

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AFFILIATIONS: 15

1Department of Surgical Oncology, Regional Cancer Center, Pt JNM Medical 16

College, Raipur, Chhattisgarh, India 17

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CORRESPONDING AUTHOR DETAILS 19

Amit Choraria 20

Department of Surgical Oncology, Regional Cancer Center, Pt JNM Medical College, 21

Raipur, Chhattisgarh, India 22

Email: [email protected] 23

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Short Running Title: Laparoscopic radical cholecystectomy for carcinoma gall 25

bladder 26

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Guarantor of Submission : The corresponding author is not the guarantor of 28

submission. 29

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Guarantor of Submission 33

Ashutosh Gupta (MCh Surgical Oncology) 34

Department of Surgical Oncology, Regional Cancer Center, Pt JNM Medical College, 35

Raipur, Chhattisgarh, India 36

Email: [email protected] 37

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report 65

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ABSTRACT 67

Introduction 68

Nowadays laparoscopic surgery is a very common form of treatment strategy for 69

digestive diseases and these ‘keyhole’ surgeries provide many benefits to the 70

patients. However, controversy exists when the laparoscopic surgery is done early 71

gallbladder cancer. The aim of our study was to report 2 such cases to see feasibility 72

and safety of laparoscopic radical cholecystectomy with lymph node dissection. 73

74

Case Report 75

2 patients underwent laparoscopic radical cholecystectomy with lymph node 76

dissection for gallbladder carcinoma. Both patients were preoperatively diagnosed. 77

Mean operative time was 172 minutes, and average estimated blood loss was 78

225ml. There was no intraoperative complication. The liver dissection was done by 79

Harmonic in one case and by Water Jet in the other case. Average hospital stay after 80

surgery was 4 days. Post-operative morbidity included minimal bile leak in one 81

patient only and no bile leak in patient operated with Waterjet system. 82

Post-operative histopathology revealed adenocarcinoma of gall bladder with no 83

lymph node invasion T2N0M0 (Stage II) in both patients. The mean lymph node 84

retrieval was 5.5. Both patients received adjuvant chemotherapy with Gemcitabine 85

and Carboplatin. 86

87

Conclusion 88

We conclude that Laparoscopic radical cholecystectomy with lymph node dissection 89

is safe and beneficial for the patients with T1b/T2 gallbladder carcinoma and is 90

useful in selected patients with a preoperative suspicion of early-stage gallbladder 91

cancer by sparing them the necessity of a second-stage open procedure. 92

93

Keywords: Laparoscopic Radical Cholecystectomy, Carcinoma Gall bladder, Case 94

Report 95


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report 97

98

INTRODUCTION 99

The most aggressive malignancy of hepatobiliary system is gall bladder carcinoma 100

and is widely known for its poor prognosis [1]. We all know that nowadays 101

laparoscopic surgery is accepted as a very common form of treatment strategy for 102

digestive diseases [2]. However, controversy exists when the laparoscopic surgery is 103

done early gallbladder cancer. Management protocol for Tis and T1a gall bladder 104

cancer requires only simple cholecystectomy with clear margins which can be done 105

either by laparoscopy or traditionally open procedure [3]. In case of T1b or more 106

advanced gall bladder cancer, management requires radical cholecystectomy which 107

includes hepatic segment 4b-5 resection and lymphadenectomy of hepatoduodenal 108

ligament [4]. 109

Majority of surgeons fear that tumor might disseminate during laparoscopy. Also as 110

this surgery is one of the most advanced type of laparoscopy which is associated 111

with a long learning curve, so surgeons find it difficult to retrieve adequate lymph 112

nodes and do liver resections. All of this hence creates controversy associated with 113

this surgery. 114

The aim of our study was to report post-operative data in 2 such cases and to check 115

feasibility and safety of laparoscopic radical cholecystectomy with lymph node 116

dissection at our center. 117

118

CASE REPORT 119

2 patients underwent laparoscopic radical cholecystectomy with lymph node 120

dissection for gallbladder carcinoma at Department of Surgical Oncology, Regional 121

Cancer Center, Raipur, and Chhattisgarh, India. 122

First patient was a sub-urban housewife lady aged 35years coming with 123

constitutional symptoms of loss of weight and appetite since 2 months. There was no 124

significant past medical or surgical history. Examination revealed a small 2cm mass 125

in right hypochondrium consistent with gall bladder mass. Other systems were 126

normal and jaundice was absent. She extensively was investigated on suspicion of 127


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gall bladder cancer. CECT abdomen revealed gall bladder mass of 2.5 cm maximum 128

dimension with cholelithiasis with no invasion to liver, no significant 129

lymphadenopathy, no dilatation of intrahepatic biliary system, and no systemic 130

metastasis. Her hematology and biochemistry was within normal limit and Ca 19-9 131

was 42.68 U/ml. As per the hospital protocol, she first underwent diagnostic 132

laparoscopy which revealed no peritoneal metastasis and then proceeded to 133

definitive surgery. A total laparoscopic standard radical cholecystectomy was done 134

and specimen was bagged in a polythene bag and was retrieved from a mini 135

laparotomy at midline supraumbilical site and sent for histopathology (Figure1). 136

Other patient was rural housewife lady aged 49 years coming with complaints of pain 137

in right hypochondium since 1 month. There was no significant past medical or 138

surgical history. Examination revealed mild tenderness but no lump. Other systems 139

were normal and jaundice was absent. She extensively was investigated on 140

suspicion of gall bladder cancer. CECT abdomen revealed gall bladder mass of 2cm 141

maximum dimension with no invasion to liver, no significant lymphadenopathy, no 142

dilatation of intrahepatic biliary system, no systemic metatstasis. Her haematology 143

and biochemistry was within normal limit and Ca 19-9 was 55.8 U/ml. As per the 144

hospital protocol, she first underwent diagnostic laparoscopy which revealed no 145

peritoneal metastasis and then proceeded to definitive surgery. A total laparoscopic 146

standard radical cholecystectomy was done and specimen was bagged in a 147

polythene bag and was retrieved from a mini laparotomy at midline supraumbilical 148

site and sent for histopathology (Figure 2). 149

Mean operative time was 172 (160, 184) minutes, and average estimated blood loss 150

was 225 ml (250ml, 200ml). The liver dissection was done by Harmonic in first case 151

and by Water jet in the second case (Figure 3). There was no intraoperative bile 152

leak. During intraoperative liver resection small biliary radicals were clipped by 153

titanium clips to avoid leak. There was no intraoperative complication in both 154

patients. Average hospital stay after surgery was 4 days. Drain removal was done on 155

8th post-operative day for both patients. 156

Post-operative morbidity included minimal bile leak in first case, which resolved on 157

4th post-operative day by conservative management. There was no biliary leak in 158

second case in which we used Water Jet for dissection. 159


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Post-operative histopathology revealed adenocarcinoma of gall bladder with no 160

lymphnode invasion T2N0M0 (Stage II) in both patients. The mean lymphnode 161

retrieval was 5.5 (5, 6). 162

Both patients received adjuvant chemotherapy 6 cycles with Gemcitabine and 163

Carboplatin. The mean follow up was 9 (12, 6) months. Follow up was done 3 164

monthly and radiological evaluation was done 6 monthly as per the hospital protocol. 165

Follow up evaluation and CECT abdomen and thorax did not reveal any recurrence. 166

Also there was no port site metastasis. Hence, there was no evidence of recurrence 167

in the study period. 168

169

DISCUSSION 170

As per standard surgical guidelines, the management of patients affected by gall 171

bladder cancer is related to the TNM stage. Simple cholecystectomy is sufficient for 172

Tis or T1a tumor. Evidence suggests similar oncologic outcomes of laparoscopy 173

versus open cholecystectomy for Tis and T1a tumors [5]. In contrast, for T1b or 174

higher stage tumor which necessitates a radical procedure, a minimally invasive 175

approach is questioned by majority of surgeons. 176

Despite the absence of any randomized controlled trial comparing results of 177

minimally invasive versus open radical cholecystectomy, current evidence seems to 178

support laparoscopy, both in an elective setting, when it is performed in case of 179

suspected gall bladder cancer, and in a completion setting, when it is performed for 180

incidentally diagnosed gall bladder cancer after cholecystectomy. Available studies 181

report low rates of conversion to open procedure. Also there are less intraoperative 182

complications with limited intraoperative blood loss. There has been no mortality 183

reported and acceptable morbidity rates. Eventually there is a shorter length of stay 184

following laparoscopy, making it feasible and safe. In addition, two comparative 185

studies reported a comparable number of retrieved lymph nodes and a comparable 186

survival rate between laparoscopic and open procedures, supporting its oncological 187

validity [6, 7]. 188

Controversy is mainly related to historical studies which had tumor recurrence with 189

laparoscopic approach [8]. For example, reports concerning port site recurrence, 190

peritoneal dissemination of cancer cells, imprecise handling of gallbladder during 191


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laparoscopy leading to accidental perforation of gall bladder [9–14]. This brought 192

about a caution for the use of laparoscopy. Contradictory to that, some evidence 193

highlights the role of gentle manipulation of gallbladder and of the use of plastic bag 194

for specimen extraction in reducing the rate of port site and peritoneal tumor 195

implantation [14–17].Also in some reports, no peritoneal or port site recurrence 196

occurred; further supporting that laparoscopic approach is not directly responsible for 197

increasing the risk of dissemination [18]. Another problem is technical difficulty of 198

performing such complex procedures by minimally invasive approach lowers its 199

acceptance. But current evidence also shows equal outcomes in radical laparoscopic 200

versus open surgeries for liver diseases, which is the main factor making the 201

procedure complex [19, 20]. Hepatic portal pedicle is a complex structure, containing 202

important structures whose damage during lymphadenectomy may result in 203

uncontrollable bleeding or injury to bile duct. This has also brought about question of 204

safety and adequacy of this approach. Also if the cystic duct margin is positive and 205

bile duct resection is required, it becomes an indication for open procedure in some 206

studies, although it is not an absolute contraindication to laparoscopy [7, 21]. 207

208

CONCLUSION 209

In conclusion, Laparoscopic radical cholecystectomy with lymph node dissection is 210

safe and beneficial for the patients with T1b/T2 gallbladder carcinoma and is useful 211

in selected patients with a preoperative suspicion of early-stage gallbladder cancer 212

by sparing them the necessity of a second-stage open procedure. 213

214

CONFLICT OF INTEREST 215

The authors declare no conflict of interests. 216

217

AUTHOR’S CONTRIBUTIONS 218

Ashutosh Gupta 219

Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 220

data 221

Group 2 - Drafting the article, Critical revision of the article 222

Group 3 - Final approval of the version to be published 223


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Amit Choraria 224


data 226



229

ShantanuTiwari 230


data 232



235

Hitesh Dubey 236


data 238



241

Rajesh Kumar Agrawal 242


data 244



247

Sourabh Nandi 248


data 250



253

254

255


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Vivek Chaudhary 256


data 258



261

REFERENCES 262

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18. Zimmitti G, Manzoni A, Guerini F, Ramera M, Bertocchi P, Airoldi F, Zaniboni 320

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FIGURE LEGENDS 333

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Figure 1: Specimen of first case. Tumor along with liver margin is seen. Also lumen 335

contains gall stones. 336

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Figure 2: Specimen of second case showing liver margin. 338

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Figure 3: Liver resection using Waterjet. 340

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FIGURES 352

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Figure 1: Specimen of first case. Tumor along with liver margin is seen. Also lumen 356

contains gall stones. 357


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Figure 2: Specimen of second case showing liver margin. 360

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Figure 3: Liver resection using Waterjet. 364

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