Bile duct injury following laparoscopic cholecystectomy

Port site recurrence of unexpected gallbladder carcinoma after a laparoscopic cholecystectomy: report of a case

Unexpected gallbladder carcinoma was identified in a 71-year-old woman after she underwent a laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis. A subsequent laparotomy for a resection of the liver bed and a dissection of the lymph nodes around the hepatoduodenal ligament was done. Two and a half years later, the patient developed subcutaneous metastasis at the epigastric trocar site through which the gallbladder was removed. A third operation was thus performed, revealing no evidence of peritoneal dissemination, liver metastasis, or lymph node metastasis, and the abdominal wall mass was resected. The histological findings confirmed the diagnosis of metastatic carcinoma of the gallbladder. We recommend that when planning LC, the possibility of malignancy should thus be kept in mind. However, if there is any sign which does not completely exclude malignancy, such as a contracture or wall thickness of the gallbladder, LC should be performed by the abdominal wall lifting method and using a protective bag for the removal of the gallbladder.

Laparoscopic surgery and the systemic immune response

OBJECTIVE

The authors review studies relating to the immune responses evoked by laparoscopic surgery.

SUMMARY BACKGROUND DATA

Laparoscopic surgery has gained rapid acceptance based on clinical grounds. Patients benefit from faster recovery, decreased pain, and quicker return to normal activities. Only more recently have attempts been made to identify the metabolic and immune responses that may underlie this clinical success. The immune responses to laparoscopy are now being evaluated in relation to the present knowledge of immune responses to traditional laparotomy and surgery in general.

METHODS

A review of the published literature of the immune and metabolic responses to laparoscopy was performed. Laparoscopic surgery is compared with the traditional laparotomy on the basis of local and systemic immune responses and patterns of tumor growth. The impact of pneumoperitoneum and insufflation gases on the immune response is also reviewed.

CONCLUSIONS

The systemic immune responses for surgery in general may not apply to laparoscopic surgery. The body's response to laparoscopy is one of lesser immune activation as opposed to immunosuppression.

Trocar site seeding of inapparent gallbladder carcinoma during laparoscopic cholecystectomy

There are increasing reports of seeding of tumor at the trocar sites following laparoscopic cholecystectomy in patients with unexpected or inapparent gallbladder carcinoma. A patient is reported here whose primary tumor appeared controlled by surgery and radiation, but who died of the disease after developing implant metastases at three untreated trocar sites. The second case report illustrates the difficulty in identifying gallbladder cancer during laparoscopic cholecystectomy, and the importance of a diligent preoperative effort to establish the diagnosis. Current literature suggests that tumor implantation occurring during laparoscopic cholecystectomy for inapparent carcinoma adversely affects prognosis, and, until the effect of laparoscopy on the spread of this tumor is better understood and controlled, open operation should be performed when carcinoma of the gallbladder is suspected. When laparoscopic cholecystectomy is done for inapparent gallbladder cancer, surgical and adjuvant radiotherapy to the trocar sites appears to improve outcome in association with extended treatment to the gallbladder bed and adjacent areas. Recent reports suggest that progress in diagnostic, surgical, and adjuvant techniques could substantially improve survival in carcinoma of the gallbladder.

Slicer and tissue retrieval system for excisional endoscopic surgery

Extraction of large specimens risks detachment of malignant cells within the peritoneal cavity and contamination of the parieties with resultant seedling implantation at the access wounds. Therefore, extraction is best conducted through a rip-proof sleeve-retrieval system which creates a "third space" in which the specimen can be sliced under visual control. Slicing of tissue is preferable to morcellation or disintegration since it preserves the structural integrity of the tissue and thereby does not jeopardize histopathological examination and staging of excised tumors. Of the two types of tissue-slicing mechanisms investigated, the compression-moving blade system (CMB) was found to be superior to wire-cutting devices. A prototype CMB slicer has been developed which has been tested experimentally and is currently undergoing clinical evaluation.

Laparoscopic cancer surgery. Lessons from gallbladder cancer

Laparoscopic cholecystectomy (LC) may inhibit the discovery of unsuspected gallbladder cancer, and the effect of LC on the prognosis of gallbladder cancer is unknown. We present two cases of unsuspected gallbladder cancer removed laparoscopically and report the discovery of peritoneal tumor implantation at the umbilical port site 21 days after LC. Although gallbladder carcinoma flow cytometry has been reported to be of prognostic value by Japanese investigators, this technique did not distinguish herein between an invasive adenocarcinoma and carcinoma in situ. A cellular doubling time of 56 h was calculated from one tumor. When unsuspected invasive gallbladder cancer is found after LC, laparoscopic port sites should be inspected at reoperation and, at a minimum, the port site through which the gallbladder was removed should be widely excised. This demonstration of cancer recurrence in laparoscopic port sites may limit the application of laparoscopy to elective cancer resection.

Unsuspected carcinoma of the gallbladder. A laparoscopic dilemma

Laparoscopic cholecystectomy is the treatment of choice for gallstones. A formal contraindication is gallbladder cancer. However, in a great number of cases, this is a previously unsuspected intraoperative finding, and sometimes its first appearance is in acute cholecystitis. We present the case of 67-year-old woman, which presented an unsuspected carcinoma of the gallbladder that developed abdominal wall implants at the umbilical and left hypocondrium site. The success of LC favors the observation of cases similar to that described in this article. Surgeons who operate using laparoscopic techniques should bear this possibility in mind and practice an extemporaneous biopsy at the slightest suspicion of malignancy, and, if it is confirmed, the operation should be continued as an open one.

Intravenous cholangiography revisited

The efficacy and safety of IVC with the new agent has not, in our opinion, been firmly established. In these circumstances we do not feel its routine use preoperatively in patients being considered for laparoscopic cholecystectomy is justified. We remain uncertain about its ultimate safety and are unconvinced that it is able, reliably, to demonstrate ductal anomalies which might increase the risk of iatrogenic injury. If imaging of ductal anatomy is important then it is best to obtain it intraoperatively. The radiologist often acts as an essential guide to the surgeon; as interventionist he frequently actually usurps the surgeon's role; and occasionally has to come to his rescue. In our opinion, he should not be asked to perform a procedure of unproven efficacy and uncertain safety in order to allow the surgeon willfully to abandon good surgical practice.