Laparoscopic radical cholecystectomy

Laparoscopic versus open extended cholecystectomy with bi-segmentectomy (s4b and s5) in patients with gallbladder cancer

Introduction:

The outcome of laparoscopic extended cholecystectomy (EC) with wedge hepatic resection (LECW) in patients with gallbladder cancer (GBC) has been compared with that of open EC with wedge hepatic resection (OECW), but studies comparing laparoscopic EC with bi-segmentectomy (LECB) with open EC with bi-segmentectomy (OECB) are lacking.

Patients and Methods:

This retrospective study comprised of 68 patients with GBC who were offered either LECB or OECB from July 2011 to July 2018. Patients were divided into laparoscopic group (LG) and open group (OG), and appropriate statistical methods were used for comparison.

Results:

Out of the total 68 patients, 30 patients were in LG and 38 patients were in OG. Demographic, clinical and biochemical characteristics were similar except significantly higher number of male patients in OG (P = 0.01). In LG versus OG, the mean operation time was 286 versus 274 min (P = 0.565), mean blood loss was 158 versus 219 ml (P = 0.006) and mean hospital stay was 6.4 versus 9 days (P = 0.0001). The complication rate was 16.6% in LG and 31.5% in OG, but this difference was not statistically significant (P = 0.259). The median number of lymph nodes was 12 in both LG and OG (P = 0.62). Distribution of patients among American Joint Committee on Cancer stages I to IV was similar in both the groups (P = 0.5). Fifty percent of the patients in both the groups received adjuvant treatment (P = 1). In LG versus OG, the recurrence rate was 20% versus 28.9% (P = 0.4), mean recurrence-free survival was 48 months versus 44 months (P = 0.35) and overall survival was 51 months versus 46 months (P = 0.45). In LG versus OG, 1, 3 and 5-year survival was 96% versus 94%, 79% versus 72% and 79% versus 62% (P = 0.45). The median follow-up was statistically significantly shorter (24 vs. 36 months) in LG versus OG (P = 0.0001).

Conclusions:

The oncological outcome and survival after LECB in patients with resectable GBC is not inferior to that after OECB. Laparoscopic approach has a potential to improve perioperative outcome in patients with GBC.

Laparoscopic surgery for early gallbladder carcinoma: A systematic review and meta-analysis

BACKGROUND

There is a controversy as to whether laparoscopic surgery leads to a poor prognosis compared to the open approach for early gallbladder carcinoma (GBC). We hypothesized that the laparoscopic approach is an alternative for early GBC.

AIM

To identify and evaluate the safety and feasibility of laparoscopic surgery in the treatment of early GBC.

METHODS

A comprehensive search of online databases, including MEDLINE (PubMed), Cochrane libraries, and Web of Science, was performed to identify non-comparative studies reporting the outcomes of laparoscopic surgery and comparative studies involving laparoscopic surgery and open surgery in early GBC from January 2009 to October 2019. A fixed-effects meta-analysis was performed for 1- and 5-year overall survival and postoperative complications, while 3-year overall survival, operation time, blood loss, the number of lymph node dissected, and postoperative hospital stay were analyzed by random-effects models.

RESULTS

The review identified 7 comparative studies and 8 non-comparative studies. 1068 patients (laparoscopic surgery: 613; open surgery: 455) were included in the meta-analysis of 1-, 3-, and 5-year overall survival with no significant differences observed [(HR = 0.54; 95%CI: 0.29-1.00; I² = 0.0%; P = 0.051), (HR = 0.75; 95%CI: 0.34-1.65; I² = 60.7%; P = 0.474), (HR = 0.71; 95%CI: 0.47-1.08; I² = 49.6%; P = 0.107), respectively]. There were no significant differences in operation time [weighted mean difference (WMD) = 18.69; 95%CI: −19.98-57.36; I² = 81.4%; P = 0.343], intraoperative blood loss (WMD = −169.14; 95%CI: −377.86-39.57; I² = 89.5%; P = 0.112), the number of lymph nodes resected (WMD = 0.12; 95%CI: −2.95-3.18; I² = 73.4%; P = 0.940), and the complication rate (OR = 0.69; 95%CI: 0.30-1.58; I² = 0.0%; P = 0.377 ) between the two groups, while patients who underwent laparoscopic surgery had a reduced length of hospital stay (WMD = −5.09; 95%CI: −8.74- −1.45; I² = 91.0%; P= 0.006).

CONCLUSION

This systematic review and meta-analysis confirms that laparoscopic surgery is a safe and feasible alternative to open surgery with comparable survival and operation-related outcomes for early GBC.

Laparoscopic Surgery for Gallbladder Cancer: An Expert Consensus Statement

BACKGROUND

Despite the increasing number of reports on the favorable outcomes of laparoscopic surgery for gallbladder cancer (GBC), there is no consensus regarding this surgical procedure.

OBJECTIVE

The study aimed to develop a consensus statement on the application of laparoscopic surgery for GBC based on expert opinions.

METHODS

A consensus meeting among experts was held on September 10, 2016, in Seoul, Korea.

RESULTS

Early concerns regarding port site/peritoneal metastasis after laparoscopic surgery have been abated by improved preoperative recognition of GBC and careful manipulation to avoid bile spillage. There is no evidence that laparoscopic surgery is associated with decreased survival compared with open surgery in patients with early-stage GBC if definitive resection during/after laparoscopic cholecystectomy is performed. Although experience with laparoscopic extended cholecystectomy for GBC has been limited to a few experts, the postoperative and survival outcomes were similar between laparoscopic and open surgeries. Laparoscopic reoperation for postoperatively diagnosed GBC is technically challenging, but its feasibility has been demonstrated by a few experts.

CONCLUSIONS

Laparoscopic surgery for GBC is still in the early phase of the adoption curve, and more evidence is required to assess this procedure.

The technique of laparoscopic hepatic bisegmentectomy with regional lymphadenectomy for gallbladder cancer

Background:

Laparoscopic hepatic bisegmentectomy (s4b and s5) with regional lymphadenectomy (LHBRL) for patients with gallbladder cancer (GBC) is rarely reported.

Aims:

The aim of the study was to describe the technique of LHBRL in patients with GBC and to present our initial experience.

Patients and Methods:

This retrospective study was conducted on twenty patients with GBC who were considered for LHBRL by the described technique. These patients either had a suspicion of GBC (SGBC) or had an incidental diagnosis of GBC (IGBC). Appropriate statistical methods were applied.

Results:

Twelve patients (60%) had SGBC and eight patients (40%) had IGBC. Eighteen patients (90%) were females and median age was 50 (range: 28–70) years. Median (range) surgical blood loss was 120 ml (80–400), operation time was 300 (200–480) min and hospital stay was 5.5 (2–10) days. No patient had iatrogenic complication during LHBRL. Five (25%) patients required conversion to open method. Four patients (20%) who developed complications were managed conservatively. All but three patients (25%) with SGBC had a benign disease on final biopsy. TNM stage of 17 patients (85%) with adenocarcinoma was T1bN0 in 3 (17.6%), T2N0 in 6 (35.3%), T3N0 in 2 (11.7%) and T1-3N1 in 6 (35.3%). The median lymph node count was 10 (range: 4–24) and resection margins were negative (R0) in all. The overall survival was 82.3%. During a median follow-up of 22 months, two patients died due to disease recurrence and one patient died due to myocardial infarction.

Conclusion:

The described technique of LHBRL is safe and feasible for patients with GBC without extrahepatic involvement.

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

BACKGROUND

Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC).

METHODS

Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group.

RESULTS

During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC- 20, IGBC - 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T1b (n = 1), T2 (n = 11) and T3 (n = 8), respectively. The median lymph node yield was 10 (4-31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6-34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site.

CONCLUSION

LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.

Minimally invasive approaches to extrapancreatic cholangiocarcinoma

BACKGROUND

Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.

METHODS

We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.

RESULTS

A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1-11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0-400 mL) and the median length of stay (LOS) was 15 days (range = 11-21 days). All patients are alive with a median follow-up of 11 months (range = 3-18 months). None of the 29 patients developed port site recurrences.

CONCLUSION

Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.

Laparoscopic completion radical cholecystectomy for T2 gallbladder cancer

BACKGROUND

The role of minimally invasive surgery in the surgical management of gallbladder cancer is a matter of controversy. Because of the authors' growing experience with laparoscopic liver and pancreatic surgery, they have begun offering patients laparoscopic completion partial hepatectomies of the gallbladder bed with laparoscopic hepatoduodenal lymphadenectomy.

METHODS

The video shows the steps needed to perform laparoscopic resection of the residual gallbladder bed, the hepatoduodenal lymph node nodes, and the residual cystic duct stump in a setting with a positive cystic stump margin. The skin and fascia around the previous extraction site are resected, and this site is used for specimen retrieval during the second operation.

RESULTS

To date, three patients have undergone laparoscopic radical cholecystectomy with hepatoduodenal lymph node dissection for gallbladder cancer. The average number of lymph nodes retrieved was 3 (range, 1-6), and the average estimated blood loss was 117 ml (range, 50-200 ml). The average operative time was 227 min (range, 120-360 min), and the average hospital length of stay was 4 days (range, 3-5 days). No morbidity or mortality was observed during 90 days of follow-up for each patient.

CONCLUSION

Although controversy exists as to the best surgical approach for gallbladder cancer diagnosed after routine laparoscopic cholecystectomy, the minimally invasive approach seems feasible and safe, even after previous hepatobiliary surgery. If the previous extraction site cannot be ascertained, all port sites can be excised locally. Larger studies are needed to determine whether the minimally invasive approach to postoperatively diagnosed early-stage gallbladder cancer has any drawbacks.

Laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy for gallbladder cancer

BACKGROUND

Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer.

METHODS

Like the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy.

RESULTS

Six patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1-6).

CONCLUSION

The minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage.