|Year : 2019 | Volume
| Issue : 2 | Page : 109-114
Short-term outcomes of minimally invasive surgery for patients presenting with suspected gallbladder cancer: Report of 8 cases
Gerald Zeng, Nan Zun Teo, Brian K. P. Goh
Department of Hepatopancreatobiliary and Transplant Surgery, Duke-Nus Medical School, Singapore General Hospital, Singapore
|Date of Submission||10-Nov-2017|
|Date of Acceptance||07-Feb-2018|
|Date of Web Publication||12-Mar-2019|
Dr. Brian K. P. Goh
Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, 20 College Road, Level 5 Academia
Source of Support: None, Conflict of Interest: None
Introduction: Minimally invasive surgery (MIS) for gallbladder cancer (GBCa) has traditionally been discouraged, with limited studies reporting on its outcomes. The aim of this study was to evaluate the short-term outcomes of MIS for patients with GBCa or suspected GBCa.
Methods: A retrospective study of 8 consecutive patients who underwent MIS for GBCa by a single surgeon over a 22-month period between 2015 and 2017.
Results: Three patients underwent robotic surgery, while five underwent conventional laparoscopic surgery. Four patients presented with histologically proven GbCa detected incidentally after cholecystectomy. All 4 patients underwent resection of Segment 4b/5. Of these, 3 underwent hilar lymphadenectomy and 1 underwent hilar lymph node sampling. Four patients presenting with suspected GBCa underwent upfront extended cholecystectomy. Two patients who had malignancy on frozen section underwent hilar lymphadenectomy. The median operation time was 242.5 (range, 165–530) min, and the median blood loss was 175 (range, 50–700) ml. The median post-operative hospital stay was 3.5 (range, 2–8) days. There were no open conversion, post-operative morbidities and mortalities. Six had histologically proven GBCa. Five were T3 and one had T2 cancers.
Conclusions: The results of the present study confirm the short-term safety and feasibility of MIS for patients with GBCa, as all eight patients underwent successful MIS with no major morbidity or mortality. Further studies with larger patient cohorts with long-term follow-up are needed to determine the oncologic outcomes and the definitive role of MIS in treating GBCa.
Keywords: Extended cholecystectomy, gallbladder cancer, laparoscopic, radical cholecystectomy, robotic
|How to cite this article:|
Zeng G, Teo NZ, Goh BK. Short-term outcomes of minimally invasive surgery for patients presenting with suspected gallbladder cancer: Report of 8 cases. J Min Access Surg 2019;15:109-14
|How to cite this URL:|
Zeng G, Teo NZ, Goh BK. Short-term outcomes of minimally invasive surgery for patients presenting with suspected gallbladder cancer: Report of 8 cases. J Min Access Surg [serial online] 2019 [cited 2019 Mar 23];15:109-14. Available from: http://www.journalofmas.com/text.asp?2019/15/2/109/228409
| ¤ Introduction|| |
Traditionally, the application of minimally invasive surgery (MIS), for the treatment of gallbladder cancer (GBCa) has been discouraged. Major concerns raised about the minimally invasive approach include the risk of port-site metastasis  and increased incidence of bile spillage resulting in the spread of malignant cells. However, adverse outcomes such as biliary spillage have been shown to be steadily decreasing over the years. Recently, several studies have demonstrated the feasibility of laparoscopic surgery, especially for early-stage GBCa, reporting similar disease-specific survival rates, when compared with the conventional open approach. More recently, several authors have been exploring the feasibility and safety of robot-assisted radical resection for GBCa, concluding that the increased dexterity and stability of the robotic platform enables it to perform more precise and subtle dissections. In light of recent technological advancements and changes in surgical practices, this study was performed to determine the feasibility and safety of MIS for suspected GBCa with regard to the short-term perioperative outcomes.
| ¤ Methods|| |
All consecutive patients who underwent attempted MIS for suspected GBCa at our institution from September 2015 to June 2017 were identified from a prospectively maintained surgical database. This study was approved by our institutional review board. All operations were performed by a single surgeon (Goh BK) who had a wide experience (>170 cases) with MIS for liver and pancreatic resections including major hepatectomy and pancreatoduodenectomy. Patients' data were subsequently obtained retrospectively from their corresponding clinical, radiological and pathological records. All clinical data were retrieved from a prospective computerised clinical database (Sunrise Clinical Manager, Eclipsys Corporation, Atlanta, GA, USA) and patient's clinical charts, while operative data were retrieved from a separate prospective computerised database (OTM 10, IBM, Armonk, NY, USA). Tumours were classified according to the American Joint Committee on Cancer/TNM staging system. The method of treatment and surgical approach recommended was based on factors, such as patient's overall fitness, as well as tumour characteristics, including location, size and focality. Ultimately, the final decision for a particular treatment approach was made after extensive discussions between the managing clinician and the patient. Cost was a major factor in deciding between the laparoscopic or the robotic approach. All cases involved in this study employed either the use of conventional laparoscopic or robotic surgical techniques. Operative techniques and equipment adopted showed minimal variability as all cases were performed by the same primary surgeon. All robotic-assisted procedures were performed using the Da Vinci Si (Intuitive Surgical) robotic platform. For patients presenting with a suspicion of GBCa, we performed an upfront extended cholecystectomy and the specimen was subsequently sent for frozen section analysis. Hilar lymphadenectomy was performed if intraoperative pathology demonstrated the presence of malignancy.
In this study, extended cholecystectomy was defined as resection of the gallbladder with a wedge of segments 4b and 5 of the liver. Radical cholecystectomy was defined as an extended cholecystectomy with hilar lymphadenectomy. Post-operative mortality was defined as any death within 90 days from surgery or within the same hospitalisation. All complications were recorded within 90 days from surgery or during the same hospital stay. The complications were graded according to the Clavien–Dindo classification.
In general, for the conventional laparoscopic approach, a 12-mm port was placed in the periumbilical region. Another 12-mm port was placed to the right of the periumbilical region. A 5-mm port was placed in the right hypochondrium and a 12-mm port in the epigastric region. An additional 5-mm port was placed in the left hypochondrium for assistance if needed. For the robotic approach, the robotic was docked above the patient's right shoulder, the 12-mm port in the right paraumbilical region was used as the camera port and a 12-mm port in the infraumbilical region was used as the assistant port mainly for suctioning. One 8-mm port in the right hypochondrium, one 8-mm epigastric and one 8-mm left hypochondrium port were used for the robotic arms. Transection of the liver parenchyma was performed using the laparoscopic or robotic harmonic scalpel utilising a clamp–crush technique. Hilar lymph node dissection was performed using a combination of the hook and harmonic scalpel. The duodenum was partially kocherised to aid in the dissection of the posterior hilar lymph nodes.
| ¤ Results|| |
Over the study period, there were a total of 8 consecutive patients who underwent MIS for GBCa or suspected GBCa in our institution. Robotic surgery was performed in 3 patients (37.5%), while the remaining 5 (62.5%) patients underwent conventional laparoscopic surgery. The baseline clinicopathological data, operative and perioperative outcomes of these patients are summarised in [Table 1].
|Table 1: Clinicopathological features of the 8 patients who underwent minimally invasive surgery for suspected gallbladder cancer|
Click here to view
Four patients (patients 4, 6, 7, 8) presented with histologically proven GbCA incidentally detected after cholecystectomy. Of these, 3 patients underwent resection of Segment 4b/5 and hilar lymphadenectomy, whereas 1 patient (patient 4) underwent resection of Sg 4b/5 and hilar lymph node sampling. Patient 4 had only lymph node sampling as the patient had symptomatic (hypotension) bradycardia intraoperatively and the operation had to be aborted prematurely. This patient underwent laparoscopic resection of Sg 4b/5, and a 6-cm mini-laparotomy was performed for lymph node as she developed bradycardia with hypotension which did not resolve. The patient subsequently declined repeat surgery to complete the lymph node dissection. Four patients (patients 1, 2, 3, 5) presented with gallbladder mass or a large polyp, of which 2 (patients 3 and 5) were found to have benign disease on frozen section (and final histology). These 2 (patients 3 and 5) patients did not undergo hilar lymphadenectomy. Patient 1 only underwent robotic-extended cholecystectomy and nodal sampling as intraoperatively she was found to have extensive metastatic lymph node involvement of which some were invading into the pancreatic head. None of the 8 patients had malignancy involving the cystic duct; hence, choledochectomy was not performed in any of these patients.
The median operation time was 242.5 min (range: 165–530 min), and the median blood loss was 175 ml (range: 50–700 ml). There were no perioperative blood transfusions. The median post-operative hospital stay was 3.5 days (range: 2–8 days). Pringle's manoeuvre was employed for 1 patient (14.2%) for 75 min. There were no post-operative morbidities or post-operative mortalities. One patient (patient 4) had intraoperative bradycardia and hypotension resulting in the surgery aborted prematurely, but the patient had no post-operative complications.
Of the 8 patients, 7 (87.5%) had a single tumour, while 1 (12.5%) had multifocal tumours. In terms of post-operative histological diagnosis, 6 (75%) were adenocarcinoma of the gallbladder, 1 was tubular adenoma with low-grade intraepithelial neoplasia and 1 (14.2%) had acute on chronic cholecystitis with cholelithiasis. There were no incidences of open conversion. Of the 6 patients with GBCa, five patients (57.1%) had a T stage of 3, while one (14.2%) had a T stage of 2. One patient (14.2%) had an N stage of 1, while the rest had an N stage of 0. In all 6 patients with GBCa, the liver parenchymal resection margins were clear of malignancy.
| ¤ Discussion|| |
The first laparoscopic procedure in humans was performed in the early 1900s  and has since soared in popularity, conferring many benefits, such as smaller surgical scars, reduced blood loss, less pain  and faster recovery times, leading to shortened hospital stays. It also allows patients to avoid the increased morbidity of the traditional open laparotomy. Traditional problems associated with laparoscopic surgery include limitations in visual and haptic perceptions, lack of hand–eye coordination and reduced haptic feedback from instruments, which increases the technical complexity of the procedure, as opposed to the conventional open approach. However, with increasing advancement in surgical skills, techniques and equipment, it is becoming widely adopted for various types of surgery, including complex surgical procedures such as liver resections.,
Specific to gallbladder surgery, the laparoscopic approach has been well established for benign conditions such as symptomatic gallstones and acute cholecystitis. Laparoscopic cholecystectomy has been proven to be superior to the open approach with respect to mortality and post-operative complications., It has also led to better overall patient satisfaction and cosmesis. However, there have been concerns regarding the laparoscopic approach for GBCa and its ability to achieve good long-term oncological outcomes, as well as to minimise the risk of port-site recurrence. While there have been occasional case reports  on port-site metastases following laparoscopic cholecystectomy for GBCa, an estimation of statistics from papers published in different eras has shown that the incidence of port-site metastasis has reduced substantially by 45% from 18.6% in the historical era (1991–1999) to 10.3% (2000–2014). These could be due to a variety of factors, such as the evolution and improvement of laparoscopic equipment, better recognition pre-operatively or improved precautionary measures during operation.
At present, there are limited studies reporting on the outcomes of MIS for GBCa, and its role remains controversial.,,,,,,,, Details of these studies have been summarised in [Table 2]. Of note, a recent large study from Korea demonstrated favourable long-term oncologic results in a 10-year prospective cohort study, supporting the oncologic safety of the laparoscopic approach. Coupled with increasingly better surgical expertise, it has been shown that for GBCa laparoscopic cholecystectomy is comparable to open cholecystectomy, with primary access technique having no effect on prognosis of patients, and satisfactory surgical results similarly being achieved through the laparoscopic method. A recent review of the literature which included 129 patients also confirmed the safety and feasibility of MIS for GBCa.
|Table 2: Summary of the clinicopathological outcomes of our 8 patients and of 9 previous large series (≥5 cases) reporting on minimally invasive surgery (robotic or laparoscopic) for gallbladder cancer|
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The surgical management of GBCa is dependent on the stage of disease. For T1a GBCa, simple cholecystectomy or laparoscopic cholecystectomy would suffice, with 5-year survival rates reaching as high as 95%–100% reported. Lymph node dissection is generally not recommended. Similarly, an extended cholecystectomy does not result in a superior survival rate. Numerous other studies , have since reported results supporting the recommendation that simple cholecystectomy is adequate for T1a GBCa. For T1b GBCa, an extended cholecystectomy is recommended in view of higher rates of recurrence after a simple cholecystectomy while for stage T2 or above, an extended cholecystectomy accompanied by wedge resection of the gallbladder bed or segmentectomy (IVb/V), is generally recommended. The traditional open approach for radical cholecystectomy is still deemed the gold standard, whereas the minimally invasive approach is still under investigation and its role remains controversial today. This is partly due to the increased technical difficulty traditionally associated with MIS for liver resection and hilar lymphadenectomy. However, based on our preliminary experience; for surgeons who are experienced with laparoscopic hepatectomy, especially major hepatectomy, the extended cholecystectomy which entails a minor hepatectomy in the anterolateral segments is not an extremely technically demanding procedure. Similarly, the MIS techniques adopted by surgeons who perform MIS for pancreatoduodenectomy can easily be translated to perform the hilar lymphadenectomy required during radical cholecystectomy.
More recently, several investigators have demonstrated that the pure laparoscopic approach with lymph node dissection has been found in some studies to be feasible with good outcomes in patients with T1b/T2 gallbladder carcinoma. Minimally invasive radical cholecystectomy has also been found to parallel the open approach in terms of achieving similar morbidity, mortality and survival rates. Mean operative times did not differ significantly, but intraoperative blood loss was significantly lower, and post-operative hospital stays have been found to be shorter for the laparoscopic approach. Repeat resections, especially for pT2 GBCa, is warranted after initial laparoscopic cholecystectomy, due to a substantial risk of residual tumours in the gallbladder bed and liver or the presence of lymph node metastasis. Today, port-site excision is no longer routinely recommended as part of definitive surgical treatment, as it has not been shown to confer survival benefit.
In patients where there is an increased risk of GBCa such as a thick-walled gallbladder or large polyp, some authors have recommended an upfront extended cholecystectomy over simple cholecystectomy or radical cholecystectomy. Termed the Lucknow approach by authors of a study from India, it involves removal of the gallbladder along with a wedge of the liver, and an intra-operative frozen section, followed by lymphadenectomy if malignancy is confirmed. This approach has the theoretical advantage of preventing potential surgical dissemination of malignant cells if the patients do indeed have GBCa and had just undergone a simple cholecystectomy. It also has the added advantage over the aggressive approach of upfront radical cholecystectomy by reducing the unnecessary morbidity of lymphadenectomy in patients without malignancy. We adopted this approach in 4 patients, of whom 2 who eventually had benign disease avoided an unnecessary hilar lymphadenectomy.
Robotic surgery was introduced to overcome the limitations of traditional laparoscopy due to its increased stability and dexterity. Over the past decade, the robotic platform has been increasingly used for complex hepato-pancreato-biliary surgeries such as major liver resections  and pancreatoduodenectomies  although its use remains limited worldwide. This is due to the increased cost and limited access of the robotic platform to both surgeons and patients. Studies on the use of robotic surgery for GBCa remain limited. One of the pioneering studies  in the field of robotic surgery for GBCa has shown promise, providing successful treatment through radical resection using a robotic surgical system. It is suggested that the Da Vinci robotic surgical system may be superior to conventional laparoscopy, being better suited for subtle dissections in deep narrow spaces, as evidenced by successful lymphadenectomy posterior to the head of the pancreas and hepatoduodenal ligament. The robotic-assisted approach was adopted for 3 patients in this study. Based on our preliminary experience, the dexterity of the robotic arms enabled us to perform the hilar dissection more easily compared to the traditional laparoscopic instruments which were rigid.
| ¤ Conclusions|| |
The results of the present study confirm the short-term safety and feasibility of MIS for patients with GBCa. All 8 patients underwent successful MIS with no major morbidity or mortality. MIS for GBCa can be safely performed by surgeons experienced with MIS liver and pancreatic resections. Further studies in larger patient cohorts and long-term oncological follow-up are needed to determine definitively the role of MIS in the treatment of GBCa.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]