Cholecystectomy and cancer
Cholecystectomy is a surgical procedure that involves the removal of the gallbladder, which is often performed to address gallbladder disease, including symptomatic gallstones. There are two primary approaches: open cholecystectomy, which involves a larger incision and is typically used in more complex cases, and laparoscopic cholecystectomy, which is minimally invasive and uses small incisions. While the main indication for this surgery is often related to gallstones, gallbladder cancer can sometimes be discovered incidentally during the procedure.
The removal of the gallbladder aims to eliminate tumors and reduce the risk of cancer spreading to the liver, lymph nodes, or other areas. Preparatory steps for the surgery include imaging tests like ultrasounds and CT scans to evaluate the extent of any potential cancer. Post-surgery, patients are monitored closely for complications such as bleeding, infection, or damage to surrounding organs. Cholecystectomy carries risks, including injury to the bile duct or other organs, but it can be a critical intervention for managing gallbladder cancer and improving patient outcomes.
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Cholecystectomy and cancer
ALSO KNOWN AS: Open cholecystectomy, laparoscopic cholecystectomy
DEFINITION: Cholecystectomy refers to the surgical removal of the gallbladder. Two approaches may be used to remove the gallbladder. An open cholecystectomy involves making a single abdominal incision through which the gallbladder is extracted. This approach is used in complicated cases where a more thorough exploration of the upper abdomen for cancer spread is anticipated. The minimally invasive laparoscopic cholecystectomy makes use of four abdominal incisions small enough to allow the insertion of a laparoscope and instruments (trocars). The gallbladder is extracted through one of the prominent ports. This approach is often reserved for uncomplicated gallbladder disease. However, gallbladder cancer is found after removal in fewer than one percent of all patients undergoing laparoscopic cholecystectomy, as noted by the Society of American Gastrointestinal and Endoscopic Surgeons in 2010. Higher recurrence of gallbladder cancer is also reported with this method.
Cancers treated: Gallbladder carcinoma, melanoma, metastatic carcinoma
Why performed: Cholecystectomy is performed to remove the primary tumor and reduce the possibility of liver tissue invasion, regional lymph node infiltration, and distant spread (metastasis) of tumor cells. Although the main indication for performing a cholecystectomy is for definitive treatment of symptomatic gallbladder stone obstruction of the bile ducts (cholelithiasis), gallbladder carcinoma is sometimes an incidental finding.
Patient preparation: The patient first undergoes several laboratory and imaging tests to confirm clinical suspicions of gallbladder cancer based upon the patient’s medical history and physical examination. They include an ultrasound and a computed tomography (CT) scan of the abdomen to assess the size and spread of the cancer. A CT scan is beneficial in visualizing the liver and bile duct anatomy in relation to the tumor. Once the diagnosis is confirmed, preoperative patient preparation includes surgical risk assessment through a general physical examination, especially of the heart (electrocardiograph, or EKG) and lungs (chest x-ray, pulmonary function tests), and temporary discontinuance of drugs that may complicate the patient’s recovery. Another consideration is ensuring the patient has nothing by mouth at least six hours before the procedure.
Steps of the procedure: The patient is positioned, and the surgical site is sterilized. An incision is made near the border of the lower right ribcage or a larger abdominal incision slightly to the right of the umbilicus. After the surgeon cuts through the skin and divides the abdominal muscles, the abdominal cavity is entered, and the liver is identified. It is common to encounter some adhesions between the liver, gallbladder, and adjacent bowelthese adhesions are cut away.
Once the liver and gallbladder are visualized, the gallbladder outlet (cystic duct) in a ligament connecting the liver to the duodenum is exposed and slightly constricted by silk suture to prevent gallstones from passing. The adjacent gallbladder artery (cystic artery) and right hepatic artery are identified to avoid tying off the latter. The gallbladder is dissected away from the liver, starting from the bottom (fundus) to the cystic duct. The cystic artery is reached, then subsequently tied off and cut. The junction between the cystic duct and the larger common bile duct is identified, and the cystic duct is tied off and cut away from the common bile duct. An alternative, retrograde approach involves tying off and cutting the cystic duct and artery first before proceeding to dissect the gallbladder away from the liver.
In more extensive cancer spread, removal of the gallbladder also involves an extended resection (part of the liver and lymph nodes) or a radical resection of the gallbladder involving adjacent structures such as a margin of the underlying liver, the common bile duct, the hepatoduodenal ligament, and nearby lymph nodes from the liver, stomach, bowel, and pancreas. Severe spread may even involve the removal of a large section of the liver and affected organs.
After the procedure: The patient is monitored in the postanesthesia care unit until fully awake and vital signs are stable. The patient may then be discharged to the surgical ward for postoperative monitoring for yellowing of the skinjaundicefever, and abdominal pain or enlargement, among other signs. Laboratory examinations and imaging studies are done if signs of deterioration are suspected. Once the patient is stable, ambulatory, urinating, and eating, the patient may be discharged after a few days.
Risks: Some of the risks of cholecystectomy are procedure-related and thus preventable. The main risk involved in cholecystectomy is bleeding from small vessels that were not cauterized or ligated intraoperatively. Another risk is the ligation of the common bile duct. Bowel injury may lead to bowel adhesions, leakage, fistulas, or abdominal cavity inflammationperitonitis. Ligation of the proper hepatic artery may also occur. Other potential complications include fever, infection, and adverse effects from anesthesia.
Results: During the surgery, surgeons may find the gallbladder filled with an irregular mass or polyps accompanied by mucus or gallstones. Tumors may extend outside the gallbladder, occasionally “replace” the gallbladder itself, and encroach on surrounding structures similarly. Microscopically, the cancerous cells resemble the secreting cells of the gallbladder walladenocarcinoma.
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