Gallbladder cancer (GBCA) is a relatively uncommon disease with dismal prognosis. As the symptoms associated with GBCA are vague and non-specific, most patients present when the disease is at an advanced stage and the majority are diagnosed when the disease is beyond the possibility of resection. On the other hand, GBCA can be discovered incidentally and appropriate oncologic surgery provides a great chance of cure for patients with GBCA. We present a case of incidentally-diagnosed GBCA and describe the surgical management for operable GBCA with a focus on the operative technique and perioperative management. A 60-year-old male presented with incidentally-discovered GBCA during a follow-up imaging study for his previously treated bladder cancer. The patient had been asymptomatic, and CT showed a growing mass in the gallbladder without evidence of metastatic disease. GBCA was suspected, and resection was recommended. He underwent extended cholecystectomy including cholecystectomy en bloc with partial hepatectomy at segment IVb and 5 and portal lymphadenectomy. His postoperative course was uneventful, and histologic examination confirmed the diagnosis of GBCA, pT3N1M0, stage IIIB.
In patients with difficult gallbladders due to anatomy prohibiting a clear critical view of safety, a subtotal cholecystectomy can be considered as a safer alternative to a total cholecystectomy. Subtotal cholecystectomies can be divided into “reconstituting” or “fenestrating.” Subtotal reconstituting cholecystectomies include closing off the lower end of the gallbladder to create a remnant gallbladder, while subtotal fenestrating cholecystectomies do not occlude the gallbladder and instead may involve suturing the cystic duct. The most common indication for subtotal fenestrating cholecystectomy is inflammation in the hepatocystic triangle, and subtotal fenestrating cholecystectomy has proven to be useful specifically for patients with a history of cirrhosis.
This case report describes the performance of a subtotal fenestrating cholecystectomy for the management of acute on chronic cholecystitis in a patient with cirrhosis initially managed with transcystic stent placement endoscopically. Management of this patient’s omental adhesions to the gallbladder required alterations to typical surgical technique, which will be described in this report. Additionally, the indications for subtotal fenestrating cholecystectomy will be discussed alongside the benefit of this technique to specific patient populations presenting with acute on chronic cholecystitis.
Open Cholecystectomy for Gallbladder Disease Jacob C. Mesiti1; Yoko Young Sang, MD2; Peter F. Rovito, MD2; 1Lake Erie College of Osteopathic Medicine 2World Surgical Foundation
Gallbladder diseases are a subset of a spectrum of pathologies of the biliary system and are a particularly common etiology of abdominal pain encountered in modern medicine. These pathologies most often share a similar underlying mechanism of disease: obstruction of a portion of the biliary tree by cholelithiasis, or gallstones.
Gallstones, for the most part, form initially in the gallbladder with the exception of primary common bile duct (CBD) stones that form primarily in the CBD. Risk factors include a wide variety of conditions both pathologic and physiologic, including hyperlipidemia, hemolysis, and pregnancy. The resulting obstruction creates a state of biliary stasis, eventually leading to inflammation, pain, and an increased risk of infection. The anatomical location of the obstruction contributes greatly to both the clinical presentation and the ultimate treatment of the disease.
A hallmark of the treatment of gallbladder disease, ranging from simple biliary colic to life-threatening emphysematous cholecystitis, is the cholecystectomy. In modernized countries, this procedure is almost invariably performed laparoscopically. However, in certain clinical scenarios, such as when a patient cannot tolerate the pneumoperitoneum associated with laparoscopic surgery or when the procedure takes place in a developing country with limited access to laparoscopic capabilities, an open approach is preferred.
Naomi Sell, MD, MHS Massachusetts General Hospital
Denise W. Gee, MD Operating Surgeon, MGH
The patient in this case is a 32-year-old female with recurrent episodes of biliary colic. An ultrasound revealed numerous gallstones within the gallbladder. Because the patient has had recurrent symptoms for the past six months, surgical removal of her gallbladder was the best option to relieve her recurrent pain and prevent future development of acute cholecystitis. Here, Dr. Denise Gee at Massachusetts General Hospital performs a laparoscopic cholecystectomy to remove the patient’s gallbladder.
Peter F. Rovito, MD General Surgeon World Surgical Foundation
Yoko Young Sang, MD Resident Physician World Surgical Foundation
The patient in this case is a 50-year-old male with a long history of gallbladder disease. Here, Dr. Rovito performs an open cholecystectomy on this patient during a surgical mission in Honduras with the World Surgical Foundation.
Liborio “June” Soledad, MD
World Surgical Foundation
Enrico Jayma, MD
World Surgical Foundation
Ted Carpio, MD
World Surgical Foundation
The patient in this case is a 53-year-old male with a 1-year history of recurrent right upper quadrant pain that radiates to the back. On workup, ultrasound revealed intraluminal gallstones. Here, Dr. Soledad, Dr. Jayma, and Dr. Carpio perform an open cholecystectomy on this patient while on a surgical mission to the Philippines with the World Surgical Foundation.
Denise W. Gee, MD
Assistant Professor of Surgery
Harvard Medical School
A female patient presented with a few months of abdominal pain following the eating of fatty foods. Imaging showed gallbladder sludge, small stones, or potentially a polyp. Here, Dr. Denise W. Gee performs a laparoscopic cholecystectomy to alleviate these symptoms. #MGH #generalsurgery #gallbladder #cholecystectomy
