1. Introduction

a. Incision

b. Peritoneal Washing Cytology

c. Incision Extension

d. Xiphoid Process Removal

e. Round Ligament Isolation and Ligation

f. Wound Protection and Gallbladder Exposure

2. Incision and Access to the Abdominal Cavity

a. Liver Ultrasonography

b. Rule Out Peritoneal Carcinomatosis

3. Evaluation of Tumor Extension

4. Kocher Maneuver

a. Para-Aortic Lymphadenectomy

b. Level 8 Common Hepatic Artery Lymphadenectomy (Part 1)

c. Level 13 Retropancreatic Lymphadenectomy

d. Portal Vein Dissection

e. Level 8 Common Hepatic Artery Lymphadenectomy (Part 2 - Left)

f. Level 8 Common Hepatic Artery Lymphadenectomy (Part 2 - Right)

g. Cystic Duct Isolation

h. Cystic Duct Division

i. Level 12b Hepatoduodenal Ligament (Along the Common Bile Duct) Lymphadenectomy and Common Bile Duct Dissection

j. Cystic Artery Identification, Isolation, and Ligation

k. Hilar Dissection

l. Review of Progress and Anatomy

5. Lymphadenectomy

a. Right Liver Mobilization

b. US-Guided Liver Resection Line Marking

c. Liver Parenchyma Division

d. Surgical Specimen Examination

e. Hemostasis

6. Partial Hepatectomy (Segments IVb and V Hepatic Resection)

a. Drain 1 Placement

b. Transverse Incision Closure

c. Drain 2 Placement

d. Midline Incision Closure

e. Skin Closure

7. Closure

8. Post-op Remarks

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 presented a case of incidentally-diagnosed GBCA and described the surgical management for operable GBCA with a focus on the operative technique and perioperative management.
A 60 man 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 enbloc with partial hepatectomy at segment 4B and 5 and portal lymphadenectomy. His postoperative course was uneventful, and histologic examination confirmed the diagnosis of GBCA, pT3N1M0, stage IIIB.
<h4>Case Overview</h4>

<h5>Background</h5>


2. Incision and Access to the Abdominal Cavity


Incision
Peritoneal Washing Cytology
Incision Extension
Xiphoid Process Removal
Round Ligament Isolation and Ligation
Wound Protection and Gallbladder Exposure




Watch this full-length, narrated surgical video of an open radical cholecystectomy with partial hepatectomy for gallbladder cancer performed by Dr. Hiromichi Ito at the Cancer Institute Hospital in Japan.

Cancer Institute Hospital of JFCR, Tokyo