Robotic Gallbladder Cancer Resection
Learn more about Dr. Iswanto Sucandy's Robotic Gallbladder Cancer Resection Operations.
Gallbladder cancer which is either identified on a CT scan as solid mass (+/- liver invasion) or incidentally after a routine laparoscopic cholecystectomy requires a thorough evaluation and specialized treatment. Once the gallbladder cancer is diagnosed, a referral to see a liver surgeon or liver specialist should be initiated. A liver biopsy of the gallbladder mass should not be performed to avoid spillage of bile, which can lead to a potential peritoneal spread (also known as peritoneal carcinomatosis). Peritoneal carcinomatosis represents a very poor prognosis and it is an absolute contraindication for surgery.
Gallbladder cancer often presents insidiously without abdominal symptoms. Quite rarely, patients present with jaundice (yellowing of eyes and skin) and weight loss. Jaundice is an ominous sign since it indicates tumor involvement/invasion of the extrahepatic biliary ducts. Imaging workup includes a high-quality CT scan and or MRI scan. Surgical resectability is carefully assessed by the liver surgeon based on the imaging findings, taking into consideration the patient’s performance status. Administration of systemic chemotherapy before the surgical liver resection is not commonly performed, unless the gallbladder cancer is considered unresectable or marginally/borderline resectable.
Once confirmed to be resectable, the operation should be planned. The gallbladder cancer surgery includes an enbloc central liver resection removing part of liver segment 4 and 5 and systematic excision of the regional lymph nodes along the bile ducts above/behind the pancreas. Thorough examination of the liver is mandatory to exclude presence of any distant hepatic metastasis from the gallbladder cancer. It is important to remove all the lymphatic tissue and lymph nodes along the area of gallbladder cancer lymphatic drainage, without causing an iatrogenic injury to blood vessels feeding the liver. In many liver surgery centers, only the traditional open operation is offered due to lack of expertise in minimally invasive liver surgery.
During the operation, the gallbladder and the adjacent liver parenchyma are sent to pathology for a frozen section evaluation to confirm negative resection margins. Patients with T1b-T3 tumor benefit from the liver resection since in approximately 40% of patients, residual tumor foci (cancer cells) are found in the specimen. Postoperative chemotherapy is given after approximately 4 weeks following the operation to optimize long-term oncology outcomes. Radiation therapy is given for patients with positive margins. Resection of the common hepatic and common bile duct is necessary if cancer cells are found in the cystic duct, during the intraoperative frozen section examination. If resection of the common hepatic and common bile duct is needed, then a Roux-en-Y hepaticojejunostomy bile duct reconstruction is performed. This way, the bile produced by the liver can reach the small bowel for digestion. The use of robotic technology allows for a delicate dissection and suturing of the bile duct around the major vessels feeding the liver.
Only a few liver surgery centers in United States that perform minimally invasive gallbladder cancer surgery, either via laparoscopic or robotic techniques. Lack of technical expertise is one of the main reasons for this. The number of harvested lymph nodes is similar between the open and minimally invasive operation. It is very important to see an experienced liver surgeon or liver specialist to achieve best treatment outcomes. Dr. Iswanto Sucandy and his team have significant experience in performing minimally invasive gallbladder cancer surgery using the robotic method with excellent outcomes. The clinical outcomes are followed very closely from each patients. We had been invited to present our surgical techniques in minimally invasive gallbladder cancer surgery at the American College of Surgeon Clinical Congress.