clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Imaging

■Ultrasound

■Contrast-enhanced CT scan (CT angiogram is preferred)

■Magnetic resonance cholangiopancreatography (MRCP)

■Cholangiography [if invasive cholangiography is necessary, percutaneous cholangiography (PTC) is preferred over endoscopic retrograde cholangiopancreatography (ERCP)]

■Direct arteriography (rarely needed)

■Important anatomic details: porcelain gallbladder, mass, enlarged/necrotic lymph nodes, arterial involvement, portal venous involvement, adjacent organ (colon, duodenum) involvement, peritoneal metastasis

■Gallbladder polyp [solitary, sessile, large (>1cm) polyps are worrisome for cancer]

■Look at anomalous pancreaticobiliary duct junction, choledochal cyst, and of course hepatic arteries

Extent of Resection According to Stage

Patients presenting with gallbladder mass on imaging or operative exploration:

■T2/3, N0/1, M0: radical cholecystectomy and lymph node dissection

■Unilateral vascular involvement: extended lobectomy and lymph node dissection

■T4, N0/1, M0: extended lobectomy and lymph node dissection, possible adjacent organ resection

■N2 or M1: no curative surgery, possible palliation by biliary or gastric bypass

Patients with cancer discovered as an incidental finding after cholecystectomy for presumed cholelithiasis:

■T1 with negative liver and cystic duct margin: no further therapy

■T1 with positive cystic duct margin: re-resection of cystic duct or common bile duct to negative margins

■T2/3/4, M0: extended lobectomy, common bile duct resection, lymph node dissection, and resection of laparoscopic port sites

■N2 or M1: no curative surgery (palliation)

Procedure

A radical cholecystectomy (including segments 4b and 5) resection will be described. If an extended lobectomy is necessary because of the bulk of the tumor or because of vascular invasion, the dissection of the porta hepatis and hilar areas is performed as described below. With gallbladder cancer, when an extended resection is necessary, it is usually an extended right lobectomy. The liver resection is then performed as described in Sect.3,“Liver,” after the vasculature to the left side is dissected free and protected and the left hepatic duct has been divided.

structures (portal vein, hepatic artery, hepatic vein) and to rule out discontiguous liver metastases

Careful inspection of vascular variation

and connective tissue dissection

The two segments (4b and 5) contiguous with the gallbladder bed are resected.

N1 lymph nodes (blue): those in the hepatoduodenal ligament (No.12) and common hepatic (No.8) and celiac arteries (No.9) are resected. Positive N2 nodes (red), retropancreatic nodes (No.13), perigastric nodes or aortocaval nodes indicate incurable disease.

Nerve plexuses around the hepatic artery should be dissected.

Full kocherization allows inspection of these nodal stations and facilitates subsequent dissection.

After kocherization, the highest peripancreatic lymph node is excised. This node is sent for frozen section histologic analysis. After excision of this node, retraction of the bile duct anteriorly allows visualization of the portal vein and facilitates safe dissection of nodal and connective tissues. Frozen section staging using this node also guides the operative procedure. If this node is positive and the patient is at high medical risk, then the radical resection is usually abandoned. A radical resection performed in the setting of a positive node should include a retropancreatic nodal dissection and aortocaval nodal dissection, with or without a pancreaticoduodenectomy.

Except in the very thin patient, it is very difficult to adequately excise the nodal tissue in the porta hepatis without resecting the common bile duct. This is particularly true if the patient has recently had a cholecystectomy, so that the scars from such surgery further complicate identification of nodal tissue and tumor. Resecting the common bile duct also allows the most certainty of resection of the cystic duct–common duct junction. Furthermore, resecting the common duct allows the safest dissection and inspection of the portal vein and hepatic arteries behind the tumor and in the hilar area.

The bridge of liver tissue between segments 4b and 3, overlying the base of the falciform, is divided (A) to allow access to the left portal pedicle. The common bile duct is divided immediately above the pancreas and reflected upward (B). The resection margin must be examined by frozen section. All nodal and connective tissues, including the celiac, hepatoduodenal, and portal-caval nodes, are dissected with the common duct, leaving behind only the skeletonized portal vein and hepatic artery.

After transection of the right hepatic duct, tissue from both the left and right ductal margins is sent for frozen section analysis. The entire gallbladder bed including segments 4b and 5 is then resected along the dotted lines shown. The portal veins and hepatic arteries are protected under direct vision. Liver parenchymal transaction is as described in Sect.3, chapters “Liver Resections” and “Left Hemihepatectomy,” usually with inflow occlusion by the Pringle maneuver, and with central venous pressure (CVP) maintained below 3cm H2O (see Sect.3, chapter “Extended Hemihepatectomies”).

Before bilioenteric anastomosis, the left and right hepatic ducts can be joined by interrupted, absorbable sutures (4-0 or 5-0 Vicryl or PDS) to minimize the number of the anastomosis. Alternatively, the two ducts can be anastomosed separately. A 70-cm Roux-en-Y jejunal loop is lifted through the shortest route that allows for no tension on the anastomosis: retrocolic or retrogastric. For details on the biliary anastomosis, please see this section, chapters “Intrahepatic Biliodigestive Anastomosis Without Indwelling Stent” and “Reconstruction of Bile Duct Injuries.” If a plastic biliary stent has been placed before surgery, it is removed and not replaced. If a metal stent has been placed, it is usually safest to cut across the metal stent at a site believed to be free of cancer. The jejunal loop is then sewn to the duct and the stent.