In a patient of symptomatic gallstone disease, laparoscopic cholecystectomy was done. On histopathology, adenocarcinoma of gall bladder was diagnosed with stage T2. Next line of treatment:
Carcinoma Gall bladder - Route of spread- Hepatic > Lymphatic > Perineural - MC route of spread- Direct hepatic invasion- Generally, GB cancer is an adenocarcinoma- Most specific marker- CA 19-9- IOC for CA bladder- CECT - 8TH AJCC (2017) TNM classification - T1A - involvement of lamina propria- T1B - involvement of muscularis propria - T2A - invasion of perimuscular connective tissue towards peritoneal side without extension to serosa - T2B - invasion of perimuscular connective tissue towards hepatic side without direct hepatic invasion- T3 - serosal perforation or direct hepatic invasion or involvement of single extrahepatic organ - T4 - involvement of poal vein or hepatic aery or two or more extrahepatic organ - N1 - metastasis to 1 - 3 lymph nodes - N2 - metastasis to 4 or more lymph nodes- M0 - no distant metastasis - M1 - distant metastasis Staging IA - T1a Lap cholecystectomy - IB - T1b - IIA - T2a - IIB - T2b - IIIA - T3 - IIIB - T1-3 N1 Extended cholecystectomy IVA - T4 N0-1 Extended cholecystectomy + Extended R hepatectomy IVB - T any M2 T any N any M2 Palliation (we give chemotherapy) Extended cholecystectomy- Enbloc removal of IVb and V segments of liver + gallbladder+LN along cystic duct, CBD, Peripoal and Retropancreatic LN. Po site excision- Whenever pneumoperitoneum is created during laparoscopic procedures, the po is inseed.- Sometimes tumor gets deposited around the po by chimney effect.- So circumferentially tumor is excised around the po and is known as Po site excision- Presence of tumor cells at po site- poor prognosis- Absence of tumor cells at po site- good prognosis Although po site excision is not frequently done nowadays.
Observation
Wedge excision of liver with lymphadenectomy and po site excision
Resection of segment IVb & V of liver with nodal clearance with po site excision
Wedge excision of liver with lymphadenectomy
Gallbladder