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Page 2 of 10 Lee et al. Mini-invasive Surg 2021;5:57 https://dx.doi.org/10.20517/2574-1225.2021.139

to perform lymphadenectomy and its extent, whether to perform a liver wedge resection or a formal
hepatectomy, and whether to perform a bile duct resection or not.

In the era of minimally invasive surgery (MIS), the treatment options for the surgeon are even more
[3]
complicated. Currently, open surgery, laparoscopic surgery, and robotic surgery are all being performed .
Therefore, it is necessary to evaluate the merits and demerits of these operation methods.

We have started a prospective study on “the laparoscopic approach for early GBC” in 2004, and have
experienced a significant number of cases since. In this article, we review our history of MIS for GBC.

STEP BY STEP ADOPTION OF LAPAROSCOPIC SURGERY FOR GBC
Laparoscopic surgery for GBC was contraindicated for a long time, although cholecystectomy was the first
laparoscopic surgery in the field of general surgery. With experience of MIS in various fields, we came to
believe that laparoscopic surgery is beneficial for the patients in terms of less pain and rapid recovery with
similar oncological outcomes. Therefore, we started a prospective study on laparoscopic surgery for early
GBC in 2004. As this is the first prospective study for applying laparoscopy to malignant disease, we decided
to plan the protocol to include only early GBC. Around 2010 was a time when many leading authors
[4]
reported their initial experiences of advanced laparoscopy. Gumbs et al. reported encouraging results of
three patients who received laparoscopic extended cholecystectomy, with no morbidity or mortality. In
2010, we also reported our “initial experience of laparoscopic approach with suspected gallbladder
cancer” . Figure 1 shows our initial algorithm of patient care for suspected GBC. Endoscopic ultrasound
[5]
was performed to determine liver invasion, and cases with liver invasion were treated with open radical
cholecystectomy. In cases with peritoneal side tumors, intraoperative ultrasound was performed by
experienced radiologists to rule out liver invasion. When there was no invasion, and the frozen section
confirmed malignancy, laparoscopic extended cholecystectomy (which includes lymphadenectomy) was
performed. Three trocars were used in the standard way for cholecystectomy. A thin layer of liver tissue was
removed with the gallbladder to avoid bile spillage and to secure a safe margin. When frozen section
confirmed malignancy, one or two trocars were additionally inserted for lymphadenectomy, and the
pericholedochal, hilar, periportal, and common hepatic nodes were routinely dissected. Figure 2 shows the
completion of lymphadenectomy.

After confirming the oncologic safety, laparoscopic surgery has been cautiously applied to GBC with liver
invasion. To demonstrate this technique, we published a case report as a video article . Laparoscopic
[6]
cholecystectomy with en bloc resection of the liver bed was performed, followed by regional
lymphadenectomy. Ultrasonic shears were used to dissect the superficial liver parenchyma, and Cavitron
Ultrasonic Surgical Aspirator was used to dissect the deeper parenchyma. The report has shown that
laparoscopic lymphadenectomy and liver resection can be safely performed. With encouraging advances in
surgical technique, we can move forward to extended cholecystectomy with liver wedge resection.

The indication for laparoscopy was further expanded to operations including bile duct resection. A video
article of extended cholecystectomy with bile duct resection was published . The patient presented with
[7]
postoperatively diagnosed GBC performed at another hospital. The cystic duct margin showed high grade
dysplasia. Laparoscopic bile duct resection with lymph node dissection was performed. The bile duct was
resected and retrocolic choledochojejunostomy was performed. The entire procedure of extended
cholecystectomy, including lymphadenectomy, liver wedge resection, and bile duct resection, can be
performed with laparoscopic procedure.