OPEN RADICAL CHOLECYSTECTOMY

Radical open Cholecystectomy is performed for gall bladder cancer. Most of the time gall bladder cancer is associated with gall stones. Pre operative diagnosis of gall bladder cancer is suspected by presence of large mass in the gall bladder during ultrasonographic examination of abdomen. But to some extent the gall bladder cancer is confirmed with pre operative PET scan. After the diagnosis of gall bladder cancer, full evaluation of gall bladder with mass and biliary system will be done and the patient will be prepared for surgery.

If facilities are available, Laparoscopic Radical Cholecystectomy is the choice for gall bladder cancer. The limitations for laparoscopic radical cholecystectomy are,

• Availability of high-resolution laparoscopic system
• Availability good hemostatic equipment like harmonic scalpel and bipolar diathermy
• Good cardiac and pulmonary function
• Availability of experienced laparoscopic surgical team.

If open radical cholecystectomy is decided to proceed all investigations relevant to general anaesthesia is done along with LFT and in case of other systemic disease the concerned specialist opinion must be obtained. After anaesthesiologist evaluation patient will be submitted for radical open cholecystectomy.                               

The procedure is done under regional analgesia combined with general anaesthesia if possible. The surgery is performed through right subcostal incision. After opening abdomen, duodenal area and hepatic flexures will be packed and retracted with retractors as in routine open cholecystectomy. Then the procedure will be done. Here the main goal is to remove the gall bladder with mass with surrounding lymphatics and lymph nodes. The differences between routine open cholecystectomy and radical open cholecystectomy are,

1. Extreme care will be taken to remove lymph nodes present in the area of Calot’s triangle.
2. Thin rim of liver tissue about, 1cm will be removed close to the gall bladder.
3. Entire cystic duct will be removed without damaging common bile duct.
4. Lymphatics present over the hepatoduodenal ligament will be removed.
5. Care will be taken to avoid gall bladder rupture during surgery which prevent the spillage of tumour cell into the abdominal cavity.

The combined use of harmonic scalpel and bipolar diathermy helps to complete the dissection. Once the dissection is over, the specimen will be removed and will be sent histopathology examination (Biopsy) to confirm the cancer.

       Radical Cholecystectomy cannot be done in cases of gall bladder cancer associated with

• Jaundice due to bile duct infiltration
• Cancer infiltrating duodenum
• Cancer infiltrating the hepatic flexure
• Gall bladder cancer with liver metastasis
• Gall bladder cancer with severe chronic liver disease.

      Limited infiltration of duodenal area or hepatic flexure area can be considered for enbloc excision of the tumor with involved organ.