A 56-year older woman was referred to our hospital presenting with a space-occupying lesion of the gallbladder. Prior to this, she was admitted to a local hospital complaining of pain localized in the right upper quadrant. Gallbladder cancer was confirmed according to an enhanced CT scanning imaging technique. For further workup and management, the patient was referred to our university hospital. In our hospital, she went through some systematic and detailed investigations. MRI revealed a gallbladder space-occupying lesion with an abnormal signal in segment IV of the liver, considered gallbladder cancer including liver invasion (Figure 1). Liver function tests were abnormal: TBIL 89.0 umol/L, DBIL 13.9 umol/L, IBIL 75.1 umol/L, ALP 69 U/L, gamma-GGT 37 U/L, ALT 216 U/L, and AST 349 U/L; serum tumor marks tests showed an elevated CA-199. The results of these examinations supported the clinical diagnosis of gallbladder cancer. The patient was scheduled for surgical treatment.
Members of our multidisciplinary team convened to discuss the treatment and workup plan for this patient. The patient was diagnosed with gallbladder cancer (cT3NXM0). A consensus was reached that the radical surgery of gallbladder cancer is feasible and beneficial for this patient. Fluorescence laparoscopic surgery using ICG was proposed based on the assumption that it could help tumor visualization. The conventional preoperative preparations were performed. In addition, ICG (concentration 2.5 mg/ml) was administered intravenously to the patient 24 h prior to surgery. The dosage of ICG was calculated and administered as 0.1 mg per kg.
During the operation, the patient was placed in the scissors position. A small incision was made along the umbilical region to introduce a 12 mm trocar, and a pneumoperitoneum was then established with carbon dioxide gas. A laparoscope was inserted and introduced for an exploration surgical procedure to be carried out. Since there was no sign of distant metastasis, four additional trocars were placed under direct vision. Real-time NIRF imaging was achieved for the whole operative procedures via the PINPOINT Endoscopic Imaging System (Stryker). The extrahepatic biliary tree appeared pale green fluorescence under the NIRF imaging technique. Post identifying the extrahepatic biliary tree, the hepatic hilum was dissected. The hepatic arteries and portal veins were then isolated and protected (Figures 2A,B). At this stage, lymphadenectomy was performed, including the clearance of lymph nodes around the hepatoduodenal ligament (No.12), common hepatic artery (No.8), retropancreatic area (No.13), and celiac artery (No.9). Dissection was also done to view the Calot's triangle more vividly. The cystic artery was then ligated. To assure a negative cystic duct margin, the cystic duct was traced and transected to the common bile duct junction under the guidance of green fluorescence. Accumulation of fluorescence was identified along the gallbladder bed with the incorporation of NIRF imaging, which indicated a tumor invasion of the liver (Figure 2C). The wedge liver resection was performed 2-cm from the fluorescent accumulation margin. Subsequently, the wedge liver and gallbladder were staffed into the retrieval bag and then pulled out through the camera port. The cross-section of the reserved liver was explored and viewed under NIRF imaging, and local green fluorescence was observed (Figure 2D). Consequently, additional liver resection was added to clear the residual lesions. Finally, hemostasis was performed. The removed gallbladder specimen was dissected and observed under NIRF imaging once more. The tumor showed a dense green fluorescence under NIRF imaging (Figures 2E,F). There were no complications during the operative procedure, which lasted for 2 h, and 100 ml of blood was recorded.
Finally, a pathological report revealed a 5 x 2.5 x 1 cm, low to moderately differentiated adenocarcinoma (Figure 3). The tumor invaded the whole layer of the gallbladder wall and has lymphovascular invasions. No tumor extension was identified in the liver. The resection margin of the cystic duct was free of tumors. No metastatic carcinoma in any lymph nodes (n = 6) was reported.
This patient recovered quickly post operatively. She started a solid diet on the 3rd day postoperatively based on her full recovery of bowel motions and activity. No postoperative complications occurred during her hospitalization stay. The patient was discharged on the 6th postoperative day and was asked to come back regularly for the following treatments. The detailed timeline of patient information in this episode of care can be seen in Figure 4.