What is the management for a 65-year-old lady with right hypochondrial pain, no stones in the common bile duct (CBD), and laparoscopic exploration showing a dilated gallbladder (GB) and peritoneal nodules?

Management of Gallbladder Cancer with Peritoneal Nodules

Extended cholecystectomy (option D) is the recommended management for this 65-year-old lady with right hypochondrial pain, dilated gallbladder, and peritoneal nodules found during laparoscopic exploration.

Rationale for Extended Cholecystectomy

Extended cholecystectomy is the most appropriate management strategy in this case based on the clinical presentation and intraoperative findings. The presence of peritoneal nodules with a dilated gallbladder strongly suggests gallbladder cancer with peritoneal spread, which requires a more aggressive surgical approach than simple cholecystectomy.

Key Findings Supporting Extended Cholecystectomy:

• 65-year-old patient (higher risk age group for gallbladder cancer)
• Right hypochondrial pain (classic presentation)
• Dilated gallbladder on laparoscopic exploration
• Peritoneal nodules (highly suspicious for malignancy)
• No stones in distal CBD (ruling out simple biliary obstruction)

Surgical Approach Details

Extended cholecystectomy involves:

• En bloc resection of the gallbladder
• Removal of gallbladder fossa (segment IVb and V of liver)
• Resection of extrahepatic bile ducts when necessary
• Regional lymphadenectomy (first and second echelon lymph nodes)
• Removal of peritoneal implants when possible

This approach offers the best chance for R0 resection (complete removal of all visible tumor with negative margins) which is critical for long-term survival 1.

Evidence Supporting This Approach

Research shows that extended radical cholecystectomy provides significant survival benefits for patients with gallbladder cancer, with 5-year overall survival rates of 65% and 10-year survival rates of 53% 1. The procedure is particularly indicated for:

• pT2 tumors (which penetrate the serosa)
• Selected pT3 tumors with localized hepatic invasion
• Cases with limited nodal disease (up to two positive nodes) 1

Why Other Options Are Less Appropriate

1. En bloc GB resection (option A): While this involves removing the gallbladder in one piece, it doesn't address the likely spread to surrounding tissues and lymph nodes that would be managed with extended cholecystectomy.

2. Simple cholecystectomy (option B): Inadequate for suspected malignancy with peritoneal spread. Studies show that simple cholecystectomy alone is only appropriate for very early-stage gallbladder cancers (Tis, T1a) 2, 3.

3. Palliative cholecystectomy (option C): While this might be considered if the disease were widely metastatic and unresectable, the findings described don't clearly indicate unresectability, making extended cholecystectomy the better option for potential cure or long-term control.

Surgical Considerations

• The procedure should aim for R0 resection (complete removal with negative margins)
• Careful assessment of the extent of disease is critical during the operation
• Conversion from laparoscopic to open approach may be necessary for complex cases
• Laparoscopic extended cholecystectomy can be considered in select cases but requires significant expertise 4

Limitations and Contraindications

Extended cholecystectomy may not be appropriate if:

• Extensive pT3 disease is present
• pT4 disease (involving multiple adjacent organs) is found
• Marked nodal disease (more than two positive nodes) is present 1
• Patient has significant comorbidities that increase surgical risk

Postoperative Management

• Close monitoring for complications
• Adjuvant therapy consideration based on final pathology
• Regular follow-up imaging to detect recurrence
• Multidisciplinary tumor board discussion for comprehensive care planning

Extended cholecystectomy represents the best chance for long-term survival in this patient with findings highly suspicious for gallbladder cancer with peritoneal spread.