What is the management for an elderly patient with right hypochondrial pain, dilated gallbladder (GB), and peritoneal nodules, with no stones in the common bile duct (CBD)?

Management of Suspected Gallbladder Malignancy with Peritoneal Nodules

The correct answer is A: En bloc GB resection with liver wedge resection, as the clinical presentation of a dilated gallbladder with peritoneal nodules in an elderly patient strongly suggests gallbladder carcinoma, which requires oncologically appropriate resection rather than simple cholecystectomy.

Clinical Context and Diagnosis

The combination of findings described—dilated gallbladder with peritoneal nodules discovered during laparoscopic exploration—is highly suspicious for gallbladder malignancy, likely advanced disease given the presence of peritoneal implants. This scenario represents either:

• Unsuspected gallbladder carcinoma discovered intraoperatively
• Advanced disease with peritoneal dissemination (peritoneal nodules suggest T4 disease or metastatic spread)

Why Simple Cholecystectomy is Contraindicated

Simple cholecystectomy (Option B) is absolutely contraindicated when gallbladder cancer is suspected or confirmed, as it violates oncologic principles and leads to catastrophic outcomes:

• Laparoscopic cholecystectomy for unsuspected gallbladder carcinoma results in port-site recurrence and peritoneal dissemination 1
• Mortality rates are significantly higher when simple cholecystectomy is performed for malignancy, with recurrence occurring in patients with pT1b and pT2 tumors within 14-37 months 1
• Bile spillage during simple cholecystectomy dramatically worsens prognosis by seeding tumor cells 1

Recommended Surgical Approach

En Bloc Resection Technique

The "Lucknow approach" or anticipatory extended cholecystectomy is specifically designed for this scenario 2:

• Remove the gallbladder with a 2-cm wedge of liver tissue en bloc without violating the cholecysto-hepatic plane 2
• This preserves oncologic principles by avoiding tumor spillage 2, 3
• Submit the specimen for frozen section histopathology immediately 2
• If malignancy is confirmed, complete the procedure with lymphadenectomy (hepatoduodenal ligament nodes) 2

Rationale for En Bloc Approach

This technique serves as surgical triage 2:

• Prevents tumor dissemination that occurs with simple cholecystectomy 3, 1
• Maintains the 2-cm liver margin required for adequate oncologic clearance 2
• Allows intraoperative decision-making based on frozen section results 2
• If benign (xanthogranulomatous cholecystitis), the patient avoids unnecessary lymphadenectomy 2
• If malignant, the procedure is immediately completed to extended cholecystectomy 2

Why Other Options Are Incorrect

Option C: Palliative Cholecystectomy

• This term is misleading—if the disease is truly unresectable (peritoneal carcinomatosis), cholecystectomy should be avoided entirely as it provides no survival benefit and risks tumor dissemination 1
• Palliative drainage (percutaneous or endoscopic) would be preferred over surgery in truly unresectable disease 4, 5

Option D: Extended Cholecystectomy

• While this is the ultimate goal if cancer is confirmed, it should be performed as part of the en bloc approach with frozen section guidance 2
• Performing extended cholecystectomy without first securing the specimen en bloc risks tumor violation during dissection 2, 3

Critical Intraoperative Considerations

If peritoneal nodules are present:

• Obtain frozen section of peritoneal nodules first to determine if disease is metastatic
• If peritoneal nodules confirm metastatic disease (M1), complete resection may not be beneficial
• However, if nodules are inflammatory or represent localized peritoneal implants from a contained perforation, en bloc resection remains appropriate 2

Key technical points:

• Use ultrasonic coagulating shears to prevent bile spillage 3
• Avoid any ligation or clipping that might violate tumor 3
• Remove specimen in an extraction bag to prevent port-site seeding 1
• Never perform simple cholecystectomy when thick-walled gallbladder or peritoneal nodules are encountered 2, 1

Special Considerations for Elderly Patients

While this patient is elderly, age alone is not a contraindication to appropriate cancer surgery 4:

• The 2017 WSES guidelines found no evidence supporting age as a contraindication for surgery 4
• However, if the patient has prohibitive surgical risk or confirmed metastatic disease, no resection should be performed 4
• In such cases, biliary drainage (if obstructed) would be the only intervention 4

Common Pitfalls to Avoid

1. Never complete a simple cholecystectomy when intraoperative findings suggest malignancy—this is the most critical error 1
2. Do not assume peritoneal nodules are always metastatic—they may represent inflammatory changes from xanthogranulomatous cholecystitis 2
3. Avoid bile spillage at all costs during dissection, as this dramatically worsens prognosis in unsuspected cancer 1
4. Do not delay frozen section—immediate intraoperative pathology guides the extent of resection 2