In a patient with an equivocal gallbladder mass suspicious for carcinoma, what is the recommended operative plan involving exploratory laparotomy, intra‑operative ultrasound, frozen‑section biopsy, and possible radical cholecystectomy?

Operative Plan for Equivocal Gallbladder Mass Suspicious for Carcinoma

When gallbladder carcinoma is suspected preoperatively or discovered intraoperatively, proceed with exploratory laparotomy, obtain frozen-section confirmation, perform intraoperative staging, and execute extended cholecystectomy immediately if the surgeon has appropriate expertise and disease is resectable. 1

Preoperative Staging Requirements

Before proceeding to laparotomy, complete the following mandatory staging workup:

• Cross-sectional imaging with CT or MRI of the abdomen to assess local extent and hepatic involvement 2
• Chest imaging (CT or X-ray) to exclude distant metastases 2
• Diagnostic laparoscopy is strongly recommended before laparotomy to detect occult peritoneal or superficial liver metastases not visible on imaging—this identifies unresectable disease in a substantial proportion of patients 1, 2, 3
• Laboratory evaluation including complete blood count and liver function tests 2

Critical caveat: Surgery should not be performed when disease resectability has not been established, nor should it be performed by surgeons untrained in radical cholecystectomy 1. If you lack expertise in hepatobiliary oncologic surgery, refer the patient to a specialized center before proceeding.

Intraoperative Protocol

Step 1: Exploratory Laparotomy with Staging

• Perform systematic exploration to assess for peritoneal implants, liver metastases, and nodal disease 1
• Intraoperative ultrasound helps delineate hepatic involvement and vascular invasion 2
• Assess nodal stations: porta hepatis, gastrohepatic ligament, and retroduodenal regions 1, 2
• Nodal disease beyond regional stations (celiac, retropancreatic, interaortocaval) indicates unresectable disease—abort radical resection 1

Step 2: Frozen Section Biopsy

• Obtain frozen-section confirmation of the gallbladder mass to establish diagnosis 1, 4
• If carcinoma is confirmed, assess depth of invasion (T stage) on frozen section to guide extent of resection 1, 2
• Frozen section should also evaluate bile duct margins if bile duct excision is planned 1

Step 3: Decision Algorithm Based on Findings

If T1a disease (lamina propria invasion only) with negative margins:

• Simple cholecystectomy is sufficient—no additional resection required 2, 5
• Proceed to observation alone 1, 2

If T1b or greater disease (muscle layer invasion or beyond) AND resectable:

• Proceed immediately to extended cholecystectomy if surgeon has expertise 1, 4
• This includes: en bloc hepatic resection (wedge of segments IVb/V with ≥2 cm margin), regional lymphadenectomy (porta hepatis, gastrohepatic ligament, retroduodenal nodes), and bile duct excision if tumor involves the biliary tree 1, 2, 4

If unresectable disease is identified:

• Obtain tissue diagnosis via biopsy 1
• Consider palliative biliary drainage if jaundice is present 1
• Abort radical resection 1

Components of Radical Cholecystectomy

When proceeding with extended cholecystectomy for T1b or higher disease:

Hepatic Resection

• En bloc wedge resection of the gallbladder bed with 2–3 cm liver margin (typically segments IVb and V) 2, 4
• Major hepatectomy (extended right hepatectomy or caudate resection) may be required for stage III–IV disease but should be limited to cases where necessary for complete tumor removal, as it increases complications without independent survival benefit 1, 2

Lymphadenectomy

• Mandatory regional lymphadenectomy including cystic duct node, common bile duct node, hepatic artery and portal vein nodes, and posterior superior pancreaticoduodenal node 1, 2, 5
• This provides accurate staging and potential survival benefit 3

Bile Duct Excision

• Add extrahepatic bile duct resection when tumor involvement of the biliary tree is suspected on imaging or intraoperative assessment 1, 2, 4
• Obtain frozen-section assessment of bile duct margins 1

Key Pitfalls to Avoid

• Do not perform laparoscopic cholecystectomy if gallbladder carcinoma is suspected preoperatively—this risks port-site seeding and inadequate oncologic resection 6, 7
• Do not proceed with radical resection if you lack hepatobiliary oncologic training—approximately 74% of patients re-explored after incidental diagnosis have residual cancer, underscoring the importance of adequate initial surgery 1
• Do not perform major hepatectomy unless required for complete tumor clearance, as it significantly increases morbidity 1
• If gallbladder cancer is discovered postoperatively on final pathology and frozen section was not obtained, the patient requires radical re-resection after repeat staging confirms absence of metastatic disease 1, 2

Adjuvant Treatment

After radical resection:

• Fluoropyrimidine-based chemoradiation is recommended for all resected gallbladder cancers except T1b, N0 disease 2
• Gemcitabine-based or fluoropyrimidine-based chemotherapy are acceptable adjuvant options 1, 2
• Fluorouracil-based chemotherapy has demonstrated survival benefit after non-curative resections 2