The excellent outcomes of laparoscopic surgery for early gallbladder cancer with no recurrence after a median follow-up of 27 months that were achieved by Cho and colleagues1 would not be easily reproduced by many surgeons. Because abundant mucosal cells are found in gallbladder bile, perforation of a tumor-bearing gallbladder can lead to intraperitoneal deposits and subsequent growth of tumor cells. Oncologically unexplained intraperitoneal recurrence of gallbladder carcinoma in situ at 9 months after laparoscopic cholecystectomy complicated with intraoperative gallbladder perforation has been reported.2 A review of 21 patients with T1 cancers resected by laparoscopic cholecystectomy shows an unfavorable 3-year survival rate of 47% with frequent episodes of bile spillage at surgery,3 though a selection bias is probably present. Bile spillage at the extraction of the specimen and during the dissection from the hepatic fossa can be avoided through use of a retrieval bag and concurrent resection of adjacent hepatic tissue as seen in the study by Cho et al, but repeated application of laparoscopic graspers, which generate high pressures locally on the tissue, can tear the fragile gallbladder wall. Even in the hands of experts, gallbladder perforation during laparoscopic cholecystectomy occurred in 6.9% of consecutive 1127 patients.4 Intraoperative cholangiography and gallbladder wall inflammation seem to be risks of bile spillage. When bile duct anomaly is suspected or unusual thickening or stiffness of the gallbladder wall is noted, liberal conversion to open surgery is advocated for patients being scheduled to have or who are undergoing laparoscopic surgery for suspected early gallbladder cancer.
Fujita T. Is Laparoscopic Surgery for Early Gallbladder Cancer Less Invasive or Dangerous?. Arch Surg. 2010;145(8):797-798. doi:10.1001/archsurg.2010.135