Case report Br. J. Surg. 1992, Vol. 79, March, 230
Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy D. Pezet, E. Fondrinier, N. Rotman*, L. Guy, P. Lemeslet, P. Lointier and J. Chipponi Service de Chirurgie Generale et Digestive, Hotel- Dieu BP 69, 63003 Clermont- Ferrand, *Service de Chirurgie Digestive, Hopital Henri- Mondor. 94010 Creteil and TCentre de Cobaltotherapie, 63400 Chamalieres, France Correspondence t o : Dr D. Pezet
The incidence of carcinoma of the gallbladder in autopsy series ranges from 0.18 to 0.81 per cent'.'. In patients operated on for biliary tract diseases, carcinoma of the gallbladder is found in 1-2 per cent of case^^.^. A preoperative diagnosis may be made in as few as 10 per cent of cases'. As laparoscopic cholecystectomy is increasingly used"', it is probable that carcinoma of the gallbladder will be removed by this technique. We report here a case of parietal seeding of a carcinoma of the gallbladder after laparoscopic cholecystectomy .
Case report
difficult and was made in only 40 per cent of the patients in one series'. In the case reported, diagnosis was made after histological examination of the gallbladder. The parietal seeding on the periumbilical incision could be due to the passage of the laparoscope or, more likely, to the extraction of the gallbladder through this incision. The parietal seeding at the site of the left trocar insertion could be explained by the frequent changes of instruments passed through this trocar or by seeding along the drain. Parietal seeding of lung, thyroid, prostate and ovarian cancers has been reported after fine needle or laparoscopic biopsies' 3 - 1 7 , but the frequency of this complication is low (0.08 per cent)16. To our knowledge, this complication has not yet been described after laparoscopic cholecystectomy. Its prevention seems difficult. Due to the low incidence of carcinoma of the gallbladder and its dismal prognosis whatever the treatment, it seems unreasonable to consider an inflammatory mass of the gallbladder as a contraindication to laparoscopic cholecystectomy. When the diagnosis of carcinoma of the gallbladder is made after operation, we suggest that either surgical resection or postoperative irradiation of the trocar sites should be included in any supplementary treatment.
References I. 2.
A 58-year-old woman was admitted in June 1990 with a 5-day history
of right upper quadrant pain and fever. She was known to have gallstones. diagnosed 10 years earlier, with repeated episodes of pain during the last year. Physical examination showed tenderness of the right upper quadrant with no palpable mass. The temperature was elevated at 38.5 C. Investigations showed a white blood cell count of 7.04 x lo', 1 with 85 per cent neutrophilia. Ultrasonography showed a distended gallbladder with a thickened but regular wall, multiple stones less than 10 mm in diameter. and no dilatation of the biliary tree. Laparoscopic cholecystectomy was performed using three trocars : the videohparoscope was introduced through a 10-mm laparoscopic trocar placed in a periumbilical incision; another 10-mm trocar was inserted in the left upper quadrant midway between the xiphoid process and the umbilicus; the third trocar was placed in the right iliac fossa for retraction of the gallbladder. The gallbladder was inflamed with necrotic areas and contained 100 ml of pus. There was no other intra-abdominal lesion. Although the dissection was difficult owing to inflammation, the gallbladder was removed intact and there was no spillage of bile. A peritoneal lavage was performed at the end of the operation. The duration of operation was 150 min. There was no macroscopic evidence of tumour on the gallbladder. Histological examination revealed a poorly differentiated carcinoma of the gallbladder infiltrating the whole thickness of the gallbladder wail. associated with perineural and vascular invasion (stage 3 ) ' . The patient left hospital on the fifth day after operation. Postoperative computed tomography showed no liver metastases. Postoperative radiotherapy of 45 Gy was given to the turnour site in 25 sessions over 6 weeks. The patient was seen in October 1990 with a complaint of periumbilical pain. Physical examination revealed a 3-cm umbilical mass and a I.5-cm nodule on the left trocar incision. The two nodules were removed; exploration of the abdomen disclosed several nodules of omenta! carcinomatosis and multiple liver metastases. Histological examination of the parietal nodules confirmed that they were metastases from the carcinoma of the gallbladder. The patient died from progression of the disease in March 1991.
3. 4. 5. 6. 7.
8.
13.
14. 15.
Discussion In this case, laparoscopic cholecystectomy seemed justified because acute cholecystitis is not a contraindication for this procedure8. Preoperative diagnosis of carcinoma of the gallbladder is rarely made2.y,'0.The lack of diagnostic images on ultrasonography is frequent in carcinoma of the gallbladder, with 60-90 per cent of the cases presenting as acute cholecystitis' ',I2. Peroperative diagnosis of carcinoma is also
230
16. 17
Kimura W, Nagai H , KUrodd A, Morioka Y . Clinicopathologic study of asymptomatic gallbladder carcinoma found at autopsy. Cuticer 1989; 64: 98-103. Silk YN, Douglas HO, Nava HR, Driscoll DL, Tartarian G. Carcinoma of the gallbladder: the Roswell Park experience. Anti Surg 1989; 210: 751-7. Burdette WJ. Cancer of the gallbladder. Ann Surg 1957; 145: 832-7. Thorbjarnarsson B, Glenn F. Carcinoma of the gallbladder. C u n w r 1959; 12: 1009-15. Peters JH. Ellison EC, Innes JT er a/. Safety and efficacy of laparoscopic cholecystectorny : a prospective analysis of I00 initial patients. Ann Surg 1991; 213: 3-12. Dubois F, Berthelot G , Levard H. Cholecystectomie par coelioscopie. Nour Pressr Mrd 1989; 18: 980-2. Nevin JE. Moran TJ. Kays S, King R. Carcinoma of the gallbladder: staging, treatment and prognosis. Cmwr 1976 ; 37: 141-8. Grace PA, Quereshi A, Coleman J rt ( I / . Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg I991 ; 78: 160-2. Piehler JM, Crichlow RW. Primary carcinoma of the gallbladder. Surg G l w c o l Oh.v/et 1978 ; 147: 929-42. Donohue JH, Nagorney D M , Grant CS, Tsushima K , Ilstrup OM, Adson MA. Carcinoma of the gallbladder. Arc h S u r ~1990: 125: 237-41. Kogd A, Yamauchi S, Izumi Y. Hamanaka N. Ultrasonographic detection of early and curable carcinoma of the gallbladder. Br J S U ~
Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy D. Pezet, E. Fondrinier, N. Rotman*, L. Guy, P. Lemeslet, P. Lointier and J. Chipponi Service de Chirurgie Generale et Digestive, Hotel- Dieu BP 69, 63003 Clermont- Ferrand, *Service de Chirurgie Digestive, Hopital Henri- Mondor. 94010 Creteil and TCentre de Cobaltotherapie, 63400 Chamalieres, France Correspondence t o : Dr D. Pezet
The incidence of carcinoma of the gallbladder in autopsy series ranges from 0.18 to 0.81 per cent'.'. In patients operated on for biliary tract diseases, carcinoma of the gallbladder is found in 1-2 per cent of case^^.^. A preoperative diagnosis may be made in as few as 10 per cent of cases'. As laparoscopic cholecystectomy is increasingly used"', it is probable that carcinoma of the gallbladder will be removed by this technique. We report here a case of parietal seeding of a carcinoma of the gallbladder after laparoscopic cholecystectomy .
Case report
difficult and was made in only 40 per cent of the patients in one series'. In the case reported, diagnosis was made after histological examination of the gallbladder. The parietal seeding on the periumbilical incision could be due to the passage of the laparoscope or, more likely, to the extraction of the gallbladder through this incision. The parietal seeding at the site of the left trocar insertion could be explained by the frequent changes of instruments passed through this trocar or by seeding along the drain. Parietal seeding of lung, thyroid, prostate and ovarian cancers has been reported after fine needle or laparoscopic biopsies' 3 - 1 7 , but the frequency of this complication is low (0.08 per cent)16. To our knowledge, this complication has not yet been described after laparoscopic cholecystectomy. Its prevention seems difficult. Due to the low incidence of carcinoma of the gallbladder and its dismal prognosis whatever the treatment, it seems unreasonable to consider an inflammatory mass of the gallbladder as a contraindication to laparoscopic cholecystectomy. When the diagnosis of carcinoma of the gallbladder is made after operation, we suggest that either surgical resection or postoperative irradiation of the trocar sites should be included in any supplementary treatment.
References I. 2.
A 58-year-old woman was admitted in June 1990 with a 5-day history
of right upper quadrant pain and fever. She was known to have gallstones. diagnosed 10 years earlier, with repeated episodes of pain during the last year. Physical examination showed tenderness of the right upper quadrant with no palpable mass. The temperature was elevated at 38.5 C. Investigations showed a white blood cell count of 7.04 x lo', 1 with 85 per cent neutrophilia. Ultrasonography showed a distended gallbladder with a thickened but regular wall, multiple stones less than 10 mm in diameter. and no dilatation of the biliary tree. Laparoscopic cholecystectomy was performed using three trocars : the videohparoscope was introduced through a 10-mm laparoscopic trocar placed in a periumbilical incision; another 10-mm trocar was inserted in the left upper quadrant midway between the xiphoid process and the umbilicus; the third trocar was placed in the right iliac fossa for retraction of the gallbladder. The gallbladder was inflamed with necrotic areas and contained 100 ml of pus. There was no other intra-abdominal lesion. Although the dissection was difficult owing to inflammation, the gallbladder was removed intact and there was no spillage of bile. A peritoneal lavage was performed at the end of the operation. The duration of operation was 150 min. There was no macroscopic evidence of tumour on the gallbladder. Histological examination revealed a poorly differentiated carcinoma of the gallbladder infiltrating the whole thickness of the gallbladder wail. associated with perineural and vascular invasion (stage 3 ) ' . The patient left hospital on the fifth day after operation. Postoperative computed tomography showed no liver metastases. Postoperative radiotherapy of 45 Gy was given to the turnour site in 25 sessions over 6 weeks. The patient was seen in October 1990 with a complaint of periumbilical pain. Physical examination revealed a 3-cm umbilical mass and a I.5-cm nodule on the left trocar incision. The two nodules were removed; exploration of the abdomen disclosed several nodules of omenta! carcinomatosis and multiple liver metastases. Histological examination of the parietal nodules confirmed that they were metastases from the carcinoma of the gallbladder. The patient died from progression of the disease in March 1991.
3. 4. 5. 6. 7.
8.
13.
14. 15.
Discussion In this case, laparoscopic cholecystectomy seemed justified because acute cholecystitis is not a contraindication for this procedure8. Preoperative diagnosis of carcinoma of the gallbladder is rarely made2.y,'0.The lack of diagnostic images on ultrasonography is frequent in carcinoma of the gallbladder, with 60-90 per cent of the cases presenting as acute cholecystitis' ',I2. Peroperative diagnosis of carcinoma is also
230
16. 17
Kimura W, Nagai H , KUrodd A, Morioka Y . Clinicopathologic study of asymptomatic gallbladder carcinoma found at autopsy. Cuticer 1989; 64: 98-103. Silk YN, Douglas HO, Nava HR, Driscoll DL, Tartarian G. Carcinoma of the gallbladder: the Roswell Park experience. Anti Surg 1989; 210: 751-7. Burdette WJ. Cancer of the gallbladder. Ann Surg 1957; 145: 832-7. Thorbjarnarsson B, Glenn F. Carcinoma of the gallbladder. C u n w r 1959; 12: 1009-15. Peters JH. Ellison EC, Innes JT er a/. Safety and efficacy of laparoscopic cholecystectorny : a prospective analysis of I00 initial patients. Ann Surg 1991; 213: 3-12. Dubois F, Berthelot G , Levard H. Cholecystectomie par coelioscopie. Nour Pressr Mrd 1989; 18: 980-2. Nevin JE. Moran TJ. Kays S, King R. Carcinoma of the gallbladder: staging, treatment and prognosis. Cmwr 1976 ; 37: 141-8. Grace PA, Quereshi A, Coleman J rt ( I / . Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg I991 ; 78: 160-2. Piehler JM, Crichlow RW. Primary carcinoma of the gallbladder. Surg G l w c o l Oh.v/et 1978 ; 147: 929-42. Donohue JH, Nagorney D M , Grant CS, Tsushima K , Ilstrup OM, Adson MA. Carcinoma of the gallbladder. Arc h S u r ~1990: 125: 237-41. Kogd A, Yamauchi S, Izumi Y. Hamanaka N. Ultrasonographic detection of early and curable carcinoma of the gallbladder. Br J S U ~
