The operations for gallbladder carcinoma have a wide range of variety from simple cholecystectomy for T1a cancer to extended right hepatectomy with regional nodal dissection for locally advanced disease. The standard operation for gallbladder cancer is a radical cholecystectomy, which involves resection of the gallbladder fossa which overlies segments IVb and V of the liver along with regional lymphadenectomy. However, involvement of the infundibulum and the cystic duct with cancer may require more extensive resections to include the bile duct and major hepatic resections to achieve negative resection margins.

It is important to understand the pattern of the lymphatic drainage of gallbladder to perform a regional lymphadenectomy. The lymphatic channels from the gallbladder drain into the cystic and pericholedochal nodes first and subsequently can follow either of two pathways. Lymphatic channels can drain into the lower retroportal and retropancreatic nodes, and then to peri-SMA nodes (Fig. 74.1, yellow line) or to the proper hepatic artery nodes to common hepatic nodes and then to celiac axis nodes (Fig. 74.2, yellow line). However, the lymphatic dissemination of tumor cells is not always in an orderly fashion and skip metastases are common.

The operation should be modified depending on the clinical scenario in which gallbladder cancer presents. If the diagnosis is made on final pathologic examination after laparoscopic cholecystectomy and it is confined to the lamina propria (T1a), no additional operation may be necessary. For T1b or above, cystic duct stump excision, possible bile duct resection, regional lymphadenectomy, and liver resection are recommended for residual disease. On the other hand, extended resections including right hepatectomy, or right extended hepatectomy along with bile duct resection and reconstruction may be needed in case of locally advanced disease at initial presentation. Often times, intraoperative findings dictate the extent of the resection necessary to obtain R0 resection and the patient and surgeon should be prepared to take on this difficult task. Port site recurrences are regarded as stage IV disease and this category of patients may not derive any benefit from wide excision of port sites. The surgeon also has to keep in mind the variations in the origin of the hepatic artery, its branches and variations in bile duct anatomy.