A 60-year-old woman with incidental gallbladder carcinoma found on cholecystectomy specimen has T2a disease (involvement of peritoneal side without hepatic involvement). The cystic duct margin is negative. According to NCCN guidelines, what additional surgery is required?

• A Re-resection with 2 cm hepatic margin (bed resection/segment IVb-V) + regional lymph node dissection (hepatoduodenal ligament) ✓
• B No further surgery; adjuvant chemotherapy alone is sufficient
• C Right hepatectomy (segments V-VIII) with portal lymphadenectomy
• D Simple port site excision only, as T2a with negative margins is cured by simple cholecystectomy

Explanation

T2 gallbladder carcinoma (tumour invading perimuscular connective tissue but not beyond the serosa or into the liver) requires re-resection: hepatic bed resection (segments IVb and V, 2cm margin) plus regional lymphadenectomy (hepatoduodenal ligament nodes). T2a (peritoneal side involvement without hepatic invasion) has somewhat better prognosis than T2b (hepatic side), but still requires liver bed resection as microscopic hepatic extension is possible. Simple cholecystectomy is adequate only for T1a/T1b. Right hepatectomy is excessive for T2 disease. Port site excision is recommended if laparoscopic cholecystectomy was performed to prevent port site recurrence.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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