Carcinoma of the gallbladder is a rare disease. Gallbladder carcinoma is detected in less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, gallbladders are now removed much earlier than they used to be. With the increase of cholecystectomies, the diagnosis of unexpected gallbladder carcinoma became more frequent. We report on how to proceed in patients with a diagnosis of gallbladder carcinoma and discuss the additional problems that have arisen since laparoscopic cholecystectomy became established. From June 1990 to December 1999, we performed 6230 cholecystectomies in the surgical department of Moabit Hospital in Berlin. Of these, 42 (0.6%) were identified as carcinoma. There were 37 women and five men, and the mean age was 69 years. In 16 patients (39%), there was a preoperative suspicion of malignancy. In 26 patients (61%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathologic examination of the resected gallbladder. In these patients, an open repeat operation was necessary in seven cases to achieve an adequate curative resection and staging. This involved additional liver bed resection and lymph node dissection of the hepatoduodenal ligament. Abdominal wall (port site) recurrence in the absence of distant metastasis was present only in two patients. We recommend removal using a bag in all gallbladders with wall thickening, irregularities, or scleroatrophic calcified gallbladder area. In stage Tis or T1, laparoscopic cholecystectomy is sufficient. In stage T2 and T3, we perform a repeat operation with liver bed resection and lymphadenectomy.

The frequency of gallbladder cancer in Europe is less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, patients with gallstones have gallbladder removal much earlier in their gallstone history. So the percentage of gallbladder carcinomas will decrease in the future. We report on our surgical procedures in patients with suspicious gallbladders having laparoscopic gallbladder removal, and how to proceed after the diagnosis of gallbladder carcinoma. From June 1990 to December 2001, we have performed 7,130 cholecystectomies in a single department. 47 of these patients (0.66%) were identified as having carcinoma. There were 40 females and 7 males, with a mean age of 70.6 years. In 17 cases (36%) there was a preoperative suspicion of malignancy. Most commonly, in 30 cases (64%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. We recommend removal with a bag for all gallbladders with a suspected wall or scleroatrophic calcified gallbladder area. In stage Tis or T1 laparoscopy + cholecystectomy is sufficient. For T2 and T3 we perform reoperation with liver bed resection and lymphadenectomy.

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The sterile processing of economic reusable instrumentation for laparoscopies needs staff well trained in sterile supply. Instrument design should allow easy dismantling and rinsing of internal parts. Insulating compounds present a problem for decontamination. Disinfection with aldehydes before cleaning the lumina of instruments must be avoided because protein coagulation will occur. A tube-in-tube concept for tubular instruments offering compatibility should be favored.

15 percent of the surgical patients today are 70 years of age and older (lethality 21%). A computer analysis of 1,782 surgical case histories has shown that not the age itself, but the high comorbidity is the essential factor ofperioperative risk : Hemoglobine < l0 g %, creatinine > 1.5 mg %, serumproteines < 6g %, potassium < 3.5 mmol/l. The intensive care in the elderly patient has to be started preoperatively as a preparatory treatment: metabolic deficiencies have to be compensated, hypercaloric infusion therapy and intensive breathing exercises are necessary. A scale of the operative risks in the elderly is proposed.