Laparoscopic cholecystectomy based on Laennec approach via the cystic plate was performed in six patients with GBN. The operative index with this approach, such as blood loss and operation duration, was comparing to traditional laparoscopic cholecystectomy. There was no morbidity or mortality. Moreover, all neoplasms were evaluated accurately and coped with the corresponding protocol according to the guideline for GBC. During followup in half a year, there was no recurrent for the patients with adenocarcinoma. Therefore, laparoscopic cholecystectomy based on Laennec approach via the cystic plate was safe and feasible to define the nature and invasion of GBC.
Membranes are anatomical barriers that separate tissues from organs and form the anatomical gap with adjacent organs or tissues, which provides the natural path for surgeons to dissect. The concept of membranous surgery based on membrane structure gradually takes shape[10]. Laparoscopic cholecystectomy via Laennec approach was performed under the guidance of natural gap between Laennec capsule and the adventitia/cystic plate of the gallbladder. With blunt separation, there were very few branches between gallbladder and liver to be dissected. Membranous anatomy was helpful us to define the surgical level "Holly Plane", which facilitates the promotion and standardization of surgical protocols. And it is also conducive to radical tumor resection and improves prognosis[11]. We used the suction to keep the field clear, then divest the gallbladder from the bed for about 8 minutes. In this study, four patients have the benign neoplasms, which were dissected safely without morbidity; one patient with GBC adenocarcinoma without lymph node metastasis (T1b) underwent the shift strategy with portal lymphadenectomy under laparoscopy, while one patient with GBC with Calot's lymph node metastasis (T2a) underwent the shift strategy with S4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy under laparoscopy. Through this approach, the whole gallbladder was dissected to keep the tumor complete, accurately evaluate tumor stage, prevent tumor spread, and select the corresponding protocol, especially for the patients with T1 or T2.
In addition, lymphadenectomy in Calot's triangle was also included in this protocol. As we know, the rates of lymph node metastasis in T1a, T1b, and T2 patients were up to 7%, 11.1%, and 44.3%, respectively[6]. The actual prevalence of lymph node metastasis was much high after adjusting for the probability of missing nodal disease. It was clearly demonstrated that a relatively large proportion of patients with T1b and T2 GBC might suffer from an occult nodal disease.[7] In this study, the T stage of the patient with GBC was T2a with the positive Calot's lymph node was, while all other lymph nodes were negative. Therefore, it was important for surgeons to perform the lymphadenectomy in Calot's triangle, which was significant to define the accurate N stage and select the accurate the corresponding strategy according to the guideline of GBC.
This approach was based on the histology of gallbladder. Only six patients were enrolled to testify the safety of this protocol for laparoscopic cholecystectomy at the current phase. Much many patients need to be testified for safety of the operation and feasibility of tumor stage, and long followup need to be testified for the efficiency for over survive. Therefore, we plan to start the perspective cohort study for the patients with potential GBC in our center, which will further testify the feasibility and effectiveness of this approach.