The judgment of missed abdominal malignant tumor in laparoscopic cholecystectomy was according to the doubling time of tumor volume, the degree of cell differentiation and the natural course of disease. Generally speaking, the time of postoperative discovery of common abdominal malignant tumors, such as liver cancer and pancreatic cancer are 10 months, gastric cancer and colorectal cancer is one year.
In this case, laparoscopic cholecystectomy was performed, and metastatic nodules were found in the laparoscopic port-sites and umbilicus ten months later. The reason lies in the fact that the surgeons completed laparoscopic cholecystectomy without carrying out thorough radiology and laboratory examination to exclude the possibility of cholelithiasis with cholangiocarcinoma preoperatively. Due to the limitation of laparoscope on limited visual field and lack of attention to the left lobe lesions before and during operating, the left lobe cholangiocarcinoma was missed.
Reasonable and comprehensive preoperative evaluation, including radiology and laboratory examination, could apply more details, partly avoid the missed diagnosis, and improve the prognosis. At the gallstone consensus meeting, the National Institutes of health stressed that patients with atypical pain or dyspepsia need further examination to determine the cause of their symptoms
From the current literature, we know that the best way to avoid the port-site metastasis is to avoid directly touching and slicing malignant tumors, and strictly follow the laparoscopic tumor operation specifications[7, 12, 13]. For this case, metastasis was still found in the port-site after laparoscopic cholecystectomy ten months later because of the mutual contaction of malignant tumor cells and Laparoscopic forceps in enterocoelia. The reason may be the deposition of malignant tumor cells in the injured site, and of course, the direct pollution of malignant tumor cannot be excluded. For the pathological report, radiology results and operation history, we could consider that the metastasis precisely origin from bile duct epithelial  and may relate to laparoscopic surgery.
Cholangiocarcinoma originated from the left lobe of the liver is closely related to cholelithiasis[15–17]. It is liable to induce cholangiocarcinoma under the stimulation of cholestasis, bacterial infection and inflammation caused by long-term cholelithiasis, but its onset is concealed and lack of specificity, which is easily covered by the symptoms of cholelithiasis and cholangitis. The high density stones and the accompanying dilatation of bile duct may cause more difficult to distinguish the adjacent soft tissue lesions of cholangiocarcinoma, the thickening of the wall of chronic inflammatory bile duct and the invasion area of early cancer.
Histologically, cholangiocarcinoma can be divided into three types: nodular type, intraductal papillary type and bile duct wall infiltrating type. Clinically, nodular type is the most common type, and the latter two are relatively rare. The enhancement mode of nodular cholangiocarcinoma in multi-phase dynamic contrast-enhanced CT or magnetic resonance(MR) scan is presented as follow: the enhancement of tumor tissue in arterial phase, the enhancement of fibrous tissue in portal phase and delayed phase, and non-enhancement of necrotic focus. Nodular type of cholangiocarcinoma has less missed diagnosis probability. The imaging features of the latter two are not typical, that may lead to higher risk of missed and misdiagnosis. Hepatic capsular shrinkage is also an imaging feature of cholangiocarcinoma with a low specificity for both benign and malignant liver lesions can occur.
Umbilical metastasis, also known as SMJN named by Dr. Hamilton Bailey.The most common pathological type of SMJN is adenocarcinoma. The most common primary tumor sites are stomach for male, colon and female ovaries; other tumors sites such as pancreas, liver, biliary tract, fallopian tube and uterus also had been reported[24–26]. The routes of metastasis could be peritoneum, blood-borne artery, vein system, lymphatic vessel, and along the ligament of embryonic origin (round ligament, falciform ligament) or laparoscopic direct implantation. Surgery and trauma increase the release of tumor cells into the blood circulation, and tissue damage has also been proved to promote the growth of tumor cells, these two factors may lead to abnormal metastasis of tumor eventually. As in this case, it was metastasized to the umbilicus by laparoscopic surgery.