Background : Minimally invasive surgery for postoperatively diagnosed gallbladder cancer is technically challenging due to inflammatory adhesions and fibrosis resulting from the previous operation. Bile duct resection might be necessary in cases of cystic duct involvement, intense fibrosis around the bile duct, and when aggressive dissection for complete lymphadenectomy might cause bile duct injury or stricture.

Methods : Technical options for cystic duct stump dissection vary. For a long remnant stump, clip ligation and excision of the remnant stump can be performed. For a short remnant stump, stump excision and suture closure of the opening is feasible. If severe fibrosis around the bile duct hinders proper dissection, bile duct segmental resection is necessary. We would like to introduce each surgical approach in this video.

Results : First, for a long remnant stump, clip ligation and excision of the stump can be performed. If frozen biopsy shows negative margins for the additionally resected cystic duct margin, bile duct resection is not necessary. Second, a short remnant stump can also be excised, and the remnant opening could be closed by laparoscopic sutures. Meticulous dissection along the common bile duct enables the identification of the previously ligated cystic duct stump, and the remnant opening is suture ligated with interrupted sutures. Lastly, for a short stump with severe fibrosis, bile duct resection is necessary. Biliary enteric anastomosis is performed for reconstruction.

Conclusions : Minimally invasive reoperation for gallbladder cancer is technically demanding. Dependening on the degree of fibrosis and length of cystic duct stump, bile duct resection should be considered.