Prognosis for gallbladder cancer (GBC) is poor, and surgical resection remains the only modality to offer a chance of cure. Up to 30% of GBCs are discovered incidentally during histopathologic examination of gallbladders following cholecystectomy. Tumor seeding can occur if there is bile spillage during these cases. Thus, if GBC is suspected intraoperatively or preoperatively, specialist consultation is advised. We sought to identify if errors in surgical decision making were common in these cases. We completed a retrospective analysis on patients who had GB cancer and a high risk event (HRE - GB perforation or bile spillage) during their laparoscopic cholecystectomy. We identified modifiable surgical decisions that may have resulted in prevention of a HRE. Between 2008 and 2012, 100 patients were treated for GB cancer in our referral catchment, of which 49 were treated surgically. Of these, 27 patients were diagnosed with GB cancer on pathology post cholecystectomy. We identified high risk events during the cholecystectomy in 11 of these 27 cases. The median survival of patients with a HRE was 21.9 months versus 31.3 months in those without a HRE. GB decompression was intentional in 7 of 11 HRE cases to aid in the cholecystectomy. In 3 of these cases, malignancy was suspected prior to GB decompression, and thus, bile spillage should have been avoidable. One out of the 11 patients did not have recent preoperative imaging that may have shown evidence of malignancy. Of the other 10, only 1 patient had evidence of a possible GBC on preoperative imaging. In summary, we identified 5 out of 27 cases of incidental GBC where different surgical decisions may have prevented a HRE. Surgeons performing cholecystectomies must be aware of the signs of gallbladder cancer and be prepared to alter the surgical plan based on a high index of suspicion.

An analysis of surgical decisions made during laparoscopic cholecystectomy in patients with incidental gall bladder cancer.