Umbilical port metastasis from gallbladder carcinoma after laparoscopic cholecystectomy

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There is also a recognized association between adenomas of the appendix and both benign and malignant neoplasia elsewhere in the body, particularly the large bowel) Therefore, colonoscopy should be performed routinely if an appendicular adenoma is identified after appendectomy. 7

References 1. Morrison JG, Llanera PP, Potts JR, III. Preoperative colonoscopic diagnosis of villous adenoma of the appendix. Report of a case and review of the literature. Dis Colon Rectum 1988; 31: 398-400. 2. Hameed K. Villous adenoma of the vermiform appendix. Arch Path 1966: 81: 465-8.

3. Gillespie PE, Chambers TJ, Chan KW, Doronzo F, Morson BC, Williams CB. Colonic adenomas--a colonoscopic survey. Gut 1979; 20: 240-5. 4. Sadahiro S, Ohruva T, Yamada Y, Saito T, Akatsuka S. A case of cecocolic intussusception of the appendix with villous adenoma. Dis Colon Rectum 1991; 34: 85-8. 5. Munk JF. Villous adenoma causing acute appendicitis. Br J Surg 1977; 64: 593-5. 6. Wolff M, Ahmed N. Epithelial neoplasms of the vermiform appendix [exclusive of carcinoids] II. Cystadenomas, papillary adenomas and adenomatous polyps of the appendix. Cancer 1976; 37:2511-22. 7. Deans GT, Spence RAG. Neoplastic lesions of the appendix. Br J Surg 1995; 82: 299-306.

Accepted for publication 11 December 1995

Umbilical port metastasis from gallbladder carcinoma after laparoscopic cholecystectomy A. J. Karayiannakis and M. J. Knight Pancreaticobiliary Unit, St George's Hospital, London, U K

A case of gallbladder carcinoma is presented where metastatic tumour developed at the abdominal wall port site following laparoscopic cholecystectomy.

Key words: gallbladder carcinoma; laparoscopic cholecystectomy; metastasis.

Introduction Laparoscopic cholecystectomy has rapidly gained widespread acceptance in the treatment of symptomatic cholelithiasis. Gallbladder carcinoma is found in 1-2% of all cholecystectomies performed and many of these are unsuspected in the pre-operative period) We report here a patient with gallbladder carcinoma, unsuspected before and during laparoscopic cholecystectomy, in whom a metastasis developed in the umbilical cannula site through which the gallbladder was removed. Case report A 59-year-old woman presented to the referring hospital with recurrent biliary colic. There was no history of jaundice and her liver function tests were normal. Abdominal ultrasonography confirmed the presence of cholelithiasis with no indication of tumour. She underwent an elective laparoscopic cholecystectomy using the four-trocar technique. The operation was uneventful and

Correspondence to: M. J. Knight, St George's Hospital, London SW 17 0QT, UK.

the gallbladder was removed intact, although with some difficulty, through the umbilical incision. There was no macroscopic evidence of tumour in the excised gallbladder. However, histological e x a m i n a t i o n revealed a well-differentiated adenocarcinoma invading the serosa. There was no vascular, lymphatic or perineural invasion and the resection margins were clear. The patient presented 3 months later complaining of a painful periumbilical swelling. A ' biopsy of the swelling confirmed metastatic adenocarcinoma from the gallbladder. Computed tomography showed that this was the only site of recurrence (Fig. I).

Discussion The presence of a wound metastasis so early after the operation in the absence of systematic dissemination suggests tumour inoculation during the procedure. This complication is not specific to laparoscopic cholecystectomy. Tumour seeding has been described after diagnostic fine-needle aspiration and laparoscopy for the diagnosis and staging of other intra-abdominal malignancies.-''3 However with the well-known difficulties in the pre-operative diagnosis of gallbladder carcinoma and the widespread use of laparoscopic cholecystectomy such a complication will inevitably become more frequent. In a review of the literature, we found several other cases of

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References

Fig. I. Computed tomography scan showing periumbilical tumour metastasis following laparoscopic cholecystectomy. unexpected gallbladder carcinoma diagnosed after laparoscopic cholecystectomy? ~-'Abdominal wall metastases have been reported to develop 3 weeks to 8 months after the operation. The lesions are usually hard and painful subcutancous masses adherent to the skin. Tumour seeding has been described not only at the site of epigastric or periumbilical cannulae through which the dissected gallbladder was removed) "' as in our case. but also in the 5-mm trocar insertion sites and in the greater omentum. ~t ~ In the former case this is due to direct implantation of turnout cells to the wound, while in the latter, the possible explanation is that rupture or extensive manipulation of the gallbladder during the procedure increases the spillage of tumour cells into the peritoneal cavity. The frequent changes of the 'contaminated" instruments and their passage through the other ports, as well as the entrapment of exfoliated tumour cells in the incision sites during deflation, can be responsible for tumour seeding in these sites. ~-'~s This report does not aim to answer the debate about the treatment of incidentally found gallbladder carcinoma but it provides an example of the potential risk of turnout seeding when laparoscopic techniques are used in the treatment of intra-abdominal malignancies.

I. Jones RS. Carcinoma of the gallbladder. Surg Clin North Am 1990; 70: 1419-28. 2. Cava A, Ronian J, Conzalez Quintela A. Martin F. Aramburo P. Subcutaneous metastasis following laparoscopy in gastric adenocarcinoma. Eitr J Surg Oncol 1990; 16: 63-7. 3. Stockdale AD, Pocock TJ. Abdominal wall metastasis following laparoscopy: a case report. Eur J Surg Om'ol 1985: I1:373 5. 4. Gornish AL, Averbach D. Schwartz MR. Carcinoma of the gallbladder found during laparoscopic cholecystectomy: a case report and review of the literature. J L~q~aroetuhJscSltrff 1991: I: 361-7. 5. O'Rourke N, Price PM, Kelly S, Sikora K. Tumour inoculation during laparoscopy. Lancet 1993; 342:368 (Letter). 6. Fligelstone L. Rhodes M. Flook D. Puntis M, Crosby D. Tumour inoculation during laparoscopy. Lancet 1993: 342: 368-9 (Letter). 7. Landen SM. Laparoscopic surgery and tumor seeding. Surgery 1993: 114:131-2 (Letter]. 8. Drouard F. Delamarre J, Capron JP. Cutaneous seeding of gallbladder cancer after laparoscopic cholecystectomy. N Engl J Med 1991: 325:1316 (Letter). 9. Clair DG, Lautz DB, Brooks DC. Rapid development of umbilical metastases after luparoscopic cholecystectomy for unsuspected gallbladder carcinoma. Surgery 1993: 113: 355-8. 10. Kim H J, Roy T. Unexpected gallbladder cancer with cutaneous seeding after laparoscopic cholecystectomy. South M e d J 1994: 87:817-20. 11. Ng JWT, Lee KKW. Chan AYT. Documentation of tumor seeding complicating laparoscopic cholecystectomy for unsuspected gallbladder carcinoma. Surgery 1994; 115:530--1 (Letter1. 12. Nduka CC, Monson JRT, Menzies-Gow N. Darzi A. Abdominal wall metastases following laparoscopy. Br J Surg 1994: 81: 648-52. 13. Pezet D, Fondrinier E, Rotman N, et al. Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy. Br J Surg 1992: 79: 230. 14. Lucciarini P, Konigsrainer A, Eberl T. Margreiter R. Tumour inoculation during laparoscopic cholccystectomy. Lamet 1993; 342:59 (Letter). 15. Barsoum GH, Windsor CWO. Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy. Br J Surg 1992: 79:846 (Letter).

Acknowledgement Dr A. J. Karayiannakis is recipient of a scholarship from the Greek State Scholarship Foundation.

Accepted fin" publication 17 December 1995