意外胆囊癌延迟根治术的进展与思考：3D腹腔镜PH路径的临床应用

Progress and considerations in delayed radical surgery for incidental gallbladder cancer: clinical application of 3D laparoscopic PH approach

摘要:

意外胆囊癌（IGC）是因胆囊良性疾病接受胆囊切除术后，通过术中或术后病理发现的胆囊癌。由于胆囊癌常伴随胆囊结石和息肉等良性病变，且常规经腹超声对早期诊断的敏感性有限，导致IGC占所有胆囊癌病例的2/3以上。为提高早期诊断率，术前应对高危患者进行高分辨率超声检查，并结合影像组学和分子标记物应用减少误诊、漏诊。大部分IGC患者处于早期阶段，残余病灶发生率高，延迟根治术可有效改善预后。然而，局部进展期患者不宜盲目实施根治术，转化手术可能是更合适的选择。延迟根治术的最佳时机为初次手术后2~8周内，具体手术时机应基于急性炎症消退后肿瘤分期和转移评估。对于T1b~T2期患者，建议进行肝Ⅳb/Ⅴ段切除术和淋巴结清扫以确保根治效果。腹腔镜技术在胆囊癌治疗中的应用日益广泛，手术安全性和肿瘤根治效果得到验证，越来越多肝胆外科医生支持微创治疗。此外，吲哚菁绿引导的荧光腹腔镜技术能够精确进行淋巴结清扫和肝切除，降低术后并发症风险。面对IGC患者肝门和肝十二指肠韧带区的复杂解剖，实施3D腹腔镜下PH路径（基于门静脉和肝动脉为解剖轴心）延迟根治术，有助于避免器官损伤和肿瘤播散。本文综述了IGC的外科治疗现状，并探讨了PH路径在腹腔镜胆囊癌根治术中的应用。

Abstract:

Incidental gallbladder cancer (IGC) is a type of gallbladder cancer identified during or after cholecystectomy for benign gallbladder diseases through intraoperative or postoperative pathological examination. Since gallbladder cancer often coexists with benign conditions such as gallstones and polyps, and routine abdominal ultrasound has limited sensitivity in early diagnosis, IGC accounts for more than two-thirds of all gallbladder cancer cases. To improve early diagnosis rates, high-risk patients should undergo high-resolution ultrasound after surgery, combined with the use of radiomics and molecular biomarkers to reduce misdiagnosis and missed diagnoses. Most IGC patients are diagnosed at early stages, with a high incidence of residual disease. Delayed radical surgery can effectively improve prognosis. However, for patients with locally advanced disease, radical surgery should not be performed indiscriminately, and conversion surgery may be a better option. The optimal timing for delayed radical surgery is within 2 to 8 weeks after the initial surgery, with specific timing based on the resolution of acute inflammation and the evaluation of tumor staging and metastasis. For patients with T1b and T2 stage cancer, liver segment IVb/V resection and lymph node dissection are recommended to ensure curative outcomes. The application of laparoscopic techniques in gallbladder cancer treatment is becoming increasingly widespread, with confirmed surgical safety and tumor control effects, leading to growing support for minimally invasive treatment among hepatobiliary surgeons. Additionally, indocyanine green-guided fluorescence laparoscopic technology allows for precise lymph node dissection and liver resection, reducing the risk of postoperative complications. In light of the complex anatomy in the hepatic hilum and hepatoduodenal ligament region in IGC patients, performing delayed radical surgery using the 3D laparoscopic PH approach (based on the portal vein and hepatic artery as the anatomical axis) helps prevent organ damage and tumor dissemination. This review summarizes the current surgical treatment of IGC and discusses the application of the PH approach in laparoscopic gallbladder cancer radical surgery.