This operative video demonstrates a robotic completion hepatic lymphadenectomy performed for pT2 gallbladder adenocarcinoma following prior radical cholecystectomy.

The patient is a 73-year-old woman with a history of diabetes mellitus, hyperlipidemia, and prior breast cancer who was incidentally found to have gallbladder wall thickening on imaging performed during evaluation for an unrelated condition.

Subsequent evaluation demonstrated hypermetabolic gallbladder wall thickening on PET/CT, concerning for malignancy without evidence of distant metastatic disease.

The patient underwent a robotic cholecystectomy with segment IVb/V hepatic resection and portal lymphatic dissection performed by another surgeon. Final pathology demonstrated:

• Biliary-type moderately differentiated adenocarcinoma

• pT2a disease (tumor invading perimuscular connective tissue on the peritoneal side)

• Negative surgical margins

• Perineural invasion present

• No regional lymph nodes identified in the specimen (pNx)

Postoperative imaging and tumor markers did not demonstrate evidence of residual or metastatic disease.

Because adequate regional lymph node staging had not been performed, the case was reviewed at a multidisciplinary tumor board. Current oncologic guidelines recommend regional lymphadenectomy for pT2 gallbladder cancer, given the relatively high incidence of nodal metastasis and the prognostic importance of nodal status.

The patient was therefore offered completion hepatic lymphadenectomy for staging and potential therapeutic benefit.

The patient underwent robotic staging laparoscopy and completion lymphadenectomy, including dissection of lymphatic tissue along the:

• Common bile duct

• Porta hepatis

• Common hepatic and left hepatic arteries

• Celiac axis

• Retropancreatic lymph node basin

Intraoperative findings included postoperative adhesions without evidence of metastatic disease.

The patient tolerated the procedure well and was discharged home on postoperative day one.

Final pathology demonstrated:

• No metastatic carcinoma identified in six regional lymph nodes (0/10)

This case illustrates the role of completion lymphadenectomy in pT2 gallbladder cancer when adequate nodal staging was not performed at the time of the initial radical cholecystectomy.