Laparoscopic Cholecystectomy Based on Laennec Approach via the Cystic Plate with Lymphadenectomy in Calot's Triangle for Gallbladder Neoplasms：initial experience and technical details

Laparoscopic Cholecystectomy Based on Laennec Approach via the Cystic Plate with Lymphadenectomy in Calot's Triangle for Gallbladder Neoplasms：initial experience and technical details | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Laparoscopic Cholecystectomy Based on Laennec Approach via the Cystic Plate with Lymphadenectomy in Calot's Triangle for Gallbladder Neoplasms：initial experience and technical details Bin Ouyang, Laizhu Zhang, Yajuan Cao, Zhongjie Xing, Jin Peng, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1711939/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim It is still challenging to define the exact stage of early gallbladder carcinoma with preoperative imaging. Generally subserous gallbladder is dissected for the potential early gallbladder carcinoma, which may cause incomplete tumor resection or tumor spread especially for the patients with T2 stage. Here, we reported our experience and safety of Laennec approach via the cystic plate to dissect the whole gallbladder with lymphadenectomy in Clot’s triangle for accurate diagnosis and staging in gallbladder neoplasms. Methods The anatomical gap between Laennec capsule and the cystic plate serves as the landmark to dissect the whole gallbladder through Laennec approach. Laparoscopic cholecystectomy based on Laennec approach via the cystic plate, together with lymphadenectomy in Calot’s triangular, was performed in 6 patients with gallbaldder neoplasms. Results All patients had less intraoperative bleeding, no gallbladder breakage, no bile leakage, and accurate intraoperative rapid pathological staging under the corresponding strategies. The duration of surgery was comparable to that of traditional laparoscopic cholecystectomy. Conclusion Laparoscopic cholecystectomy based on Laennec approach via the cystic plate, together with lymphadenectomy in Calot’s triangular is safe for gallblader neoplasms. In the future, the prospective clinical trial is going on to confirm the feasibility and effectiveness in the therapy of early gallbladder. Laennec approach csytic plate Laparoscopic cholecystectomy Gallbladder neoplasms patient safety Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Gallbladder cancer (GBC) is the sixth common malignancy of the digestive tract with poor prognosis when diagnosed at an advanced stage. Early diagnosis and precise therapy of GBC are particularly important for prognosis[1]. The Guidelines for the Diagnosis and Treatment of GBC states that Stage T3 or T4 can be defined accurately with preoperative imaging, such as enhanced multilayer spiral CT or MRI, therefore the patients undergo the corresponding surgical protocol [2]. However, it is challenging to differentiate stage T1 and T2 for GBC with radiological examination, even that the sensitivities of the ability to differentiate the or = T2 lesions is up to 79.3%[8]. Therefore, surgeons have to seek intraoperative frozen pathology to identify the tumor nature and invasion depth of gallbladder neoplasms (GBN) after laparoscopic cholecystectomy[3–4]. Generally subserous cholecystectomy is performed, which has the potential risk to cause incomplete tumor resection, tumor spread, or inaccurate stage for the patients with T2 stage [ 3 – 4 ] . Moreover the patients with T1b or T2 stage tumors are recommended for expanded radical resection to improve survival prognosis [ 5 ] . Gallbladder has 3 layers, including mucosa, muscularis, and serosa/adventitia. In the gallbladder fossa, adventitia is composed of collagen, elastic tissue, fat, vessels, lymphatics and nerves, which continues as the cystic plate. Generally this adventitia with the cystic plate is left in the gallbladder bed after subserous cholecystectomy. It has been previously confirmed that Laennec capsule, surrounding all the parenchymal, is free from the visceral peritoneum, adventitia and cystic plate, and inferior vena cava outside the liver, and extends into liver along with the hepatic pedicle and out liver with hepatic veins [ 12 ] . In 2018 we proposed that Laennec capsule could be used as a landmarker for anatomical hepatic resection, guiding extrahepatic isolation (perihepatic and retrohepatic isolation) and intrahepatic isolation (hepatic pedicle and hepatic vein isolation), which was nominated as the Laennec approach for hepatectomy [ 13 ] . There is the gap between adventitia/the cystic plate and Laennec capule closing the parenchymal, which may serves as the landmark to dissect the gallbladder from the gallbladder bed. Therefore, the reasonable protocol, Laennec approach via the cystic plate for laparoscopic cholecystectomy in Fig. 1 , was designed for the potential early GBC. The protocol, including gallbladder dissected completely through the Laennec gap between adventitia/the cystic plate and Laennec capsule together with lymphadenectomy in the Calot triangular, expands the scope and depth of resection, further avoids the risk of tumor destruction, and contributes to the accurate staging of the potential GBC, which in turn allows for timely remedial surgery according to the guidelines. The initial experience and technical details were described as follows. Methods Study design This study was performed in Nanjing Central Hospital and Drum Tower Hospital. The protocol was approved by the Research Ethics Committee of Nanjing Central Hospital (2021NJCHLL003) and Drum Tower Hospital (2020-310-02), and conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Informed consents were obtained in writing from each patient. Since June 2021, the patients, as the subjects with potential early GBC, were enrolled into this trial. The preoperative diagnosis was dependent on ultrasonography and MRI with contrast. The patients with more than T3 GBC were excluded. Some basic information of six patients was summarized in Table 1 . Table 1 basic information of the paitents in this trial Number Gender Age Diagnosis Date Location Tumor size (cm) No. 1 Female 60 gallbladder polypoid with stone 2020/9/26 Fundus 0.8*1.7 No. 2 Male 55 gallbladder polypoid with stone 2021/6/11 Fundus 1.3*1.8 No. 3 Female 70 gallbladder polypoid 2021/7/30 Neck 1.1*2.4 No. 4 Female 57 gallbladder polypoid 2021/10/8 Body 1.1*1.5 No. 5 Male 45 gallbladder polypoid 2021/10/17 Body 1.0*1.6 No. 6 Male 66 gallbladder adenocarcinoma 2021/10/19 Fundus 1.6*3.2 Procedures The patient's position and Trocar layout was similar to traditional laparoscopic cholecystectomy [ 14 ] . The patient was placed on the table in the supine position. After induction of general endotracheal anesthesia, the abdomen was sterilely prepped and draped. A 10 mm incision was made beneath the umbilicus for laparoscope. A pneumoperitoneum of 15 mmHg was established. Diagnostic laparoscopy was then performed to check the tumor invasion or metastasis. Then 12 mm trocar as the operating port was placed in the xiphoid position, followed by a 5-ram trocar to retract the fundus of the gallbladder upward in the fight lower abdomen. A 5-mm trocar was placed as the first assistant port in the fight subcostal position. All patients underwent laparoscopic cholecystecectomy via Laennec approach with lymphadenectomy in Calot's triangle, which were described as follows in Fig. 2 and the supplemental video 1. To check out metastasis through abdominal exploration, dissect the ventral visceral peritoneum of the Calot’s triangle along common bile duct (Fig. 2 A) and the dorsal visceral peritoneum along the right hepatic pedicle (Fig. 2 B), separate and detach the gallbladder artery and gallbladder duct close to the common bile duct, dissect lymph nodes in the Calot triangular (Fig. 2 C), then dissect the visceral peritoneum of the liver close to the gallbladder bed with an electrocoagulation hook, and bluntly separate into the Laennec gap (Fig. 2 ), detach the gallbladder plate (Fig. 2 D), and completely strip the whole gallbladder including adventitia through the Laennec approach (Fig. 2 E-G), the gallbladder bed is rinsed and hemostated tightly, and bile leakage are carefully examined (Fig. 2 H). The gallbladder were opened to confirm the tumor site and the depth of the invasion, and to be sent for the frozen pathology. All the procedures were performed by the same attending surgeon (Prof. YU Decai). Furthermore, the samples,including gallbladder and lymph nodes, were sent to the frozen pathological examination. All patients with benighn neoplasms recovered after the frozen pathological examination, while the other patients with malignant neoplasms underwent the coppresonding strategy according to the stage. Procedure evaluation and followup The procedure relevant index, such as frozen pathological results, duration for the key steps, estimated blood loss, bile leakage, morbidity and mortality, were collected. All patients were followed up for six months for morbidity, mortality, and tumor recurrence. Results Since June 2021, six patients were enrolled into this study. Among them including 2 men and 4 women, aged 28 to 61 years old, the preoperative diagnosis was gallbladder neoplasm. Ultrasonography and MRI with contrast showed that the tumor size ranged from 1.1 to 3.2 cm, of which 2 cases had gallbladder stones, and usually had occasional right upper quadrant vague pain discomfort, and the remaining 4 cases had no obvious clinical symptoms. Figure 1 illustrated the anatomical hierarchy of laparoscopic cholecystectomy via the Laennec approach The representative MR imagings were presented in Fig. 2 for Patient No 3. All key index were summarized in Table 1 . Six patients, as the subjects with potential early GBC, underwent laparoscopic cholecystecectomy based on Laennec approach via the cystic plate with Calot triangular lymph node dissection, which were described in Fig. 3 and supplemental video 1 with cystic plate dissected first, and in Fig. 4 and the supplemental video 2 with cystic plate dissected lastly. The procedure relevant index of the paitents in this trial were summarized in Table 2 . Table 2 procedure relevant index of the paitents in this trial Number Duration for Calot’s triangle dissection (mins) Duration for Gallbladder bed divestiture (mins) Pathological diagnosis Shift strategy Blood loss (ml) Bile leakage Duration of surgery (mins) Morbidity ( Clavien-Dindo Classification) Hospital stay (days) No. 1 11 13 Inflammatory polyps No 10 No 55 Grade I 3 No. 2 9 10 Cholesterol polyps No 20 No 50 Grade I 3 No. 3 8 12 Adenoma No 10 No 60 Grade I 3 No. 4 6 10 Adenoma No 20 No 45 Grade I 3 No. 5 8 11 T1b Adenocarcinoma without Calot's lymph node metastasis Portal lymphadenectomy 30 No 120 Grade I 5 No. 6 13 15 T2a Adenocarcinoma with Calot's lymph node metastasis S4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy 100 No 235 Grade I 13 Mean 8.75 12 20 120 6 The frozen pathological examination showed that two cases were adenoma, one cholesterol polyp, one Inflammatory polyp, and two adenocarcinoma. Four patients with benighn neoplasms recovered after the frozen pathological examination. Patient No. 2 with GBC without lymph node metastasis (T1b) underwent the shift strategy with portal lymphadenectomy under laparoscopy. Patient No. 6 with GBC with Calot's lymph node metastasis, defined as stage IIIB (T2a, N1. M0), underwent the shift strategy with S4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy under laparoscopy. All procedures were successfully completed under laparoscopy, and the operation time was 25 to 235 minutes with estimated blood loss from 10 to 100 ml, The drainage tube was placed after the operation in two patients with adenocarcinoma. No complications, such as bleeding and bile leakage, occurred. Four subjects with benign neoplasms were discharged on POD 3 for the clinical trial. The patient undergoing portal lymphadenectomy was discharged on POD 5, while the patient undergoing radical resection was discharged on POD 13. There was no recurrence on the patients with adenocarcinoma after six month. Discussion Laparoscopic cholecystectomy based on Laennec approach via the cystic plate was performed in six patients with GBN. The operative index with this approach, such as blood loss and operation duration, was comparing to traditional laparoscopic cholecystectomy. There was no morbidity or mortality. Moreover, all neoplasms were evaluated accurately and coped with the corresponding protocol according to the guideline for GBC. During followup in half a year, there was no recurrent for the patients with adenocarcinoma. Therefore, laparoscopic cholecystectomy based on Laennec approach via the cystic plate was safe and feasible to define the nature and invasion of GBC. Membranes are anatomical barriers that separate tissues from organs and form the anatomical gap with adjacent organs or tissues, which provides the natural path for surgeons to dissect. The concept of membranous surgery based on membrane structure gradually takes shape [ 10 ] . Laparoscopic cholecystectomy via Laennec approach was performed under the guidance of natural gap between Laennec capsule and the adventitia/cystic plate of the gallbladder. With blunt separation, there were very few branches between gallbladder and liver to be dissected. Membranous anatomy was helpful us to define the surgical level "Holly Plane", which facilitates the promotion and standardization of surgical protocols. And it is also conducive to radical tumor resection and improves prognosis [ 11 ] . We used the suction to keep the field clear, then divest the gallbladder from the bed for about 8 minutes. In this study, four patients have the benign neoplasms, which were dissected safely without morbidity; one patient with GBC adenocarcinoma without lymph node metastasis (T1b) underwent the shift strategy with portal lymphadenectomy under laparoscopy, while one patient with GBC with Calot's lymph node metastasis (T2a) underwent the shift strategy with S4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy under laparoscopy. Through this approach, the whole gallbladder was dissected to keep the tumor complete, accurately evaluate tumor stage, prevent tumor spread, and select the corresponding protocol, especially for the patients with T1 or T2. In addition, lymphadenectomy in Calot's triangle was also included in this protocol. As we know, the rates of lymph node metastasis in T1a, T1b, and T2 patients were up to 7%, 11.1%, and 44.3%, respectively[6]. The actual prevalence of lymph node metastasis was much high after adjusting for the probability of missing nodal disease. It was clearly demonstrated that a relatively large proportion of patients with T1b and T2 GBC might suffer from an occult nodal disease.[7] In this study, the T stage of the patient with GBC was T2a with the positive Calot's lymph node was, while all other lymph nodes were negative. Therefore, it was important for surgeons to perform the lymphadenectomy in Calot's triangle, which was significant to define the accurate N stage and select the accurate the corresponding strategy according to the guideline of GBC. This approach was based on the histology of gallbladder. Only six patients were enrolled to testify the safety of this protocol for laparoscopic cholecystectomy at the current phase. Much many patients need to be testified for safety of the operation and feasibility of tumor stage, and long followup need to be testified for the efficiency for over survive. Therefore, we plan to start the perspective cohort study for the patients with potential GBC in our center, which will further testify the feasibility and effectiveness of this approach. Declarations Ethics approval and consent to participate :This study was performed in Nanjing Central Hospital and Drum Tower Hospital. The protocol was approved by the Research Ethics Committee of Nanjing Central Hospital (2021NJCHLL003) and Drum Tower Hospital (2020-310-02), and conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Informed consent was obtained in writing from each patient Availability of data and materials： The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Funding and Competing interests： This research was supported by the National Natural Science Foundation of China (ID: 82173129). The authors declare that they have no conflict of interest. Authors' contributions: Decai Yu attended the design of this study and checked this article. Bin Ouyang and Laizhu Zhang participated in the writing and correction of articles. Yajuan Cao, Jin Peng, Zhongjie Xing and Yang Yue attend the operation of these patients. The main operator was Decai Yu. Acknowledgements: Informed consent of all authors for the writing and submission of the article References Wu Xin,Li Binglu,Zheng Chaoji, et al. Incidental gallbladder cancer after laparoscopic cholecystectomy: incidence, management, and prognosis.[J]. Asia Pac J Clin Oncol, 2020(3): 158-164. Agresta F, Campanile FC, Vettoretto N, et al. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg. 2015 May;400(4):429-53. Ando Takuya,Sakata Jun,Nomura Tatsuya, et al. Anatomic location of residual disease after initial cholecystectomy independently determines outcomes after re-resection for incidental gallbladder cancer.[J]. Langenbecks Arch Surg, 2021(5): 1521-1532. Vinuela Eduardo,Vega Eduardo-A,Yamashita Suguru, et al. Incidental Gallbladder Cancer: Residual Cancer Discovered at Oncologic Extended Resection Determines Outcome: A Report from High- and Low-Incidence Countries.[J]. Ann Surg Oncol, 2017(8): 2334-2343. [Guideline for the diagnosis and treatment of gallbladder carcinoma (2019 edition)].[J]. Zhonghua wai ke za zhi [Chinese journal of surgery], 2020(4): 243-251. Yang Yingnan,Tu Zhuolong,Cai Huajie, et al. A predictive nomogram for lymph node metastasis of incidental gallbladder cancer: a SEER population-based study.[J]. BMC Cancer, 2020(1): 828. Huang Xi-Tai,Huang Chen-Song,Li Jian-Hui, et al. Evaluating the adequacy of nodal status in node-negative gallbladder cancer with T1b-T2 stages: use of nodal staging score.[J]. HPB : the official journal of the International Hepato Pancreato Biliary Association, 2020(5): 795-801. Kim Soo-Jin,Lee Jeong-Min,Lee Jae-Young, et al. Accuracy of preoperative T-staging of gallbladder carcinoma using MDCT.[J]. AJR. American journal of roentgenology, 2008(1): 74-80. Joo Ijin,Lee Jae-Young,Baek Jee-Hyun, et al. Preoperative differentiation between T1a and ≥T1b gallbladder cancer: combined interpretation of high-resolution ultrasound and multidetector-row computed tomography.[J]. European radiology, 2014(8): 34-1828. Gong J-P. [Scientific paradigm of membrane anatomy].[J]. Zhonghua wei chang wai ke za zhi ,Chinese journal of gastrointestinal surgery, 2021(7): 557-559. Zhao Y-Z,Zhang X-J. [Re-recognition and thinking of membrane anatomy].[J]. Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery, 2021(12): 1119-1121. Sugioka Atsushi,Kato Yutaro,Tanahashi Yoshinao. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec's capsule: proposal of a novel comprehensive surgical anatomy of the liver.[J]. Journal of hepato-biliary-pancreatic sciences, 2017(1): 17-23. Hu Yue,Shi Jiong,Wang Shaohe, et al. Laennec's approach for laparoscopic anatomic hepatectomy based on Laennec's capsule.[J]. BMC Gastroenterol, 2019(1): 194. Thapar P, Salvi P, Killedar M, et al. Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study. Surg Endosc. 2021 Aug;35(8):4231-4240. Additional Declarations No competing interests reported. Supplementary Files LaennecLCSVideo1cysticplatefirst0.mp4 LaennecLCSVideo2cysticplatelastly0.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1711939","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":112513353,"identity":"0cc257ca-16bd-47ca-a625-e891496d9526","order_by":0,"name":"Bin Ouyang","email":"","orcid":"","institution":"Nanjing Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Ouyang","suffix":""},{"id":112513354,"identity":"10e4b9f4-c830-4054-b894-9792a36d8483","order_by":1,"name":"Laizhu Zhang","email":"","orcid":"","institution":"The Affiliated Drum Tower Hospital, Nanjing University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laizhu","middleName":"","lastName":"Zhang","suffix":""},{"id":112513355,"identity":"b300fa6a-7cfa-420b-b29e-e3383e3fd014","order_by":2,"name":"Yajuan Cao","email":"","orcid":"","institution":"The Affiliated Drum Tower Hospital, Nanjing University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yajuan","middleName":"","lastName":"Cao","suffix":""},{"id":112513356,"identity":"5009dbe4-abd0-4bcc-a30d-4af70ea64a56","order_by":3,"name":"Zhongjie Xing","email":"","orcid":"","institution":"Nanjing Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhongjie","middleName":"","lastName":"Xing","suffix":""},{"id":112513358,"identity":"91bb11fa-a5e4-41b3-948f-44596b3872bd","order_by":4,"name":"Jin Peng","email":"","orcid":"","institution":"The Affiliated Drum Tower Hospital, Nanjing University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Peng","suffix":""},{"id":112513359,"identity":"aa898ed0-6f5e-457d-a879-332c5330447c","order_by":5,"name":"Yang Yue","email":"","orcid":"","institution":"The Affiliated Drum Tower Hospital, Nanjing University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Yue","suffix":""},{"id":112513362,"identity":"a4768863-8821-47a7-99ee-1c8326b31b0a","order_by":6,"name":"Decai Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYHACAyCWkGNgOACk2UjQYkyyFobEBjCbGC0GN5I3PvhRY5G+nfGMAcOHssMM/LMbCGlJKzbsOSaRu7PhjAHjjHOHGSTuHCCkJcdMmoFNInfDgTMGzLxthxkMJBIIajH/zfBPIt0ApOUvkVrMmBnbJBLAWhiJ0SJ55lmxZG+fhOGGA8cKDvacS+eRuEFAC9/x5I0ffnyrkze4cRgYdGXWcvwzCGhROABjSRwARyYPfvVAIN8AY/E34FY1CkbBKBgFIxsAAB9GR2D9kzPsAAAAAElFTkSuQmCC","orcid":"","institution":"Nanjing Central Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Decai","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2022-05-31 12:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1711939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1711939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":22691764,"identity":"519e6e11-ed61-4fda-9ee8-3e6d3f6728d3","added_by":"auto","created_at":"2022-06-15 17:01:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":7057503,"visible":true,"origin":"","legend":"\u003cp\u003eThe representative HE sections in the junction between gallbladder fossa and free wall of patient 3. In Figure A the junction of the gallbladder bed and the serosa of the gallbladder was presented under\u0026nbsp;a\u0026nbsp;20x\u0026nbsp;macro lens. The gallbladder fossa is mainly divided into three layers, as marked with different color zone in Figure B, from the inside to the outside are the mucous membrane, muscular layer and connective tissue (adventitia). Traditional approach for cholecystectomy, marked with red arrow, were performed along muscular layer, while Laennec approach, marked with yellow arrow, were perfored along Laennec capsule closing to adventitia. Figures C and D were presented under\u0026nbsp;a\u0026nbsp;40x\u0026nbsp;and 100x macro lens from the area marked in the box in Figure A and C, respectively.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/6dcce4f6c6fda9cbef5f5c0b.png"},{"id":22691762,"identity":"b5e1e273-44f1-4195-adfe-cc7f2cb477a9","added_by":"auto","created_at":"2022-06-15 17:01:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":297902,"visible":true,"origin":"","legend":"\u003cp\u003eMRI features of Gallbladder adenoma from Patient No 3. Axial T2-weighted (A) and T1-weighted (C) images show marked asymmetric mural thickening that is moderately hyperintense without diffusion restriction (B), and shows poor contrast enhancement in artery, portal, and vein phase (D-F). The tumor size was 2.4 cm times 1.1 cm\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/a8a5fd5419ed294d535ab6b6.png"},{"id":22691763,"identity":"9c0789f1-401c-4c87-9f86-8c5e7f206a99","added_by":"auto","created_at":"2022-06-15 17:01:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":7034517,"visible":true,"origin":"","legend":"\u003cp\u003e\tProcedures for laparoscopic cholecystectomy based on Laennec approach with cystic plate dissected first for Patient No. 3. Firstly dissect the ventral visceral peritoneum of the Calot’s triangle along common bile duct (A) and the dorsal visceral peritoneum along the right hepatic pedicle (B), separate and detach the gallbladder artery and gallbladder duct (C), then dissect the visceral peritoneum of the liver close to the gallbladder bed with an electrocoagulation hook , bluntly separate into the Laennec gap, detach the gallbladder plate (D), and completely strip the gallbladder from the gallbladder bed through the Laennec approach (E-G), the gallbladder bed is rinsed and tightly hemostated, and bile leakage is carefully examined (H). The red line was marked to guide the dissection path. The shadow zone was coved by Laennec capsule (H).\u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/3d5d9521db02e84a51f052f2.png"},{"id":22691765,"identity":"7c80b2da-7476-4cb9-a592-b529a9b419cc","added_by":"auto","created_at":"2022-06-15 17:01:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":5831637,"visible":true,"origin":"","legend":"\u003cp\u003e\tProcedures for laparoscopic cholecystectomy based on Laennec approach with cystic plate dissected lastly for Patient No. 5. Firstly dissect the ventral visceral peritoneum of the Calot’s triangle along common bile duct (A) and the dorsal visceral peritoneum along the right hepatic pedicle (B), separate and detach the gallbladder artery and gallbladder duct (C). then dissect the visceral peritoneum of the liver close to the gallbladder bed with an electrocoagulation hook , bluntly separate into the Laennec gap, and completely strip the gallbladder from the gallbladder bed membrane through the Laennec approach （D-E), detach the gallbladder plate (E), the gallbladder bed is rinsed and tightly hemostated, and bile leakage are carefully examined (F). The red line was marked to guide the dissection path. The shadow zone was coved by Laennec capsule. CBD means common bile duct; MHV middle hepatic vein; LN lymph node\u003c/p\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/31bbe94d37c427db47ee7c35.png"},{"id":27914744,"identity":"7dd973e7-bc87-474e-bddc-f5edc0c7e3ce","added_by":"auto","created_at":"2022-10-18 08:45:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7405044,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/e1a2c158-e709-4c10-9c6d-e1d87b61a6ce.pdf"},{"id":22691771,"identity":"e09cd6b3-4e0e-4442-8abc-14f548b9fb28","added_by":"auto","created_at":"2022-06-15 17:01:12","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":160449399,"visible":true,"origin":"","legend":"","description":"","filename":"LaennecLCSVideo1cysticplatefirst0.mp4","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/a2b31ff38af8b7b2294dd79d.mp4"},{"id":22691767,"identity":"85328464-1264-4fb0-80fd-b46f70310ba8","added_by":"auto","created_at":"2022-06-15 17:01:11","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":157538575,"visible":true,"origin":"","legend":"","description":"","filename":"LaennecLCSVideo2cysticplatelastly0.mp4","url":"https://assets-eu.researchsquare.com/files/rs-1711939/v1/a805ebf96c17acb2c0d2eebb.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic Cholecystectomy Based on Laennec Approach via the Cystic Plate with Lymphadenectomy in Calot's Triangle for Gallbladder Neoplasms：initial experience and technical details","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGallbladder cancer (GBC) is the sixth common malignancy of the digestive tract with poor prognosis when diagnosed at an advanced stage. Early diagnosis and precise therapy of GBC are particularly important for prognosis[1]. The Guidelines for the Diagnosis and Treatment of GBC states that Stage T3 or T4 can be defined accurately with preoperative imaging, such as enhanced multilayer spiral CT or MRI, therefore the patients undergo the corresponding surgical protocol [2]. However, it is challenging to differentiate stage T1 and T2 for GBC with radiological examination, even that the sensitivities of the ability to differentiate the \u0026lt;\u0026thinsp;or =\u0026thinsp;T1 versus \u0026gt;\u0026thinsp;or =\u0026thinsp;T2 lesions is up to 79.3%[8]. Therefore, surgeons have to seek intraoperative frozen pathology to identify the tumor nature and invasion depth of gallbladder neoplasms (GBN) after laparoscopic cholecystectomy[3\u0026ndash;4]. Generally subserous cholecystectomy is performed, which has the potential risk to cause incomplete tumor resection, tumor spread, or inaccurate stage for the patients with T2 stage\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Moreover the patients with T1b or T2 stage tumors are recommended for expanded radical resection to improve survival prognosis\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGallbladder has 3 layers, including mucosa, muscularis, and serosa/adventitia. In the gallbladder fossa, adventitia is composed of collagen, elastic tissue, fat, vessels, lymphatics and nerves, which continues as the cystic plate. Generally this adventitia with the cystic plate is left in the gallbladder bed after subserous cholecystectomy. It has been previously confirmed that Laennec capsule, surrounding all the parenchymal, is free from the visceral peritoneum, adventitia and cystic plate, and inferior vena cava outside the liver, and extends into liver along with the hepatic pedicle and out liver with hepatic veins\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. In 2018 we proposed that Laennec capsule could be used as a landmarker for anatomical hepatic resection, guiding extrahepatic isolation (perihepatic and retrohepatic isolation) and intrahepatic isolation (hepatic pedicle and hepatic vein isolation), which was nominated as the Laennec approach for hepatectomy\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. There is the gap between adventitia/the cystic plate and Laennec capule closing the parenchymal, which may serves as the landmark to dissect the gallbladder from the gallbladder bed.\u003c/p\u003e \u003cp\u003eTherefore, the reasonable protocol, Laennec approach via the cystic plate for laparoscopic cholecystectomy in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, was designed for the potential early GBC. The protocol, including gallbladder dissected completely through the Laennec gap between adventitia/the cystic plate and Laennec capsule together with lymphadenectomy in the Calot triangular, expands the scope and depth of resection, further avoids the risk of tumor destruction, and contributes to the accurate staging of the potential GBC, which in turn allows for timely remedial surgery according to the guidelines. The initial experience and technical details were described as follows.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec3\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eThis study was performed in Nanjing Central Hospital and Drum Tower Hospital. The protocol was approved by the Research Ethics Committee of Nanjing Central Hospital (2021NJCHLL003) and Drum Tower Hospital (2020-310-02), and conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Informed consents were obtained in writing from each patient. Since June 2021, the patients, as the subjects with potential early GBC, were enrolled into this trial. The preoperative diagnosis was dependent on ultrasonography and MRI with contrast. The patients with more than T3 GBC were excluded. Some basic information of six patients was summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003eTable 1\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u0026nbsp;basic information of the paitents in this trial\u003c/p\u003e\n \u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003eDate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003eTumor size (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNo. 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003egallbladder\u0026nbsp;polypoid with stone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003e2020/9/26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eFundus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003e0.8*1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNo. 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003egallbladder\u0026nbsp;polypoid with stone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003e2021/6/11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eFundus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003e1.3*1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNo. 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003egallbladder\u0026nbsp;polypoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003e2021/7/30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eNeck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003e1.1*2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNo. 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003egallbladder\u0026nbsp;polypoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003e2021/10/8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003e1.1*1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNo. 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003egallbladder\u0026nbsp;polypoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003e2021/10/17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003e1.0*1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.23339317773788%\"\u003e\n \u003cp\u003eNo. 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.976660682226212%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.9245960502693%\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.982046678635548%\"\u003e\n \u003cp\u003egallbladder\u0026nbsp;adenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.412926391382406%\"\u003e\n \u003cp\u003e2021/10/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\"\u003e\n \u003cp\u003eFundus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.210053859964095%\"\u003e\n \u003cp\u003e1.6*3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003ch2 class=\"gridtable\"\u003eProcedures\u003c/h2\u003e\n \u003cp\u003eThe patient\u0026apos;s position and Trocar layout was similar to traditional laparoscopic cholecystectomy\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The patient was placed on the table in the supine position. After induction of general endotracheal anesthesia, the abdomen was sterilely prepped and draped. A 10 mm incision was made beneath the umbilicus for laparoscope. A pneumoperitoneum of 15 mmHg was established. Diagnostic laparoscopy was then performed to check the tumor invasion or metastasis. Then 12 mm trocar as the operating port was placed in the xiphoid position, followed by a 5-ram trocar to retract the fundus of the gallbladder upward in the fight lower abdomen. A 5-mm trocar was placed as the first assistant port in the fight subcostal position.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp class=\"Section2\" id=\"Sec4\"\u003eAll patients underwent laparoscopic cholecystecectomy via Laennec approach with lymphadenectomy in Calot\u0026apos;s triangle, which were described as follows in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and the supplemental video 1. To check out metastasis through abdominal exploration, dissect the ventral visceral peritoneum of the Calot\u0026rsquo;s triangle along common bile duct (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA) and the dorsal visceral peritoneum along the right hepatic pedicle (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB), separate and detach the gallbladder artery and gallbladder duct close to the common bile duct, dissect lymph nodes in the Calot triangular (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC), then dissect the visceral peritoneum of the liver close to the gallbladder bed with an electrocoagulation hook, and bluntly separate into the Laennec gap (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), detach the gallbladder plate (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eD), and completely strip the whole gallbladder including adventitia through the Laennec approach (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eE-G), the gallbladder bed is rinsed and hemostated tightly, and bile leakage are carefully examined (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eH). The gallbladder were opened to confirm the tumor site and the depth of the invasion, and to be sent for the frozen pathology. All the procedures were performed by the same attending surgeon (Prof. YU Decai).\u003c/p\u003e\n\u003cp\u003eFurthermore, the samples,including gallbladder and lymph nodes, were sent to the frozen pathological examination. All patients with benighn neoplasms recovered after the frozen pathological examination, while the other patients with malignant neoplasms underwent the coppresonding strategy according to the stage.\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003eProcedure evaluation and followup\u003c/h2\u003e\n \u003cp\u003eThe procedure relevant index, such as frozen pathological results, duration for the key steps, estimated blood loss, bile leakage, morbidity and mortality, were collected. All patients were followed up for six months for morbidity, mortality, and tumor recurrence.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSince June 2021, six patients were enrolled into this study. Among them including 2 men and 4 women, aged 28 to 61 years old, the preoperative diagnosis was gallbladder neoplasm. Ultrasonography and MRI with contrast showed that the tumor size ranged from 1.1 to 3.2 cm, of which 2 cases had gallbladder stones, and usually had occasional right upper quadrant vague pain discomfort, and the remaining 4 cases had no obvious clinical symptoms. Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e illustrated the anatomical hierarchy of laparoscopic cholecystectomy via the Laennec approach The representative MR imagings were presented in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e for Patient No 3. All key index were summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Six patients, as the subjects with potential early GBC, underwent laparoscopic cholecystecectomy based on Laennec approach via the cystic plate with Calot triangular lymph node dissection, which were described in Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and supplemental video 1 with cystic plate dissected first, and in Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e and the supplemental video 2 with cystic plate dissected lastly. The procedure relevant index of the paitents in this trial were summarized in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eTable 2\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eprocedure relevant index of the paitents in this trial\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003eDuration for Calot\u0026rsquo;s triangle dissection (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003eDuration for Gallbladder bed divestiture \u0026nbsp;(mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003ePathological diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eShift strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003eBlood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eBile leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003eDuration of surgery (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eMorbidity ( Clavien-Dindo Classification)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eHospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNo. 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003eInflammatory polyps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNo. 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003eCholesterol polyps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNo. 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003eAdenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNo. 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003eAdenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNo. 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003eT1b Adenocarcinoma without Calot\u0026apos;s lymph node metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003ePortal lymphadenectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eNo. 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003eT2a Adenocarcinoma with Calot\u0026apos;s lymph node metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003eS4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"6.821106821106821%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.90990990990991%\"\u003e\n \u003cp\u003e8.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.454311454311455%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.167310167310168%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.335907335907336%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.850707850707851%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.622908622908623%\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.87001287001287%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.483912483912484%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe frozen pathological examination showed that two cases were adenoma, one cholesterol polyp, one Inflammatory polyp, and two adenocarcinoma. Four patients with benighn neoplasms recovered after the frozen pathological examination. Patient No. 2 with GBC without lymph node metastasis (T1b) underwent the shift strategy with portal lymphadenectomy under laparoscopy. Patient No. 6 with GBC with Calot\u0026apos;s lymph node metastasis, defined as stage IIIB (T2a, N1. M0), underwent the shift strategy with S4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy under laparoscopy.\u003c/p\u003e\n\u003cp\u003eAll procedures were successfully completed under laparoscopy, and the operation time was 25 to 235 minutes with estimated blood loss from 10 to 100 ml, The drainage tube was placed after the operation in two patients with adenocarcinoma. No complications, such as bleeding and bile leakage, occurred. Four subjects with benign neoplasms were discharged on POD 3 for the clinical trial. The patient undergoing portal lymphadenectomy was discharged on POD 5, while the patient undergoing radical resection was discharged on POD 13. There was no recurrence on the patients with adenocarcinoma after six month.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLaparoscopic cholecystectomy based on Laennec approach via the cystic plate was performed in six patients with GBN. The operative index with this approach, such as blood loss and operation duration, was comparing to traditional laparoscopic cholecystectomy. There was no morbidity or mortality. Moreover, all neoplasms were evaluated accurately and coped with the corresponding protocol according to the guideline for GBC. During followup in half a year, there was no recurrent for the patients with adenocarcinoma. Therefore, laparoscopic cholecystectomy based on Laennec approach via the cystic plate was safe and feasible to define the nature and invasion of GBC.\u003c/p\u003e \u003cp\u003eMembranes are anatomical barriers that separate tissues from organs and form the anatomical gap with adjacent organs or tissues, which provides the natural path for surgeons to dissect. The concept of membranous surgery based on membrane structure gradually takes shape\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Laparoscopic cholecystectomy via Laennec approach was performed under the guidance of natural gap between Laennec capsule and the adventitia/cystic plate of the gallbladder. With blunt separation, there were very few branches between gallbladder and liver to be dissected. Membranous anatomy was helpful us to define the surgical level \"Holly Plane\", which facilitates the promotion and standardization of surgical protocols. And it is also conducive to radical tumor resection and improves prognosis\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. We used the suction to keep the field clear, then divest the gallbladder from the bed for about 8 minutes. In this study, four patients have the benign neoplasms, which were dissected safely without morbidity; one patient with GBC adenocarcinoma without lymph node metastasis (T1b) underwent the shift strategy with portal lymphadenectomy under laparoscopy, while one patient with GBC with Calot's lymph node metastasis (T2a) underwent the shift strategy with S4b/5 wedge resection with portal lymphadenectomy and Roux-en-Y hepaticojejunostomy under laparoscopy. Through this approach, the whole gallbladder was dissected to keep the tumor complete, accurately evaluate tumor stage, prevent tumor spread, and select the corresponding protocol, especially for the patients with T1 or T2.\u003c/p\u003e \u003cp\u003eIn addition, lymphadenectomy in Calot's triangle was also included in this protocol. As we know, the rates of lymph node metastasis in T1a, T1b, and T2 patients were up to 7%, 11.1%, and 44.3%, respectively[6]. The actual prevalence of lymph node metastasis was much high after adjusting for the probability of missing nodal disease. It was clearly demonstrated that a relatively large proportion of patients with T1b and T2 GBC might suffer from an occult nodal disease.[7] In this study, the T stage of the patient with GBC was T2a with the positive Calot's lymph node was, while all other lymph nodes were negative. Therefore, it was important for surgeons to perform the lymphadenectomy in Calot's triangle, which was significant to define the accurate N stage and select the accurate the corresponding strategy according to the guideline of GBC.\u003c/p\u003e \u003cp\u003eThis approach was based on the histology of gallbladder. Only six patients were enrolled to testify the safety of this protocol for laparoscopic cholecystectomy at the current phase. Much many patients need to be testified for safety of the operation and feasibility of tumor stage, and long followup need to be testified for the efficiency for over survive. Therefore, we plan to start the perspective cohort study for the patients with potential GBC in our center, which will further testify the feasibility and effectiveness of this approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:This study was performed in Nanjing Central Hospital and Drum Tower Hospital. The protocol was approved by the Research Ethics Committee of Nanjing Central Hospital (2021NJCHLL003) and Drum Tower Hospital (2020-310-02), and conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Informed consent was obtained in writing from each patient\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials：\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and Competing interests：\u003c/strong\u003eThis research was supported by the National Natural Science Foundation of China (ID: 82173129). The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions: \u003c/strong\u003eDecai Yu attended the design of this study and checked this article. Bin Ouyang and Laizhu Zhang participated in the writing and correction of articles. Yajuan Cao, Jin Peng, Zhongjie Xing and Yang Yue attend the operation of these patients. The main operator was Decai Yu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Informed consent of all authors for the writing and submission of the article\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWu Xin,Li Binglu,Zheng Chaoji, et al. Incidental gallbladder cancer after laparoscopic cholecystectomy: incidence, management, and prognosis.[J]. Asia Pac J Clin Oncol, 2020(3): 158-164.\u003c/li\u003e\n\u003cli\u003eAgresta F, Campanile FC, Vettoretto N, et al. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg. 2015 May;400(4):429-53.\u003c/li\u003e\n\u003cli\u003eAndo Takuya,Sakata Jun,Nomura Tatsuya, et al. Anatomic location of residual disease after initial cholecystectomy independently determines outcomes after re-resection for incidental gallbladder cancer.[J]. Langenbecks Arch Surg, 2021(5): 1521-1532.\u003c/li\u003e\n\u003cli\u003eVinuela Eduardo,Vega Eduardo-A,Yamashita Suguru, et al. Incidental Gallbladder Cancer: Residual Cancer Discovered at Oncologic Extended Resection Determines Outcome: A Report from High- and Low-Incidence Countries.[J]. Ann Surg Oncol, 2017(8): 2334-2343.\u003c/li\u003e\n\u003cli\u003e[Guideline for the diagnosis and treatment of gallbladder carcinoma (2019 edition)].[J]. Zhonghua wai ke za zhi [Chinese journal of surgery], 2020(4): 243-251.\u003c/li\u003e\n\u003cli\u003eYang Yingnan,Tu Zhuolong,Cai Huajie, et al. A predictive nomogram for lymph node metastasis of incidental gallbladder cancer: a SEER population-based study.[J]. BMC Cancer, 2020(1): 828.\u003c/li\u003e\n\u003cli\u003eHuang Xi-Tai,Huang Chen-Song,Li Jian-Hui, et al. Evaluating the adequacy of nodal status in node-negative gallbladder cancer with T1b-T2 stages: use of nodal staging score.[J]. HPB : the official journal of the International Hepato Pancreato Biliary Association, 2020(5): 795-801.\u003c/li\u003e\n\u003cli\u003eKim Soo-Jin,Lee Jeong-Min,Lee Jae-Young, et al. Accuracy of preoperative T-staging of gallbladder carcinoma using MDCT.[J]. AJR. American journal of roentgenology, 2008(1): 74-80.\u003c/li\u003e\n\u003cli\u003eJoo Ijin,Lee Jae-Young,Baek Jee-Hyun, et al. Preoperative differentiation between T1a and \u0026ge;T1b gallbladder cancer: combined interpretation of high-resolution ultrasound and multidetector-row computed tomography.[J]. European radiology, 2014(8): 34-1828.\u003c/li\u003e\n\u003cli\u003eGong J-P. [Scientific paradigm of membrane anatomy].[J]. Zhonghua wei chang wai ke za zhi ,Chinese journal of gastrointestinal surgery, 2021(7): 557-559.\u003c/li\u003e\n\u003cli\u003eZhao Y-Z,Zhang X-J. [Re-recognition and thinking of membrane anatomy].[J]. Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery, 2021(12): 1119-1121.\u003c/li\u003e\n\u003cli\u003eSugioka Atsushi,Kato Yutaro,Tanahashi Yoshinao. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec\u0026apos;s capsule: proposal of a novel comprehensive surgical anatomy of the liver.[J]. Journal of hepato-biliary-pancreatic sciences, 2017(1): 17-23.\u003c/li\u003e\n\u003cli\u003eHu Yue,Shi Jiong,Wang Shaohe, et al. Laennec\u0026apos;s approach for laparoscopic anatomic hepatectomy based on Laennec\u0026apos;s capsule.[J]. BMC Gastroenterol, 2019(1): 194.\u003c/li\u003e\n\u003cli\u003eThapar P, Salvi P, Killedar M, et al. Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study. Surg Endosc. 2021 Aug;35(8):4231-4240.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Laennec approach, csytic plate, Laparoscopic cholecystectomy, Gallbladder neoplasms; patient safety","lastPublishedDoi":"10.21203/rs.3.rs-1711939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1711939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e It is still challenging to define the exact stage of early gallbladder carcinoma with preoperative imaging. Generally subserous gallbladder is dissected for the potential early gallbladder carcinoma, which may cause incomplete tumor resection or tumor spread especially for the patients with T2 stage. Here, we reported our experience and safety of Laennec approach via the cystic plate to dissect the whole gallbladder with lymphadenectomy in Clot’s triangle for accurate diagnosis and staging in gallbladder neoplasms.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e The anatomical gap between Laennec capsule and the cystic plate serves as the landmark to dissect the whole gallbladder through Laennec approach. Laparoscopic cholecystectomy based on Laennec approach via the cystic plate, together with lymphadenectomy in Calot’s triangular, was performed in 6 patients with gallbaldder neoplasms. \u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eAll patients had less intraoperative bleeding, no gallbladder breakage, no bile leakage, and accurate intraoperative rapid pathological staging under the corresponding strategies. The duration of surgery was comparable to that of traditional laparoscopic cholecystectomy. \u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e Laparoscopic cholecystectomy based on Laennec approach via the cystic plate, together with lymphadenectomy in Calot’s triangular is safe for gallblader neoplasms. In the future, the prospective clinical trial is going on to confirm the feasibility and effectiveness in the therapy of early gallbladder.\u003c/p\u003e","manuscriptTitle":"Laparoscopic Cholecystectomy Based on Laennec Approach via the Cystic Plate with Lymphadenectomy in Calot's Triangle for Gallbladder Neoplasms：initial experience and technical details","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-15 17:01:02","doi":"10.21203/rs.3.rs-1711939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6de69a4d-810c-4ac3-b66a-ca4673412879","owner":[],"postedDate":"June 15th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-10-18T08:45:02+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-15 17:01:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1711939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1711939","identity":"rs-1711939","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}