PMC3930071_01
Preoperative Diagnostic. (A) Preop.-CT scan. A hypodense pseudocystic mass on the 5th liver segment, mimicking abscessed gallbladder cancer (bile stones are recognizable on the hilar part of the tumor). (B) MRI scan. Bubbles of free air inside the "tumour".
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F1
An ultrasound scan of the liver and an abdominal CT scan (Figure 1A) detected a disomogeneous hypoechoic-hypodense mass with many internal hyperechoic/hyperdense stones in the 5th segment of the liver.
Intraoperative finding: Intrahepatic perforation of the gallbladder. Due to strong hilar adhesions and structure visualization difficulties in laparoscopic view (A), a conversion to "open" approach was decided (B).
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F2
Laparoscopy showed a bulging lesion involving the gallbladder, liver, great omentum and duodenum, (Figure 2A) while no signs of peritoneal carcinomatosis were detected. After resection of the omental adhesions and the spearing of the duodenum, the bulging was resected en-bloc with the gallbladder (Figures 2B-3) and gallbladder bed performing an atypical resection of the 5th hepatic segment.
Specimen examination. A) A typical partial resection of the 5th Segment en-bloc with the gallbladder. Intrahepatic position of the gallbladder. B) Macroscopic details of the pathologic specimen: intrahepatic position of the gallbladder. C) Microscopic detail of the specimen (Zoom 10 X): chronic inflammatory cells (giant plurinucleated cells) mixed with hepatic regeneration nodes in the context of a granuloma under the gallbladder bed, effect of intrahepatic perforation. (Courtesy of Dr. Loredana Villari. Pathology Institute. Vittorio-Emanuele Hospital. Catania.).
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F3
After resection of the omental adhesions and the spearing of the duodenum, the bulging was resected en-bloc with the gallbladder (Figures 2B-3) and gallbladder bed performing an atypical resection of the 5th hepatic segment. The phlogistic nature of the tumor was histologically confirmed by three intra-operative sections (later frozen) and on the definitive histologic examination (Figure 3B, C).