Early part of the eighteenth century was the beginning of surgery for biliary diseases. In 1743, Jean Louis Petit, Paris, coined the term “biliary colic” (“colique hepatique”). He presented his seminal paper at the Paris Surgical Academy entitled “Considerations Concerning Tumors Produced by Retained Bile in the Gallbladder….” [7]. In the United States, John Bobbs [8] is credited with the first cholecystostomy in Indianapolis in 1867. A decade later in 1878, Theodore Kocher in Berne, Switzerland, who was trained under Billroth and Langenbuch did his cholecystostomy in two stages [9]. The Kocher maneuver named was first used for gastric surgery, and only later utilized for biliary surgery by Vautrin. Kocher also pioneered internal choledochoduodenostomy to remove common bile duct calculi. Along with Dr. Matti, he wrote the book Hundert Operationen an den Gallenwegen (A hundred operations on the bile ducts). Carl Langenbuch of Germany is credited with performing the first cholecystectomy at the Lazarus Hospital in Berlin in July, 1882 [10]. George Pack in 1955 was the first to report 3 cases, where radical liver resection (right hepatic lobectomy) along with portal lymph node dissection was performed for the treatment of gallbladder cancer [11].

Toward the end of the twentieth century in 1985, Prof Dr Med Erich Muhe of Böblingen, Germany, did the first laparoscopic cholecystectomy [12]. Since then it has become the gold standard for removal of gallbladder for benign disease. At present, surgeons use other minimally invasive techniques to remove the gallbladder [13, 14]. Biliary surgery continues to evolve with the help of advancements in imaging with ultrasound in liver and biliary surgery [15], computerized tomography (CT) scan of the liver [16] and magnetic resonance (MR) imaging [17]. After popularization of laparoscopic cholecystectomy, there is a new presentation of gallbladder cancer, namely after minimally invasive cholecystectomy. The number of incidental cancers detected in the pathology specimen is approximately one for every hundred gallbladders that are removed for a presumed benign etiology [7].

Anatomically, the gallbladder lies in the subhepatic area close to Couinaud’s liver segments 4b and 5. The GB wall is composed of an innermost layer of mucosa which is lined by simple columnar epithelium; beneath this is a layer of lamina propria. The GB wall lacks submucosa. A layer of muscular tissue (smooth muscle) is present beneath the lamina propria. The outermost layer is made up of thick connective tissue called adventitia which is present in the area where GB is attached to the liver tissue (GB bed). In the unattached area, facing the free peritoneal cavity, there is an outer layer of mesothelium and loose connective tissue called serosa. The subserosal plane is the least bloody plane of dissection during routine cholecystectomy. The cystic plate is the gallbladder serosa on the liver which is usually left behind after dissection in the subserosal plane. According to American Joint Committee on Cancer staging, the lymph nodal station N1 is defined as regional (hepatic hilus) which corresponds to nodes around cystic duct, common hepatic duct, portal vein and hepatic artery. N2 station refers to metastases nodes around celiac artery, superior mesenteric artery, periduodenal and peripancreatic nodes.

GB cancers spread by direct extension to contiguous structures or via veins draining segments IV and V to the liver. GB cancer can also spread to regional lymph nodes and to the peritoneal cavity by direct extension or after bile spillage. In addition, GB cancer has a propensity to seed and grow along needle track sites, including port sites. GB cancers very rarely metastasize via blood stream.

There are three common presentations of GB cancer. The most common is a presentation as incidental gallbladder cancer. As such, it may be (a) detected during surgery (cholecystectomy) or (b) detected on postoperative pathology review of the resected gallbladder specimen. Gallbladder cancer can also be detected as a large invasive mass in GB fossa detected on imaging. Finally, it may be detected as a small mass or polyp in the GB found on preoperative imaging. These presentations will be discussed separately.

IGBC refers to GB cancer discovered incidentally at the time of surgery (cholecystectomy) or detected postoperatively in the GB specimen removed for a presumed benign pathology.

Since the liberal use of laparoscopic technology for cholecystectomies in the early 1990s, there is increased detection of GB cancers. In a study by [18], almost 50 % of the cancers were discovered incidentally. If suspicion of gallbladder cancer arises during initial laparoscopic surgery for presumed gallstone disease or cholecystitis, intraoperative staging should be done. Metastatic disease should be ruled out by sending frozen section on any suspected lesion or lymph node. A thorough laparoscopic examination of the abdominal cavity should be done. The exploration should include inspection of the liver, including intraoperative ultrasound, gastrohepatic ligament, porta hepatis, pelvis and peritoneal cavity. Additionally, frozen section of the gallbladder should be sent when the diagnosis is in doubt, after resection, and to confirm negative margins. In one study, frozen section biopsy had an accuracy of 88 % [19] and sensitivity and specificity of over 90 and 100 %, respectively [20]. However, the accuracy of T stage which is critical for management though is less than 100 % [20].

If frozen section confirms GB malignancy and the lesion is resectable, then an extended cholecystectomy should be performed after conversion to an open procedure [21]. If expertise is not available, then surgery should be deferred. The patient should then be transferred to an experienced center. Such approach is reasonable and does not affect the prognosis [22, 23].

The most common presentation of early GB cancer is incidental discovery after unsuspected cholecystectomy in the pathology specimen. In a study by Duffy et al., 47 % of the GB cancers were detected after laparoscopic cholecystectomy [24, 25]. In those patients, a careful review of the GB specimen for the level of invasion (T staging), assessment of resected margins and search for malignancy in the nodes if any retrieved is important. Also, these patients need to be worked up carefully to rule out any metastatic disease. Documentation of spillage of bile or gall stones during the initial surgery must be done, as GB cancer is notorious to spread and recur at port sites and peritoneal surfaces. Further management after cholecystectomy is based on staging and surgical margins.