Surgical resection offers the only potentially curative therapy for gall bladder cancer [11]. Surgery is indicated in Stage 0–II, i.e. Tis, T1, T2, N0 where it may be curative. Periaortic, pericaval, superior mesenteric artery and/or coeliac lymph node involvement (i.e. N2 disease) has a prognosis similar to patients with distant metastasis. This group constitutes unresectable disease (Table 3.2).

For T1a tumours, i.e. invading the lamina propria without muscular layer involvement, a simple cholecystectomy is adequate and offers cure rates of 73–100% [12, 13]. Patients diagnosed with incidental T1a gall bladder carcinoma after a laparoscopic cholecystectomy do not require re-resection as it does not offer any survival advantage [14].

Lymph node metastasis occurs in 15 and 62% of patients with T1b and T2 tumours, respectively [15, 16]. These patients benefit from extended or radical cholecystectomy which involves resection of the gall bladder with an en masse liver wedge resection and periportal lymphadenectomy. An intraoperative frozen section of the cystic duct margin is mandatory. Failure to achieve a negative margin at the cystic duct or frank involvement of the extrahepatic bile duct warrants an extrahepatic biliary tract excision with hepaticojejunostomy. An incidental diagnosis of T1b/T2 gall bladder cancer after simple cholecystectomy warrants a re-resection or revision radical cholecystectomy.

Stage III and Stage IVa, i.e. tumours involving adjacent organs like the stomach, duodenum colon, pancreas and the extrahepatic biliary tree, may be resectable in a selected group of patients. Surgery in this situation entails en masse resection of the involved organs and is best reserved for the fit patient at a high volume centre. Although prognosis remains guarded for this group of patients, retrospective series report favourable survival for these patients if an R0 resection can be achieved [17, 18]. However, the majority of Stage IVa tumours have involvement of the hepatic artery or portal vein rendering them unresectable. There is no role for debulking surgery; surgical exploration should only be undertaken if an R0 resection is feasible.

Although surgery offers the only option for long-term control of cholangiocarcinoma, the 5-year survival rates are very poor, especially for node-positive disease even if an R0 resection is achieved. Resectability rates depend not only on tumour location but equally on the available surgical expertise as these are very specialized surgical procedures. Resectability rates for distal, intrahepatic and perihilar lesions have been reported as 91%, 60% and 56%, respectively [19].

Intrahepatic cholangiocarcinomas are managed by a formal hepatic resection and distal cholangiocarcinomas are resected with a pancreaticoduodenectomy. Perihilar tumours are the most surgically challenging. Even at high volume centres, resectability rates are less than 50%. Resection of the extrahepatic bile ducts alone leads to high rates of local recurrence either at the confluence of the hepatic ducts or at the caudate lobe branches. Addition of a hepatectomy with a caudate lobectomy improves outcomes [20, 21]. The type of surgical resection depends on the Bismuth subtype. For type I and II tumours, the procedure involves an en bloc resection of the extrahepatic ducts (with a 5–10 mm margin) with the gall bladder, regional lymphadenectomy and hepaticojejunostomy. A hepatic lobectomy is often required to achieve adequate margins on the bile ducts. Type III lesions usually require an additional lobectomy or trisectionectomy. As the caudate lobe branches are frequently involved in type II and III tumours, most centres recommend a caudate lobectomy in these patients. Extended resections involving the portal vein and/or multiple hepatic resections can be offered for the select few with type III and IV tumours at centres of excellence [22].