Questions to be addressed:
- Are there stones?
- Is there any pathology?
- Is there tumor?
- Measure the length and greatest diameter of gallbladder and length and diameter of cystic duct. Note whether the specimen is intact or it was previously opened. Describe the serosal surface (Color? Texture? Thickened? Fibrous adhesions? Fibrin? Gangrenous?). Mention if a portion of liver is attached.
- Open entire organ longitudinally through the serosal surface, beginning at the fundus, extending at least partially into the cystic duct. Describe the contents of the gallbladder (bile, mucus, stones) and estimate volume. Measure the thickness of the wall. Describe the mucosal surface and wall (Velvety and maroon? Granular and yellow?).
- If stones are present, estimate their number and size (give a range of sizes). Describe their appearance (black, brown, tan; multifaceted, round; hard, chalky). Note if any stones are located in the cystic duct.
- Search for lymph nodes along the gallbladder neck.
- If neoplasia is suspected, ink the cauterized (adventitial) margin (rough surface) and cystic duct margin. Describe relationship of tumor to the margins (cauterized and cystic duct) and the serosal surface. Describe the lesions (Polypoid? Diffuse thickening of the wall, i.e., porcelain gallbladder? Focally thickened wall? Depth of invasion estimate on gross--into muscle, through muscle, through muscle and at deep margin?).
- Sections for benign/routine gallbladder:
- Three full thickness sections (one each from the fundus, body, and cystic duct), placed in one cassette.
- Additional sections for non-routine gallbladder:
- Other lesions (such as polyps or ulcerations), if present
- The cystic duct lymph node, if present
- If neoplasia is suspected:
- Inked deep and cystic duct margins
- Sections of the tumor (1 section per cm of tumor, or entire tumor) demonstrating relationship to critical structures (margins, serosal surface, adventitial margin)
The specimen is received following formalin fixation, labeled with the patient's name and medical record number, designated "_". The specimen consists of a gallbladder measuring _ x _ x _ cm. The serosal surface is _ (ie. smooth and glistening without any defects or masses). The gallbladder is opened to reveal _ (ie. viscous green bile and numerous multifaceted white/grey/black stones measuring _ cm in diameter to _ cm in diameter). The wall is _ cm thick and slightly edematous. The mucosal surface is _ (ie. green and velvety with focal punctate (1 mm) ulcerations). No masses are identified. No lymph nodes are present. Representative sections from the fundus, body and cystic duct are submitted in one cassette as "1A."
Review and SignoutEdit
Include the presence of cholelithiasis in the diagnosis line. If there is tumor, make sure the adequate staging features are noted.
- Gallbladder, cholecystectomy:
- Gallbladder with no specific pathologic change.
- Chronic cholecystitis.
- Chronic cholecystitis with cholelithiasis.
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