*4.1.1.2 Locally advanced tumors >T2*

The extent of liver resection remains controversial. Thus, an IVb-V bisegmentectomy or a more extensive hepatic resection of the trisegmentectomy type may be proposed, and for tumors invading the hepatic pedicle, an enlarged right hepatectomy or a central hepatectomy (IV, V, VIII) associated with a segment I resection. Segment I resection is especially useful for tumors invading the hepatic hilum. Direct invasion of the colon, duodenum or liver is not an absolute contraindication to resection, but the morbidity and mortality of these combined resections are high. Ganglion dissection should include extensive resection of the hepatic pedicle ganglia, anterior and posterior pancreatic ganglia and peeling of the hepatic artery until birth in the celiac trunk. Some authors recommend extensive curling, extended to the celiac trunk, to the trunk of the superior mesenteric artery down the anterior aspect of the aorta (para-aortic ganglia). Involvement of the hepatic pedicle and the main bile duct is early in gallbladder cancer without necessarily having a clinical impact (jaundice) or contact with the tumor [22]. In addition, removal of the main bile duct facilitates nodal dissection of the hepatic pedicle. It is therefore recommended for tumors >T2.

#### *4.1.1.3 Palliative surgery*

Surgical biliary shunts (and trans-tumor intubations) have not been demonstrated superior to prosthetic drainage in terms of quality of life or survival time. Their mortality (>25% in several series) and their morbidity are not negligible. However, the surgical biliary drainage usually allows prolonged palliation to the entire survival patients [22].
