|Year : 2019 | Volume
| Issue : 1 | Page : 9-13
Safety and feasibility of elective laparoscopic cholecystectomy in liver cirrhosis with portal hypertension
Akhter Ganai1, Majid Mushtaque1, Sheikh Junaid1, Arshad Rashid2
1 Department of Surgery, District Hospital Budgam, Kashmir Health Services, Srinagar, Jammu and Kashmir, India
2 Department of Surgery, District Hospital Budgam, Kashmir Health Services; Department of Surgery, Government Medical College and Associated Hospitals, Srinagar, Jammu and Kashmir, India
|Date of Submission||28-May-2019|
|Date of Acceptance||28-May-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Arshad Rashid
G 22, Green Lane, Shah Anwar Colony, Hyderpora, Srinagar - 190 014, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Aims: The aim of the present study was to evaluate the safety of laparoscopic cholecystectomy in patients with liver cirrhosis and portal hypertension.
Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of six years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The diagnosis of cirrhosis was made based on preoperative workup, intraoperative findings, and histo-pathological study based on liver biopsy. The outcomes of laparoscopic cholecystectomy in patients with cirrhosis were compared to those without it with regards to perioperative morbidity and mortality.
Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them 42 patients were diagnosed to have features of cirrhosis and portal hypertension after laparoscopy and subsequently 36 were confirmed to have cirrhosis on histopathology. There were 15 males and 21 females in these 36 patients. The diagnosis of cirrhosis was established preoperatively in 21 patients. The operative time and hospital stay were significantly increased in the cirrhotic group. None of our patients in the cirrhotic group required conversion. Perioperative complications were seen more often in the patients with cirrhosis [5 (13.89%) versus 207 (6.69%); P value = 0.0126]. Ascites was the most frequent post-operative complication seen in cirrhotic patients.
Conclusion: Laparoscopic cholecystectomy, though technically demanding in cirrhotic patients can be safely done even in a peripheral health set-up with acceptable morbidity rate.
Keywords: Cavernoma, cholecystectomy, cirrhosis, laparoscopic, portal hypertension
|How to cite this article:|
Ganai A, Mushtaque M, Junaid S, Rashid A. Safety and feasibility of elective laparoscopic cholecystectomy in liver cirrhosis with portal hypertension. Saudi J Laparosc 2019;4:9-13
|How to cite this URL:|
Ganai A, Mushtaque M, Junaid S, Rashid A. Safety and feasibility of elective laparoscopic cholecystectomy in liver cirrhosis with portal hypertension. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 18];4:9-13. Available from: http://www.saudijl.org/text.asp?2019/4/1/9/267853
| Introduction|| |
Gallstone disease is more common in patients with cirrhosis of the liver. Its incidence is 29.4% in patients with cirrhosis when compared with 12.8% for those without it. This increased incidence is presumed to be because of various physiological alterations in the hepatobiliary system due to increased pressure in the portal veins. The various factors that have been implicated are gallbladder dysmotility in the fibrous transformed liver, reduction in bile acidity, increased unconjugated bilirubin secretion, and increased intravascular hemolysis due to hypersplenism.
Laparoscopic cholecystectomy is the gold standard procedure for symptomatic gallstones. Despite its many advantages over open cholecystectomy, surgeons have been circumspect in offering it to patients with documented portal hypertension and cirrhosis. In fact, portal hypertension is considered as a relative contraindication to laparoscopic cholecystectomy. With the ever-increasing experience of surgeons with laparoscopy, many tertiary care centers reported on the successful outcome of laparoscopic cholecystectomy in patients with cirrhosis.,, However, to the best of our knowledge, no paper has reported on this outcome from district or sub-district hospitals. The current paper is an attempt to determine the safety of laparoscopic cholecystectomy in the elective setting in biopsy-proven cases of liver cirrhosis with portal hypertension in peripheral health-care facilities.
| Materials and Methods|| |
Ours was a prospective study conducted in three hospitals (two district-level and one subdistrict-level) of the Department of Health Services, Kashmir, over a period of 6 years from February 2013 to February 2019. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. Four well-experienced laparoscopic surgeons (the authors) operated the patients. Laparoscopic cholecystectomy was performed using Image One high-definition camera supplied by Karl Storz, Germany, mounted on a Hopkins II 30 laparoscope. The video was visualized on a high-definition wide-screen monitor (Karl Storz, Germany). All the procedures were recorded for subsequent review. The pneumoperitoneum was created by open method by a subumbilical incision using the umbilical cicatrix tube. A standard 4-port cholecystectomy was done with subtle modifications, mentioned in the discussion part, as and when needed. A subhepatic drain was kept in place in all the cases. All the patients were followed up on an outpatient basis every weekly for three visits.
The diagnosis of cirrhosis was made based on preoperative workup, intraoperative findings [Figure 1] and [Figure 2], and histopathological study. Liver biopsies were taken generally from an area on the anterior surface of the left lobe of the liver or of macroscopic suspect areas using a core biopsy needle supplied by BARD, inserted through a separate 2-mm skin incision, at least 2 cm from the liver edge, containing at least five portal areas. Macroscopic diagnosis of cirrhosis was made based on the following criteria: (1) diffuse nodules on the liver surface or (2) shallow nodules (i.e., nodules usually of large diameter, slightly protruding from the liver surface) if the liver was hard on palpation and rigid on lifting with a blunt probe and if clear-cut features of portal hypertension were observed. Histological activity index was used to confirm the diagnosis of cirrhosis.
|Figure 1: Omental adhesions with the parietal wall showing neovascularization with portosystemic collaterals. In the background a nodular liver is visible|
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|Figure 2: Difficulty in exposing the Calot's triangle as the liver is fibrotic and stiff in cirrhosis|
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The outcomes of laparoscopic cholecystectomy in patients with cirrhosis were compared to those without it with regard to perioperative morbidity and mortality. An approval from the institutional ethical committee was obtained for the purpose of this study. Written and informed consent was taken from the patients for publication and analysis of their data after explaining to them the protocol of the study in their own language. The data thus collected were compiled and analyzed using SPSS version 21 for Mac (IBM Corporation, New York, USA). To calculate the P value, Fisher's exact test and Pearson's Chi-square test were applied to compare the frequencies for categorical parameters, and the unpaired t-test was used to compare the means (two-tailed) among continuous variables. The results were calculated on 95% confidence interval. A P < 0.05 was considered statistically significant.
| Results|| |
During the study period, a total of 3127 laparoscopic cholecystectomies were performed. Out of them, 42 patients were diagnosed to have features of cirrhosis and portal hypertension after laparoscopy, and subsequently, 36 were confirmed to have cirrhosis on histopathology. There were 15 males and 21 females in these 36 patients. The diagnosis of cirrhosis was established preoperatively in 21 (58.34%) patients. The patients with cirrhosis and portal hypertension were significantly older than the noncirrhotic patients (57.36 8.61 versus 46.13 14.35 years) and women predominated in the latter group. Patients with cirrhosis were more likely to have other associated medical comorbidities, such as diabetes, hypertension, and chronic hepatitis. The demographic profile of the patients is given in [Table 1].
The operative time was significantly increased in the cirrhotic group [Table 2]. None of our patients in the cirrhotic group required conversion. Perioperative complications were seen more often in the patients with cirrhosis (5 [13.89%] vs. 207 [6.69%]; P = 0.0126). Although morbidity was significantly more in the cirrhotic group, it did not translate into any mortality. We did not encounter any biliary injury or major bleeding in the patients with cirrhosis and portal hypertension. The various perioperative complications encountered are given in [Table 3].
| Discussion|| |
Surgery as a science is a constantly evolving subject. The contraindication of yesterday becomes an indication today. Same is the case with laparoscopic cholecystectomy in case of patients with cirrhosis. Once considered as a contraindication, the safety of laparoscopic cholecystectomy has been well documented in many well-conducted studies and meta-analysis.,,,,,,,,, All of these studies have reported outcomes from university-based centers and tertiary care hospitals. To the best of our knowledge, ours is the first study documenting the feasibility of laparoscopic cholecystectomy in cirrhotic patients in a peripheral health set-up.
We had a preoperative diagnosis of cirrhosis in 21 patients. Those patients were optimized before surgery by adequate hydration and by maintaining their coagulation profile. Performing a successful laparoscopic cholecystectomy in patients with portal hypertension and liver cirrhosis is technically demanding.,, The various factors that we observed contributing to this challenge were fibrotic stiff liver (n = 36), enlarged left lobe resulting in a more lateral position of gall bladder (n = 23), presence of venous collaterals around porta including cavernoma (n = 9), increased vascularity of gall bladder bed (n = 17), and subclinical coagulopathy (n = 12). However, we did not encounter any neovascularization around umbilicus as has been described by Shaikh and Muneer.
Fibrotic liver leads to decreased liver compliance as such retraction of gallbladder fundus to expose Calot's triangle becomes difficult. We circumvented this problem by using a 6-inch gauze-piece kept over the hepatoduodenal ligament that pushed the liver away from the Calot's triangle, resulting in its better exposure. An additional 5-mm port, inserted between the epigastric and subcostal port, was used sometimes (n = 7) to improve exposure by means of a nontraumatic liver retractor, especially in the setting of a hugely enlarged left lobe. In the event of intraoperative difficulty in cirrhotic patients, some authors have mandated the use of subtotal cholecystectomy;, however, we did not find any need of such modification in our patients.
As expected, the overall perioperative morbidity was more in the cirrhotic group. However, contrary to the published data,,,,,,, we did not encounter any major bleed in this group. We ascribe this to the fact that bipolar energy and ultrasonic energy source was used liberally in such patients, and we made a concerted effort to stick to the proper plane during dissection from liver bed. The use of ultrasonic energy devices for controlling difficult liver bed has been described earlier also.,, The gauze-piece that we used for retraction and lifting the liver from Calot's triangle also served as a landmark of the portal area, avoiding inadvertent injury to the portal venous collaterals in cirrhotic patients. In a study by Laurence et al., the mortality rate for patients with cirrhosis who underwent laparoscopic cholecystectomy was 0.8%; however, there were no in-hospital deaths in either group in our study.
Ascites was the most frequent postoperative complication seen in the cirrhotic group. It presented as persistent drainage of serous transudative fluid from the drain and was managed by restricting sodium and using oral diuretics (spironolactone 25 mg QID). Ascites increases the risk for wound dehiscence, intra-abdominal infection, and respiratory insufficiency. However, we did not encounter any of these complications in our patients. Preoperative administration of diuretics has been advocated to limit the development of ascites. Published literature reveals an increased incidence of biliary injuries in cirrhotic patients;,, however, we did not encounter any such event in our cirrhotic patients. This may be explained on the basis of lesser number of patients in the cirrhotic arm and the extra care taken to dissect the Calot's triangle. The gauze-piece also served as a maker of common bile duct.
Laparoscopic cholecystectomy in cirrhotic patients ensures a quicker recovery and increases the patients' tolerability to the procedure. It has not escaped our mind that performing a laparoscopic cholecystectomy in such patients is safer for the surgical team, as most of these patients are infected with hepatitis B and C virus and there are lesser chances of contact with patient's blood and viscera. The access to the abdomen by small ports reduces the incidence of ascites leak from surgical wound and the incidence of ascites infection, since it decreases inadvertent bacterial seeding and contamination of ascites. The magnified view gained in laparoscopy with current optics and high-definition monitors allows the identification of portal vein collaterals avoiding, thereby injury and bleeding. As less of adhesions are formed in laparoscopic surgery, future surgical procedures required are less challenging. It is particularly important as most of these patients end up with hepatic failure and more often than not land up with a transplant.
One of the limitations of the current study is that it was not a randomized controlled study, but we enrolled all the patients planned for laparoscopic cholecystectomy, irrespective of them being cirrhotic or noncirrhotic during the study period, thus trying to minimize the selection bias. The strength of our study is that only those patients with histopathologically proven cirrhosis were taken in the cirrhosis arm. The other strength of our study is that well-experienced surgeons who had completed their learning curve did the cholecystectomies, irrespective of the state of liver cirrhosis. Ours was a multicenter study adhering to a single robust protocol, thereby adding to the strength of the study.
| Conclusion|| |
Patients with cirrhosis undergoing cholecystectomy have a higher incidence of postoperative complications than patients without cirrhosis. Our study demonstrates that laparoscopic cholecystectomy, though technically demanding in cirrhotic patients, can be safely done even in a peripheral health set-up with acceptable morbidity rate. The technical challenges can be offset by proper instrumentation and expertise. However, appropriate preoperative optimization and meticulous intraoperative techniques are quintessential for safer results.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]