Page 11 - Journal of Laparoscopic Surgery

WJOLS

Role and Advantages of Laparoscopic Surgery in Liver Cirrhosis

surgery is definitely not safe in patients with cirrhosis as it is The major risk in cirrhotic is transmission of hepatitis B
associated with a high rate of morbidity and mortality due to and/or C virus in cirrhotic from the patient to the operating
associated malnutrition, coagulopathies and ascites. But a team. Hence, a safe disposal of sharps and gentle and meticulous
review of articles proved that laparoscopy is safer than open transfers of instruments are key to the safety.
surgery in mild to moderate cases of cirrhosis. As said earlier, patience during operation makes it safe and
This study reviewed: meticulous hemostasis will prevent the unavoidable blood loss
• The risk of laparoscopy and laparoscopic surgery in in patients with cirrhosis.
cirrhotic patients, An open technique (Hassan’s trocar) for access to prevent
• Previous role and current trends in the use of laparoscopy inadvertent puncture of an umbilical varix or placement of trocar
in the diagnosis of liver cirrhosis, and away from umbilicus in whom the umbilical varices are evident,
• Safety and efficacy of laparoscopy in the treatment of various is another precaution that can be taken. 11
surgical conditions in cirrhotic patients. Modification of surgery in the form of subtotal
cholecystectomy, use of ultrasonic energy like harmonic scalpel,
SAFETY CONSIDERATIONS IN CIRRHOTIC glue, oxidized cellulose are other means to prevent more
PATIENTS UNDERGOING LAPAROSCOPIC bleeding. 11
PROCEDURES
Factor 1: The Surgeon ROLE OF LAPAROSCOPY IN DIAGNOSIS OF
LIVER CIRRHOSIS
A tremendous amount of patience is necessary during the
procedure because conversion does not help to control the Historically, histopathology of the biopsied liver specimen has
coagulopathy which is the main danger in cirrhosis (Schiff et al been the gold standard of the diagnosis of cirrhosis of liver.
8
2005). During their study, they converted 3 out of 24 The danger associated with the invasive procedures made
laparoscopic procedures in cirrhotics, two were due to surgeon’s surgeons cautious in performing those procedures. Hence, other
inexperience. Hence, the experience of surgeon plays a key role biochemical and indirect tests were performed to give evidence
in performing a safe surgery in patients with cirrhosis of liver. as to the status of liver. Ultrasound provided a good
noninvasive means but its ability to diagnose early cirrhosis is
Factor 2: Anesthetic Techniques debated. It can very well provide clue to the damaged liver in
As such, an adequate circulation and volume maintenance is the form of architectural damage and portal engorgement in
the key to a successful anesthesia in all cases. It does not advanced stage of disease, but its ability to diagnose cirrhosis
change in cirrhotics as hepatosplanchnic perfusion may be in early stage is debatable. Moreover, it gives false-positive
impaired in cirrhotic cases. But certain drugs like isoflurance results of metastatic disease in some cases of macronodular
increase hepatic regional blood flow, halothane is noted of cirrhosis.
increase hepatic arterial resistance. Fentanyl, vencuronium and Laparoscopy has an advantage over other diagnostic means
pancuronium do not significantly affect hepatic blood flow and especially in liver cirrhosis. It gives a visual impression of the
may be preferable in cirrhotic patients. 9 severity of the case and also macroscopic evidence of the
destruction of liver. Direct visualization of both lobes of liver
Factor 3: Preoperative Preparation gives a comprehensive view of the amount of liver diseased by
In elective surgery, a good preoperative preparation is surgery cirrhosis. A biopsy performed laparoscopically has the
half done. No words can describe the importance of recognition advantage of taking the specimen under direct vision and not
of coagulopathies by proper investigations and correcting them blindly as taken by needle biopsy which may not hit the target
prophylactic Vit-K administration and/or transfusion with fresh and falsely give a negative report though there may be
frozen plasma, lowering of portal hypertension with medications, cirrhosis. 19
maintain adequate fluid and electrolyte balance and control of Laparoscopy also allows application of direct pressure or
10
infection if present. Garrison et al (1984) had identified absolute a heater probe to attain hemostasis in the event of bleeding
serum albumin concentration, presence of infection or from a biopsy site and may hence be carried out safely
contamination and number of seconds partial thromboplastin despite hematological abnormalities (e.g. PTR > 1.3; platelet
3
time is deviated from its control value as the three main < 80,000/mm ) which routinely contraindicate blind
preoperative variables that predict surgical outcome in cirrhotic percutaneous biopsy.
patients. 10 The use of diagnostic laparoscopy has, therefore, expanded
in liver cirrhosis so much that Vargas et al (1995) recommended
Factor 4: Good Operative Technique that diagnostic laparoscopy should be incorporated into the
4
Some authors have advocated a number of operative techniques training programs for gastroenterologists in America. Haydon
to help minimize the morbidity associated with surgery in and Hayes (1997) also advocated that physicians in the United
cirrhotic patients undergoing laparoscopic procedures. Kingdom should be the ones performing diagnostic laparoscopy.

World Journal of Laparoscopic Surgery, September-December 2011;4(3):136-139 137