Page 12 - Journal of Laparoscopic Surgery

Rajiv Gupta

LAPAROSCOPY AS TREATMENT MODALITY IN laparoscopic repair yields less morbidity and fewer recurrences.
PATIENTS WITH ASSOCIATED CIRRHOSIS The study further highlighted that the preservation of the
Laparoscopic Cholecystectomy in Cirrhotic Patients anterior abdominal wall in laparoscopic repair avoids the
interruption of collateral veins which are not infrequently
The incidence of gallstones is reported to be twice in patients distended in cirrhotic patients.
with cirrhosis than in general population. 13-15 Most stones are There is a tendency to develop umbilical hernias in cirrhosis
small pigment stones which are friable and are also associated due to increased porta systemic communication and opening
16
with more complications. Laparoscopic cholecystectomy is of obliterated umbilical veins to accommodate the pressure.
hence the most widely performed surgery on patients with Laparoscopic umbilical hernia repair in cirrhotic patients appears
cirrhosis. to offer advantages over the open methods. Ascites may add
20
Open cholecystectomy is associated with high rates of
morbidity (5-30%) and mortality (7-25%) in cases with cirrhosis. to this effect of producing umbilical hernia due to increased
intra-abdominal pressure.
Hence, laparoscopic surgery was studied as an alternative and Successful laparoscopic repair of recurrent incarcerated
better procedure for cirrhotic patient as it is associated with umbilical hernia in a cirrhotic patient with refractory ascites has
less bleeding because better visualization with magnification, also been reported. In the report, the authors used dual mesh
4
shorter duration of hospital stay. There are certain difficulties prosthesis and advocated meticulous sterile fashion of mesh
like, some adhesions around gallbladder and hilum of liver, thick insertion and fixation. This is important since ascitic fluid
margin of liver which makes traction on liver difficult and infection, which may occur after surgery may affect the hernia
increased vascularity of gallbladder bed. But the use of mesh repair. The possibility of mesh migration due to the ascitic
additional port and extracting the gallbladder fundus first, or a fluid can be reduced by placing the mesh in a preperitoneal
partial cholecystectomy makes life easier for the surgeon and space. 12
also for the patient. Laparoscopic cholecystectomy is more Ascites itself may be treated laparoscopically more
useful for mild and moderate degree of cirrhosis, but is Child– effectively by placing the peritoneovenous shunt. Surgical
21
Pugh’s class C, it still remains relatively contraindicated. The treatment of ascites is reserved for severe ascites, others can
experience of Yeh et al (2002) with LC in 226 cirrhotic patients be treated medically. In cases of ascites with renal failure,
represents the largest series published so far. However, no insertion of peritoneal dialysis catheters under vision. 22
patient with Child-Pugh’s class C was operated upon. Curro
et al (2005) compared four Child-Pugh’s class C patients who Other Laparoscopic Procedures in
had LC with 38 Child-Pugh’s A and B patients in the same Cirrhotic Patients
center and found a morbidity rate of 75% in the Child-Pugh’s C
2
patients compared with 26% in the A and B group. The authors Cobb et al (2004) reported 52 laparoscopic procedures

further advised that surgery in Child-Pugh’s C patients should performed on 50 cirrhotic patients.These procedures, including
be avoided except in acute emergencies where conservative cholecystectomies, splenectomies, colectomies, diagnostic
procedures, such as gallbladder aspiration and partial laparoscopies, ventral hernia repairs, nissen fundoplication,
cholecystectomies may be considered. Even in such instances, Heller’s myotomy, gastric bypass and radical nephrectomy had
percutaneous drainage of the gallbladder and other conservative a morbidity rate of 16% but no mortality. Tsugawa et al (2001) 3
procedures may suffice. 18 had earlier compared open and laparoscopic appendicectomies
3
among patients with liver cirrhosis. They reported fewer rates
Laparoscopic Hernia Repair in Cirrhosis of wound infection and wound bleeding in the laparoscopic
The main concern during hernia repair is the approach. In group. Many other laparoscopic procedures including
21,22
cirrhosis, the abdominal wall may be riddled with multiple laparoscopic liver resections for hepatocellular carcinomas

engorged vein due to associated portal hypertension. and laparoscopic ultrasound with radiofrequency ablation are
Performing an open repair of hernia is riddled with bleeding due now routinely done in cirrhotic patients in some centers.
to these veins and bleeding disorders.
Laparoscopically, all these distended veins are avoided and CONCLUSION
the abdominal wall is left untouched. The whole surgery is Cirrhosis of liver because of its associated comorbidity, is not a
behind the abdominal wall and just involves insertion of a mesh contraindication of any simple or advance procedure by
between the peritoneum and the abdominal wall. Hence, avoiding laparoscopy. Although technically challenging because portal
all the potentially distended veins and bleeding. 20 hypertension, varices and thrombocytopenia frequently coexist,
In a report of 14 cirrhotic patients who underwent basic and advanced laparoscopic procedures are safe for
laparoscopic incisional and umbilical hernia repair, Giulio et al patients with mild to moderate cirrhosis of the liver. However,
(2006) observed that though open repair in cirrhotic patients its safety in advanced disease like Child-Pugh’s class C is not
has significant recurrence rates and frequent wound infections, yet proven, we advocate caution in such cases and further

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