Page 37 - World Journal of Laparoscopic Surgery

CASE REPORT
Danger of Laparoscopic Umbilical Port in Portal Hypertensive

Cirrhotic Patient: A Case Report

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Suppadech Tunruttanakul , Kotchakorn Verasmith 2

AbstrAct
Laparoscopic surgery has been proved to be safe and better option for Child-Pugh (CP) score class I and II cirrhotic patients. Various challenging
laparoscopic surgeries have been applied to this group of patients. This case report was of an obese man, CP class I alcoholic cirrhotic patient
with radiological evidence of portal hypertension, inflicted with cecal adenocarcinoma. Laparoscopic right hemicolectomy was planned. First
camera port incision was made on infraumbilical position and injured to large paraumbilical collateral, which drained blood from the main
portal vein. The patient was survived but suffered from postoperative ascites and postponing definite surgery. The preoperative computed
tomography was reviewed and detailed of these collateral vessels. This report aims to raise awareness of this potential complication and reveal
the imaging with discussion of avoiding options.
Keywords: Cirrhosis, Laparoscopic surgery, Paraumbilical collaterals, Portal hypertension.
World Journal of Laparoscopic Surgery (2019): 10.5005/jp-journals-10033-1371

IntroductIon 1 Department of Surgery, Sawanpracharak Hospital, Nakhon Sawan,
Liver cirrhosis has been a contraindication for laparoscopic Thailand
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cholecystectomy. However, currently, many high-level evidences 2 Department of Radiology, Sawanpracharak Hospital, Nakhon Sawan,
have revealed that it is safe and maybe better than open surgery Thailand
in terms of fewer complications, length of hospital stay, and Corresponding Author: Suppadech Tunruttanakul, Department of
recovery. 2,3 Nevertheless, these safties are limited only on Surgery, Sawanpracharak Hospital, Nakhon Sawan, Thailand, Phone:
2,3
CP score class I and II cirrhotic patients. In the beginning, +66 897590770, e-mail: sdtaaa@yahoo.com
laparoscopic surgery in cirrhotic patients was mostly limited to How to cite this article: Tunruttanakul S, Verasmith K. Danger of
cholecystectomies. With more developed in minimally invasive Laparoscopic Umbilical Port in Portal Hypertensive Cirrhotic Patient:
surgical equipment, the procedures have expanded to cover A Case Report. World J Lap Surg 2019;12(2):83–85.
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many more challenging surgeries such as gastrectomy, colorectal Source of support: Nil

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surgery, splenectomy, etc. Conflict of interest: None
Most of the laparoscopic procedures begin with creating
abdominal tunnel for a trocar for the laparoscopic camera, which
is usually located around the umbilical area. Majority of studies Liver function test: total protein 8.0 g/dL, albumin 3.6 g/dL,
included an umbilical port in the procedure. 5,7–9 This case report globulin 4.4 g/dL, aspartate aminotransferase 32 U/L, alanine
aims to alert surgeons to aware of a potentially serious bleeding aminotransferase 17 U/L, alkaline phosphatase 69 U/L, total bilirubin
complication that can occur from creating an umbilical port in a 1.02 mg/dL, and direct bilirubin 0.53 mg/dL.
cirrhotic patient with portal hypertension. Coagulogram: prothrombin time (PT) 14.8 second with
international normalization ratio (INR) 1.21, partial thromboplastin
clInIcAl cAse descrIptIon time (PTT) 26.0 with ratio 0.98.

Blood urea nitrogen 8 mg/dL and creatinine 1.09 mg/dL (g =
A 66-year-old male, known-case alcoholic cirrhosis, came to the gram, dL = deciliter, μL = microliter, U/L = international unit per
hospital with clinical constipation and occasional abdominal liter and mg = milligram).
pain. Colonoscopy was later utilized and detected fungating mass According to the patient’s blood tests, most of the results were
located in the cecal area. Pathologic examination later confirmed normal except slight thrombocytopenia, which can reflect having
adenocarcinoma. Computed tomography was then organized portal hypertension. Child–Pugh score was calculated, and the score
and revealed circumferential, enhancing mass at the cecum. was five (no ascites and hepatic encephalopathy), which categorized
Morphologically liver cirrhosis and portal hypertension (seen the patient as CP class I liver cirrhosis.
collateral vessels) without ascites were also reported in the study. It can be summarized that the patient was inflicted resectable
There was no evidence of distant metastasis, and the patient was cecal cancer with CP class I alcoholic liver cirrhosis with portal
fit with had only cirrhosis as his underlying disease. Regarding hypertension. Surgical treatment was then planned laparoscopically.
body mass index classification, he was categorized as obesity with Preoperatively, only some packed red cell was prepared, and
body mass index 32.4 (bodyweight 83 kg and height 160 cm). His prophylactic antibiotics were given. General anesthesia with some
preoperative blood test results were as followings. monitoring was applied without any concern. Umbilical incision
Complete blood count: hemoglobin 8.5 g/dL, white blood was made on infraumbilical location, around one centimeter (cm) in
counts 4,230/μL, and platelet counts 1,13,000/μL. length with open technique under direct vision. After peritoneum
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