Page 39 - World Journal of Laparoscopic Surgery

Cirrhosis Umbilical Port Risk
entered, a large amount of blood was gushed out. Stop bleeding • Reviewing of preoperative imaging to search for a collateral
was attempted through the 1 cm wound, but was unsuccessful vessel such as our case. However, CT scan was not routinely
due to small incision, blood rapidly obscuring surgical field and utilized especially in laparoscopic cholecystectomy cases.
patient’s thick abdominal wall. The incision was then extended to
around 5 cm, the bleeding vessel was identified as around 1.2 cm
vein just above the layer of peritoneum and then controlled with conclusIon
suture-ligation. Patient’s conditions at that time were unstable with Although various laparoscopic surgeries are recently supported in
hypotension, and volume of blood loss was around one liter. The CP class I and II cirrhotic patients. However, these groups of patients
procedure was then terminated, and the patient was transferred still possess a higher chance of procedure-related complication.
to be resuscitated in the intensive care unit. Postoperatively, the Collateral vessels secondary to portal hypertension can cause
patient has gradually improved with medical controlled ascites. serious major bleeding from creating an umbilical port that should
The second operation was planned after the patient has recovered. be aware.
Preoperative computed tomography was later reviewed
(Fig. 1) and shown the large collateral vessel beneath the anterior references
abdominal wall, which ran from the hilar area of the liver through
the falciform ligament to anterior abdominal wall, ran down to 1. Yerdel MA, Tsuge H, Mimura H, et al. Laparoscopic cholecystectomy
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outcomes. 4–6 Most of the literature didn’t report regarding portal gastrectomy in gastric cancer patients with liver cirrhosis. Surg
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Gastroenterol 2014;20(19):5794–5800. DOI: 10.3748/wjg.v20.i19.5794.
11
Earl TM and Chapman WC in textbook of hepatobiliary surgery. 7. El-Awadi S, El-Nakeeb A, Youssef T, et al. Laparoscopic versus open
To avoid collateral vessel, there was also a recommendation to cholecystectomy in cirrhotic patients: a prospective randomized
choose an infraumbilical incision rather than a supraumbilical study. Int J Surg 2009;7(1):66–69. DOI: 10.1016/j.ijsu.2008.10.013.
12
location. Our case report revealed that even infraumbilical 8. Hamad MA, Thabet M, Badawy A, et al. Laparoscopic versus open
incision might not be able to avoid anterior abdominal collateral cholecystectomy in patients with liver cirrhosis: a prospective,
vessels. The incidence of paraumbilical vein and abdominal randomized study. J Laparoendosc Adv Surg Tech A 2010;20(5):
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13
epigastric veins, was around 43% in portal hypertensive patients. 9. Ji W, Li LT, Wang ZM, et al. A randomized controlled trial of
Even though, to our knowledge, the subset incidence of these laparoscopic versus open cholecystectomy in patients with cirrhotic
collaterals, which drain into inferior epigastric veins that cause portal hypertension. World J Gastroenterol 2005;11(16):2513–2517.
DOI: 10.3748/wjg.v11.i16.2513.
risk of injury from infraumbilical incision, is still unknown. The 10. Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy
collateral vessel diameter can be very large, such as our case, and in patients with cirrhosis. J Am Coll Surg 2003;197(6):921–926. DOI:
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around laparoscopic port during intra-abdominal gas inflation, 11. Earl TM, Chapman WC. Nonhepatic surgery in the cirrhotic patient.
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However, in the unexpected bleeding event, this small incision can pancreas. 2, 6th ed., Elsevier; 2017. pp. 1161–1167.
prevent adequate visualization and causes delaying hemostatic 12. Nguyen KT, Kitisin K, Steel J, et al. Cirrhosis is not a contraindication
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operative field. Preventive measures should be the best way for 13. Moubarak E, Bouvier A, Boursier J, et al. Portosystemic collateral
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• Place the other ports first and place the umbilical port under 14. Palanisamy S, Sabnis SC, Patel ND, et al. Laparoscopic major
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• Completely avoid the midline of umbilical area. 14 2015;19(12):2215–2222. DOI: 10.1007/s11605-015-2933-x.

World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019) 85