Reprints Available Directly from the Publisher Photocopying Permitted by License Only Laparoscopic Cholecystectomy for Cholelithiasis in Patients with Liver Cirrhosis

We performed laparoscopic cholecystectomy for symptomatic cholelithiasis on four patients with cirrhosis of the liver, two of whom had clinical portal hypertension and splenomegaly. Preoperative examination disclosed hypersplenism in one patient, while mild thrombocytopenia and decreased prothrombin concentration were noted in three patients. However, no remarkable bleeding tendency was recognized clinically in any of the patients. Preoperatively, by Child-Pugh's criteria, three patients had class B disease and one class A disease. Intraoperatively, remarkable inflammatory change or fibrotic change of the gallbladder wall and Calot's triangle was observed in two cases, and collateral veins and lymphangial congestion were observed in all four cases. In the first case, extreme bleeding and lymphorrhea from dissected sites were observed, and a 1.5 unit of transfusion of whole blood was required during operation. Postoperatively, increase in ascites which was controlled with diuretics was recognized in one ease. However, the postoperative course was uneventful in all cases, and no serious complications were recognized. That laparoscopic cholecystectomy can be safely performed in patients with cirrhosis if careful and appropriate management of bleeding and lymphorrhea from sites of dissection is ensured, is en-couragng.


to laparoscop
c cholecystectomy are becoming fewer as surgeons gain experience and confidence in using the new equip- ment and techniques required for this procedure (1)(2)(3).

However, liver cirrhosis is still usually considered a rel- ative or absolute contraindication to laparoscopic chole- cystectomy, and only a few reports have be n made of the performance of laparoscopic cholecystectomy in patients with liver cirrhosis.The indications for laparoscopic cholecystectomy in cirrhotic patients remain unclear and controversial (1,3,4).For patients with cholelithiasis, our philosophy from the inception of laparoscopic cholecystectomy at our clinic has been to attempt to use laparoscopic procedures for all patients undergoing cholecystectomy.We report Address for correspondence: Tetsuro Ishikawa, M.D., 1st.Dept. of Surgery, Osaka City, University Medical School, 1-5-7 Asahi-machi, Abeno-lm Osaka 545 Japan.

here the findings of four consecutive patients with liver cirrhosis who underwent successful laparoscopic cholecystectomy, and make some suggestions regarding effec- tive intraoperative management of these patients.

PATIENTS AND METHODS
The findings obtained for four consecutive patients with symptomatic cholelithiasis and cirrhosis of the liver who underwent laparoscopic cholecystectomy in our institute, were retrospectively reviewed.All four patients had been diagnosed with cirrhosis based on the results of pathologic examination.Clinical history, diagnosis, and preoperative data are listed for each patient in   Ultrason graphy, computed tomography (CT) and drip in- fusion cholangiography (DIC) or endoscopic retrograde cholangiography (ERC) studies were performed preoper- atively.Preoperative examination including blood cell counts, liver function tests including serum levels of total protein, albumin, aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase, and coagulation and fibdnolytic factors were performed  for all four patients.Child-Pugh's classification (5) was used to grade the severity of liver dysfunction.

Intraoperative findings including surgical procedure used, operating time, transfusion requirements, and operative complications were also recorded.Postoperative findings including duration of fever and use of analgesics, time until normal diet, and changes in liver function tests were also recorded.


RESULTS


Patients

Of 145 consecutive patients who underwent laparoscopic cholecystectomy between March 1992 and December 1993, 4 had cirrhosis of the liver (Figs. 1 and 2).They in- cluded 1 male and 3 females, between 37 and 71 years of age.Cases 1 and 3 manifested systemic signs of acute cholecystitis, such as high

rant pains, and leu
ocytosis on each admission.These signs disappeared with antibiotic treatment before operation.

Cases 2 and 3 suffered from fight hypochondralg a and back pain.Three had postnecrotic hepatitis C viral infec- tion and one had alcoholic cirrhosis combined with he- patitis B viral infection.Two had portal hypertension with esophageal varices and splenomegaly.The esophageal varices have been controlled with sclerotheraphy.Mild to moderate ascites were present in cases 1, 2, and 3, and controlled with diuretics (Table 1).All four patients had been demonstrated by ultrasonography to have gallstones.

In case 3, DIC and ERC revealed nonfilling of the gall-  2) disclosed thrombocytopenia in cases 1, 2, and 3, with platelet counts ranging between 49,000 and 96,000/mm3, and leukocytopenia in cases 1 and 4 (2300 and 3100/mm3, respec- tively).Liver function tests disclosed hypoalbuminemia (range, 2.5-3.2g/dl) and decreased hepaplastin time in all cases, and mild hyperbilirubinemia in cases 1, 3, and 4. Levels of indocyanine green excretion after 15 minutes (ICG R15) were very high in cases 1 and 3, indicating se- vere hepatic dysfunction.Prothrombin and antithrombin III concentrations were below normal in cases 1, 2, and 3

(ranges, 69-73% and 52-56%, respectively), however, no bleeding te dency was clinically recognized in any patients.Preoperatively, by Child-Pugh's criteria, cases 1, 2, and 3 had class B disease, while case 4 had class A dis- ease (Table 1

Surgical Procedure

All patien
s underwent general anesthesia and la- paroscopy with a 0-or 30 degree forward viewing tele- scope, CO2 insufflator, and electrocautery.

The fn'st trocar was inserted using an open technique to avoid injury of collateral veins in the abdominal wall.The cystic duct and artery were exposed and ligated with titanium clips or absorbable monofilament ligatur s.Intraoperative cholangiographywasperformedinroutine fashion afteriden- tification of the cystic duct near its junction with the gallbladder.In cases 1 and 3, severe inflammatory and fibrotic changes around Calot's triangle were noted, and therefore dissection from the fundus to hilum of the gallbladder with frequent hemostasis was begun without dissection and iso- lation of the cystic duct.Following mobilization of the gall-LAPAROSCOPIC CHOLECYSTECTOMY FOR CHOLELITHIASIS 149 Figure I Laparoscopic view in case 1. Liver atrophy and increase in thickness of the gallbladder wall are pronounced.And also, mild ascites are evident.GB, gallbladder; LI, liver.RBC, red blood cell; WBC, white blood cell; TP, total protein; ALB, albumin; AST, aspartate aminotransferas; ALT, alanine aminotransferase; T-BIL, total bilirubin; ALP, alkaline phos- phatase; ICG R 5, indocyanine green excretion after 15 minutes; HPT, hepaplastin time; PT%, concentration of prothrombin bladder, exposure of the cystic duct and artery became eas- ier, and these structures were dissected (Fig. 3).

In cases 1 and 2, bleeding and lymphorrhea were con- trolled mainly with electrocautery, which resulted in ex- treme bleeding (1,100 and 600 ml, respectively) and lymphorrhea.Therefore, in cases 3 and 4, either clipping or ligation was frequently performed at sites of dessec- tion.Fibrin glue was used to secure hemostasis at sites of dissection in cases 1 and 3, and a Penrose drain was placed.

Operating times (range, 105-370 minutes) and bleed- ing volumes (50-1,100 ml) are summarized in Table 3.A 1.5 unit whole blood transfusion was required in case 1 (Table 3).

Postoperative Course and Outcome In case 2, rebleeding from the abdominal wall on the first postoperative day was managed by transfusion of 1 unit of whole blood, and no surgical treatment was required.In case 3, moderate ascites developed, and was controlled with di- uretics.There were no significant differences in results of liver function tests before and after operation (Table 4).

The postoperative courses were almost entirely un- eventful, and no serious complications occurred in any of the 4 patients.Cases 1 and 4 were hospitalized for 6 and 7 days after surgery until skin sutures were removed.Discharge were delayed in two case, because of alco- holism in case 2, and of persistent ascites in case 3 (Table 5).Of the four patients, three are alive and without com- plaint between 7 and 11 months after surgery; in case 1, however, death due to rebleeding from esophageal varicies occurred 13 months after surgery.


DISCUSSION

Conventional open cholecystectomy in patients with liver cirrhosis is a common but difficult clinical problem, since it is well established that this procedure carries a high risk of mortality and morbidity for these patients.Various au- thors (6-8) have de

nstrated m
rtality rates ranging from 7.5% to 25.5%, and morbidity rates ranging from 12.2% to 23.6%.In addition, incidences of intraoperative transfusion ranging from 42.6% to 61.9% have been re- ported.Bloch and coworkers (8) suggested that operative intervention for symptomatic cholelithiasis is indicated for Child A or B patients before liver function deteriorates to class C status and before emergency intervention be- comes necessary.Laparoscopic cholecystectomy, which has the benefit of being a minimally i vasive procedure (9,10) also has the possible disadvantage of poor control of significant intraoperative hemorrhage, since the same limitations in the use of surgical instruments and difficulties in placement of surgical packs or direct manual compression of bleeding sites under laparoscopic guidance exist.Given these considerations, many surgeons believe that cirrho- sis is an absolute or relative ontraindication to the performance of laparoscopic cholecystectomy.In addition, reports of the use of laparoscopic surgery in cirrhotic pa- tients have appeared only occasionally (1,3,4)  From our experience, problems and measures taken to ensure safety in laparoscopic procedures include the fol- lowing.At the