Michael Dennis Dela Paz, MD. AMOSUP Seamen’s Hospital, Intramuros, Manila
This is a case study aims to evaluate the safety and outcome of laparoscopic cholecystectomy in patients with incidental intraoperative findings of liver cirrhosis.
This is a case of a 55-years old diabetic female who had chronic intermittent right upper quadrant abdominal pain and had a recent whole abdominal ultrasound findings of diffuse fatty liver and cholelithiasis. She had no episode of jaundice and her physical examination findings and ancillary laboratory results were unremarkable. Laparoscopic Cholecystectomy was done. Incidentally, the liver was noted to be cirrhotic which was pulsating and contracting around the slightly distended gallbladder. Exposure of the critical view of safety was done by grasping the fundus of the gallbladder and lifting it up laterally nwhich upon slight retraction of the gallbladder from the liver bed cause bleeding on the junction of the gallbladder and the liver. The surgeon decided to seek help to an experienced surgeon. Together, they decided to continue the procedure laparoscopically with caution using the dome down approach. A piece of gauze was inserted and used as a cushion that pushed the liver superiorly to expose the gallbladder. Electrocautery near the gallbladder wall was done using a hook to separate the gallbladder from the liver bed with immediate gentle and suffice cauterization of ever small amount of bleeding along the liver bed. Upon released of the gallbladder up to the infundibulo-cystic junction, the cystic duct and cystic artery were isolated, identified and ligated using clips. Cholecystectomy was done and, upon re-examination, the liver bed was noted to be dry without any active bleeding. Post-operative, the patient was noted to be unremarkable and was discharged after 24 hours without any symptoms of pain nor complication of bleeding.
Laparoscopic cholecystectomy can be considered an effective and safe treatment for gallbladder stones in selected patients. It is important that it should be attempted by surgeons with sufficient experience and skills in handling cirrhotic liver because the liver tends to resist the proper exposure of the gallbladder as it constantly pulsate and distortedly contracted around the gallbladder tending it to be intrahepatic. The danger of causing high pressure bleeding along the liver parenchyma is always a possible complication so that cautious cushioned gentle retraction and attentive gentle suffice cauterization along the plane of dissection and the hepatic bed is needed. The patient benefited from the procedure by reduced post-operative pain and hospital stay.