Laparoscopic cholecystectomy (LC) is generally safe for patients with compensated cirrhosis (Child-Pugh class A), but risk of complications increases with severity of cirrhosis. While LC has advantages over open cholecystectomy, cirrhotic patients face higher risks of bleeding, infection, and organ failure due to their underlying liver condition. Proper patient selection using Child-Pugh classification and pre-operative stabilization are important. With appropriate precautions and for patients with well-compensated cirrhosis, LC can be performed safely.

1. By
Mohamed El-sayed Abosdira
Assistant lecturer at general surgery
department
Sohag university hospital

2. Lap. Chole in cirrhotic liver
safe or not safe
to do or not to do ??

3. Cholelithiasis is a common finding in patients with
cirrhosis.
Gallstones are twice as common in cirrhotic patients
as in the general population.
Its incidence is 29.4% for patients with cirrhosis
compared with 12.8% for patients without cirrhosis.

4. Pathogenic factors seem to be responsible for
the high incidence of gallstones in cirrhosis
including :
intravascular hemolysis,
hyper-splenism,
reduction in biliary acidity,
increased levels of estrogen,
and functional alterations of the gallbladder
(reduction in motility and emptying)
Naheed T et. al 2008

5. Postoperative morbidity and mortality rates are
significantly lower with LC compared with those for open
cholecystectomy.
Although laparoscopic cholecystectomy (LC) has become
the gold standard for symptomatic gallstones,
cirrhosis has been considered an absolute or relative
contraindication.
“Shiekh et al 2009”

6. Laparoscopic cholecystectomy has been proven safe
and feasible for symptomatic gallstones, but its role in
cirrhotic patients remains controversial.
Yerdel et al in 1993 reported the first study of
laparoscopic cholecystectomy in cirrhosis. Although a
small number of patients were included in the study, no
morbidity or mortality occurred.

7. Proper patient selection after estimating the risk is an essential
requirement.
The Child-Pugh classification is helpful in estimating the risk
and provides an idea of the patient's liver reserve.
The need for blood transfusion and patient mortality and
morbidity all correlate with the Child-Pugh classification.
it is documented that the greater the severity of the cirrhosis,
the greater is the incidence of complications.

8. Block et al reported a mortality of 27% among Child-
Pugh C, 9% among Child-Pugh B, and no mortality
among Child-Pugh A patients.
Kogut et al also reported a zero percent mortality
among Child-Pugh A patients, and Wu et al suggested
that Child-Pugh A patients can even be regarded as “non
cirrhotic” in biliary surgery.;

9. Between January 2006 and July 2010,
from 503 patients under LC,
we reviewed 43 cirrhotic patients of
Child-Pugh Classification A, B, and C,
with symptomatic gallstones.

10. RESULTS:
Conversion to an open procedure was necessary in 5
patients due to multiple factors.
The mean operative time and length of hospital stay were
significantly longer and higher in cirrhotic group
(P<0.05).
Postoperative complications were observed in 37.2% of
patients.

11. Trocar site hematoma (P=0.02),
wound complications (P=0.02),
intra-abdominal collection (P=0.01) occurred more frequently in
patients with cirrhosis (Child B and C class) than in patients without
cirrhosis.

12. One case of continuing hemorrhage from the
gallbladder bed required a reoperation for hemostasis.
Two patients with Child-Pugh class C and 1 patient
with class B cirrhosis developed ascites after surgery;
1 patient with Child-Pugh class A had bile leakage.
No deaths occurred. “Juan MB. et al 2011”

13. Hamid et al recommend that in areas where liver
disease is prevalent, all patients undergoing surgery
should have prothrombin time, serum albumin,
hepatitis B, c surface antigen, and careful abdominal
ultrasound with particular emphasis on the liver.
.

14. Median hospital stay was 3 days. This series
suggests that well compensated cirrhosis can not
be considered a contraindication to laparoscopic
cholecystectomy

15. Complications of lap chole
in cirrhotic pt.
Patients with cirrhosis undergoing cholecystectomy have a higher incidence
of postoperative complications than patients without cirrhosis.
intraoperative bleeding,
postoperative hepatic failure
Ascites
sepsis
Multiple organ failure

16. Difficulties
There are some technical difficulties with performing
laparoscopic cholecystectomy in patients with cirrhosis.
The cirrhotic liver parenchyma is stiff from fibrous
transformation and could interfere with the frequently used
maneuver in LC where retraction of the gallbladder fundus
is performed to expose the triangle of Calot.

17. In order to avoid this difficulty, some authors have
proposed the insertion of an additional 5 mm trochar
and a liver retractor.
The pneumoperitoneum in LC has also been a concern
due to presumed reduction in blood flow to the liver and
kidney parenchyma .It is suggested that laparoscopic
procedures in patients with liver cirrhosis are performed
with a lower intra-abdominal pressure .

18. Finally, in dealing with the difficult liver bed and hilum
in patients with portal hypertension, some authors have
mandated the use of ultrasonic shears or performed
laparoscopic subtotal cholecystectomy.
“Jonas Strömberg 2015”

19. Pre-Operative measures
•Vitamin K may be administered preoperatively, since
malabsorption causes vitamin K deficiency that further
exacerbates the inherent coagulopathy of the cirrhotic
patient.
• Reduced levels of coagulation factors can be replaced
by fresh frozen plasma or cryoprecipitate.
Furthermore, the administration of blood platelets may
be considered if the preoperative platelet count is less
than 50.000/mL.

20. Ascites development can be limited by the preoperative
administration of diuretics or by laparocentesis.

21. Conclusion
Cirrhotic patients are at higher risk of developing
postoperative infection (antibiotic requiring) and a
higher number of patients are requiring postoperative
blood transfusion, suggesting a bleeding tendency in
this patient group.
However, cholecystectomy should not be delayed and
can be performed as a safe procedure in patients with
compensated and decompensated liver cirrhosis.

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