This document discusses cholecystectomy in a patient with liver cirrhosis. It provides background on gallstone disease and cirrhosis. Laparoscopic cholecystectomy is generally safer than open for cirrhotic patients, though it carries higher risks than in non-cirrhotic patients due to issues like bleeding and difficult anatomy. Predictive models like Child-Pugh and MELD scores can help assess operative risk. While challenging, laparoscopic cholecystectomy can be performed in carefully selected cirrhotic patients by experienced surgeons.

1. Cholecystectomy in
patient with Liver
Cirrhosis
PUSHPA LAL BHADEL
FCPS Resident
DEPARTMENT OF SURGERY
KATHMANDU MODEL HOSPITAL
Moderator
Dr. Udaya Koirala

2. Case
Mr. SK, 50 Y, Male
Chief complain:
Right upper quadrant pain x 10 days

3. Case contd.
History of presenting illness
 Known case of Cholelithiasis for 11 years
 Apparently well 10 days back
 Pain over right upper quadrant
 Gradual onset, pricking nature, mild intensity, non-radiating, no
aggravating/relieving factors
 No H/O fever, nausea/vomiting, abdominal distension, yellowish
discoloration of skin, altered bowel habit, decreased appetite, cough,
weight loss

4. Case contd.
Past history
 Known case of Portal Hypertension and liver cirrhosis for 11 years
 Had undergone Banding for Bleeding esophageal varices 11 years
back
 Was treated for Bicytopenia (Thrombocytopenia & Leukopenia) 7
years back

5. Case contd.
Family history
Not significant
Personal history
Left alcohol since 11 years
Non-smoker
Non-vegetarian diet

6. Case contd.
Treatment history
Was being followed up regularly in OPD for current
condition
Under Tab. Spironolactone and Tab. Propranolol for Portal
HTN

7. Case contd.
General examination:
 Conscious, co-operative, oriented, sitting comfortably in bed
Vitals:
 Pulse:76 bpm, regular
 Blood pressure: 110/70 mm Hg
 Respiratory rate: 18 breaths/min
 Temperature: 97.8 0F
No icterus, clubbing

8. Case contd.
Systemic examination:
Abdomen:
 Inspection:
• Normal contour, centrally placed inverted umbilicus, moves
with respiration, no venous prominences, pigmentation, visible
lump, hernial orifices intact
 Palpation:
• Superficial: local temperature not elevated, non-tender
• Deep: no lump or tenderness
• Organ palpation:
oLiver not enlarged
oSpleen not palpable
oKidneys: not ballotable

9. Case contd.
 Percussion: upper border of liver percussed at 5th ICS, resonant
 Auscultation: normal bowel sound
 DRE: not done
Cardiorespiratory system:
 No abnormalities detected

10. Case contd.
Investigations:
 Hb: 14.8
 TLC: 4000
 N: 55 L: 40
 Platelets:
85,000
 PT/INR: 14/1
 Bil. T/D: 35/7
 ALP: 99
 ALT: 35
 AST: 39
 RFT: WNL
 PBS:
oRBC: normocytic normochromic
oWBC: leukopenia with normal
morphology
oPlatelets: reduced on smear

11. Case contd.
Ultrasound (June 29, 2020)
 Cholelithiasis (multiple)
 Mild splenomegaly (13.3 cm)

12. Introduction
Cirrhosis
Irreversible chronic parenchymal necrosis of liver followed by
fibrosis and nodule formation
Liver architecture diffusely abnormal
Interferes with liver blood flow (causing portal hypertension)
Interferes with hepatic function (resulting hepatic
insufficiency)

13. Introduction
Etiology:
 Alcohol: 60-70%
 Viral hepatitis (Hep B, Hep C): 10%
 Biliary disease, e.g. Primary sclerosing cholangitis, Primary biliary
cirrhosis: 5-10%
 Metabolic diseases, e.g. Wilson’s disease, Hereditary
hemochromatosis, Alpha-1 antitrypsin deficiency: 5%
 Autoimmune hepatitis
 Drugs: methyldopa, Isoniazid, halothane, methotrexate
 Cystic fibrosis

15. Introduction
 Archaeologists have found gall stones in body of a young woman who lived as
early as 2000 yrs. old 1
 Langenbuch: 1st successful cholecystectomy; 1882 2
 Dr. Erich Muhe of Boblengen (Germany): 1st laparoscopic cholecystectomy, 1985
 10-20% of adult population are diagnosed with gall stones
 Cholecystectomy: one of most common abdominal surgical procedure
1 Beal JM. Historical perspective of gallstone disease. Surg Gynecol Obstet. 1984;158(2):181-9.
2 Short surgical stay: two hospital days for cholecystectomy. Am J Surg. 1988;156(4):332-3.

16. Introduction cont.…
Incidence of cholelithiasis in cirrhosis vs general population 1
• 9.5 – 13.7% vs 5.2%
In autopsy cases prevalence is 2
• 29.4% - 46% in cirrhosis
• 13% in general population
1 Genzini T, De miranda MP, De oliveira e silva A, et al. Cholelithiasis in cirrhotic patients. (Analysis of cholelithiasis among patients with liver cirrhosis
in São Paulo, Brazil). Arq Gastroenterol. 1996;33(2):52-9.
2 Iber FL, Caruso G, Polepalle C, Kuchipudi V, Chinoy M. Increasing prevalence of gallstones in male veterans with alcoholic cirrhosis. Am J
Gastroenterol. 1990;85(12):1593-6.

17. Introduction cont.…
Reasons for higher incidence1:
• Decreased bile salt production
• Increased estrogen levels
• Reduction in gallbladder motility and emptying
• Higher level of unconjugated bilirubin
Open cholecystectomy: standard approach in such patient
After 1980s, Lap. Cholecystectomy : standard approach to most 2
1 Keus F, De jong JA, Gooszen HG, Van laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis.
Cochrane Database Syst Rev. 2006;(4):CD006231.
2 Liguory C, Vitale GC. Biliary perestroika. Am J Surg. 1990;160(3):237-8.

18. Introduction cont.…
 Initially discouraging results: morbidity and mortality rates of 23 - 25% 1
 Liver cirrhosis: one major factor responsible for morbidity and mortality
 Other factors 2:
• Hemorrhage associated with portal HTN
• Coagulopathy and thrombocytopenia
• Abdominal adhesions
• Reduced compliance of fibrotic liver
1 Garrison RN, Cryer HM, Howard DA, Polk HC. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg.
1984;199(6):648-55.
2 Lacy AM, Balaguer C, Andrade E, et al. Laparoscopic cholecystectomy in cirrhotic patients. Indication or contradiction?. Surg Endosc.
1995;9(4):407-8.

19. Risk factors for surgery in cirrhotics
Variables related to increased morbidity and mortality 1
1 Lopez-delgado JC, Ballus J, Esteve F, et al. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol. 2016;22(9):2657-
67.
• Emergency surgery
• Child-Pugh class C
• Portal HTN
• Anemia
• Ascites
• Encephalopathy
• Infection
• Jaundice
• Hypoalbuminemia
• Hypoxemia
• PT not amenable to Vit.-
K/FFP

20. Risk factors for surgery in cirrhotics cont.
Three independent variables predicting mortality after
major surgical procedures 1
• Age
• American Society of Anesthesiologists (ASA) physical status
classification
• Model of End Stage Liver Disease (MELD) score
1 Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132(4):1261-9.

21. Predictive models
Child-Pugh classification:
Parameter
Points assigned
1 2 3
Ascites Absent Slight Moderate
Bilirubin
<2 mg/dL (<34.2
micromol/L)
2 to 3 mg/dL (34.2 to
51.3 micromol/L)
>3 mg/dL (>51.3
micromol/L)
Albumin >3.5 g/dL (35 g/L)
2.8 to 3.5 g/dL (28 to 35
g/L)
<2.8 g/dL (<28 g/L)
Prothrombin time
Seconds over control <4 4 to 6 >6
INR <1.7 1.7 to 2.3 >2.3
Encephalopathy None Grade 1 to 2 Grade 3 to 4

22. Predictive models
 Child-Pugh class A: 5-6 (well compensated disease)
 Child-Pugh class B: 7-9 (significant functional compromise)
 Child-Pugh class C: 10-15 (decompensated disease)
 Patient survival:
Class A Class B Class C
One-year 100 % 80 % 45 %
Two-year 85 % 60 % 35 %

23. Predictive models
MELD score
 Based upon Bilirubin levels, Creatinine, INR and etiology of Cirrhosis

24. Lap. vs Open Cholecystectomy
Laurence et.al., 2005 patients with cirrhosis 1:
 LC (n=1756) and OC (n=249)
 Lap. approach compared to open was associated with
 Fewer post-operative complications (17.6 % vs 47.7 %)
 Fewer infectious complications (5.9 % vs 19.9 %)
 Lower post operative hepatic insufficiency rate (7.7% vs 18.1%)
 Lower mortality rate (0.8 % vs 2 %)
 Conversion rate was 5.8 %
 Prevalence rate of Child A, B and C patients were similar,
 76.6, 21.77 and 1.59% for LC and 67.2, 28.73 and 4.02 for OC respectively
1 Laurence JM, Tran PD, Richardson AJ, Pleass HC, Lam VW. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes
and meta-analysis of randomized trials. HPB (Oxford). 2012;14(3):153-61.

25. Lap. vs Open Cholecystectomy
Puggioni et. al., meta-analysis of four case 1
 Less operative blood loss (113 vs 425.2 ml)
 Shorter operative time (123.3 vs 150.2 mins.)
 Decreased length of hospital stay (6 vs 12.2 days)
 No statistical significance in morbidity (9.52 vs 15%), mortality
(4.76 vs 0 %) or wound infection (0 vs 0.13 %)
1 Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197(6):921-6.

26. Lap. vs Open Cholecystectomy
Common complications following LC 1
• Postoperative worsening of ascites
• Intraoperative bleeding
• Intra-abdominal collections
• Pulmonary infection
• Blood transfusion
• Recurrent stones in GB remnant (subtotal
cholecystectomy)
1 Yeh CN, Chen MF, Jan YY. Laparoscopic cholecystectomy in 226 cirrhotic patients. Experience of a single center in Taiwan. Surg Endosc.
2002;16(11):1583-7.

27. Lap. vs Open Cholecystectomy
Conversion from lap. to open
 Ranges from 4.75% – 5.8% 1
 Reasons:
• Difficulty in identifying anatomy
• Uncontrolled bleeding
• Massive intracavitary adherences
• Need for CBD exploration
• Suspected bile duct injury
MELD score >14: effective predictor for conversion 2
1 Machado NO. Laparoscopic cholecystectomy in cirrhotics. JSLS. 2012;16(3):392-400.
2 Delis S, Bakoyiannis A, Madariaga J, Bramis J, Tassopoulos N, Dervenis C. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD
score and Child-Pugh classification in predicting outcome. Surg Endosc. 2010;24(2):407-12.

28. LC in cirrhotic vs non-cirrhotics
 A metanalysis comparing LC in cirrhosis and normal 1
• Higher conversion rate
• Longer operative time
• Increased intraoperative bleeding
• Increased estimated blood loss
• Increased overall morbidity
 Emergency procedures associated with 2
• Higher morbidity, longer postoperative hospitalization and increased
mortality (7 folds)
1 Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197(6):921-6.
2 Carbonell AM, Wolfe LG, Demaria EJ. Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients.
Hernia. 2005;9(4):353-7.

29. LC in cirrhotic vs non-cirrhotics
Major challenges:
• Adhesions with increased neovascularity
• Difficult retraction of liver
• Inadequate exposure of liver
• Inadequate exposure of cholecystohepatic triangle
• A high-risk gallbladder bed

30. Major advantages
 Quicker recovery
 Less contact with patient’s blood and viscera
 Reduced incidence of ascites leak
 Greater magnification of view
 Less abdominal trauma
 Positive abdominal pressure decreases bleeding
 Less peritoneal adhesion thus makes subsequent interventions easier

31. Final consideration
Challenging surgery
Treatment should be individualized
Correction of coagulopathy
PTC is an option
Elective over emergency
Surgery as life saving in patient with Child-pugh class C