Ann Hepatobiliary Pancreat Surg.  2023 Nov;27(4):366-371. 10.14701/ahbps.23-037.

Feasibility of laparoscopic cholecystectomy for symptomatic gallstone disease with portal cavernoma: Can prior portal vein decompression be avoided?

• Har B
• Mishra S
• Mahesh AS
• Shrimal A
• Bhojwani R

• KMID: 2548502
• DOI: http://doi.org/10.14701/ahbps.23-037

Abstract

Backgrounds/Aims
Biliary surgery in patients with extrahepatic portal vein obstruction with portal cavernoma (PC) is technically challenging, and associated with the risk of bleeding. Therefore, prior portal vein decompression is usually recommended before definitive biliary surgery. Only a few studies have so far reported the safety of isolated laparoscopic cholecystectomy. We aimed to evaluate our experience of laparoscopic cholecystectomy in patients with PC without prior portal decompression.
Methods
Prospectively maintained data for patients with PC who underwent laparoscopic cholecystectomy for symptomatic gallstone disease without portal decompression were analyzed. Clinical features, imaging, intraoperative factors, conversion rate, complications of surgery, and long-term outcomes were assessed.
Results
Sixteen patients underwent cholecystectomy without portal decompression from 2012 to 2021, of which interventions 14 were laparoscopic cholecystectomies. One patient required conversion (7.1%) to open surgery. Jaundice was present in 5 patients (35.7%), and underwent endoscopic stone clearance before surgery. Median intraoperative blood loss, operative time, and hospital stay were 100 mL (20−400 mL), 105 min (60−220 min), and 2 days (1−7 days), respectively. Blood transfusion was required in two patients (14.2%). Prior endoscopic or percutaneous intervention was associated with significant blood loss and prolonged intraoperative time.
Conclusions
In centers with experience, prior portal decompression can be avoided in patients with PC requiring isolated cholecystectomy to treat gallstones or their complications. Laparoscopic surgery is safe and feasible for these patients, and gives excellent outcomes in the selected group.

Keyword

Portal cavernoma; Portal cavernoma cholangiopathy; Laparoscopic cholecystectomy; Portal decompression

Figure

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  Fig. 1 Steps of laparoscopic cholecystectomy in portal cavernoma. (A) Dilated collateral vein over cystic duct (white arrow), and prominent collateral in the hepatoduodenal ligament (red arrow). (B) Dissected Calot’s triangle and ligation of cystic artery. (C) Doubly clipped cystic duct along with the dilated vein. Red arrow, cystic duct. (D) Liberal use of energy source (Harmonic Ace; Ethicon Endo-Surgery) for division of cystic duct. (E) Collaterals in Calot’s triangle clipped (red arrow), cystic duct stump (blue arrow), cystic artery stump (white arrow). Yellow arrow, clipped gallbladder stump. (F) Use of energy source (Harmonic Ace; Ethicon Endo-Surgery) for dissection of gall bladder from cystic plate.

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