Primary laparoscopic cholecystectomy in patients with portal cavernoma and non-obstructive portal biliopathy: Two case reports.

A laparoscopic cholecystectomy can be technically challenging with co-existing portal hypertension, as commonly seen with cirrhosis of the liver. Extra hepatic portal vein obstruction (EHPVO) although less common, is a significant cause of portal hypertension in India. EHPVO has a unique clinical profile, which differentiates it from portal hypertension associated with cirrhosis of the liver. This impacts therapy in EHPVO algorithmically and operatively. We report two cases of symptomatic gall stones with portal cavernoma. Further evaluation revealed non-obstructive portal biliopathy. Both underwent a successful laparoscopic cholecystectomy. We highlight the importance of careful operative strategy, diligent haemostasis and the feasibility of performing a laparoscopic cholecystectomy in patients with symptomatic gall stones associated with a portal cavernoma.

INTRODUCTION

Laparoscopic cholecystectomy has been reported in portal hypertension patients with cirrhosis of the liver.[1] There are fewer reports of this in patients with extra hepatic portal vein obstruction (EHPVO), accompanied with cavernous transformation of the portal vein.[23] Involvement of the gall bladder by venous collaterals predisposes to inadvertent portal venous haemorrhage during the cholecystectomy.[4] This can be avoided by optimal pre-operative preparation and a cautious surgical strategy. In those with associated obstructive portal biliopathy, a decompressive porto-venous shunt helps to render the peri-hepatic-portal area safer for cholecystectomy and also facilitates the performance of a biliary drainage procedure.[5] We report our experience of laparoscopic cholecystectomy in two cases of symptomatic cholelithiasis associated with portal cavernoma.

CASE REPORTS

Case 1

A 25-year-old young man presented with recurrent right upper abdominal pain for 18 months. Abdominal sonography revealed cholelithiasis, a normal biliary tree, cavernous transformation of the portal vein, splenomegaly and significant peri-portal and peri-pancreatic venous collaterals. Upper gastro-intestinal endoscopy showed grade 2 oesophageal varices. Haematological, coagulation and liver profiles were normal except for raised serum alkaline phosphatase (437 IU/L) and gamma-glutamyl transpeptidase - 1329.3 U/L levels. Magnetic resonance cholangio pancreaticograpy (MRCP) revealed mild extrinsic compression of the mid common bile duct (CBD) and no biliary dilatation.

Case 2

A 39-year-old male patient presented with a history of recurrent upper abdominal pain and vomiting for 2 years. On evaluation, he was found then to have cholelithiasis with a portal cavernoma, which were followed-up conservatively. Recent imaging confirmed the same. Haematological, liver and coagulation profiles were normal. MRCP revealed mild extrinsic compression of the CBD and no biliary dilatation. Upper gastro-intestinal endoscopy was normal.

In view of symptomatic cholelithiasis with non-obstructive portal biliopathy the patients were taken up for cholecystectomy through a laparoscopic approach. Blood was cross-matched and two units of packed cells were arranged on a standby basis. Carboperitoneum was created by closed technique at the site of primary laparoscopic access, which was aided by optical guidance. In the first patient, this site was the umbilicus because of splenomegaly and access in the second at the left Palmar's point. Subsequent ports were placed under vision to prevent inadvertent injury to collateral venous channels on the abdominal wall for a ‘four-port’ cholecystectomy. The first patient was found to have a Calot's triangle bordering ‘smooth-surfaced’ portal cavernoma, minimal gall bladder varices and lateral abdominal wall venous collaterals [Figure 1]. The second patient had dilated venous collaterals that bordered the Calot's triangle, the cystic duct and both curvatures of the distal stomach [Figure 2].

Figure 1

Laparoscopic view of Case 1 showing large ‘smooth-surfaced’ portal cavernoma abutting the Calot's triangle area and some gall bladder varices too

Figure 2

Laparoscopic view of Case 2 showing ‘clipped’ varices along the cystic duct

The gall bladder was distended and thin walled in both patients, with a normal liver. Dissection of the Calot's triangle was performed with care to avoid bleeding. This was aided by ultrasonic endoshears (Harmonic Ace™, Ethicon Endo-surgery, USA) and a 5 mm bipolar electro-thermal fusion device (LigaSure™, Covidien AG, USA). A ‘critical-view’ of safety was first created to delineate the cystic artery and the cystic duct discreetly. These were successively clipped and transected. The gall bladder was freed from its fossa cautiously. A Jackson-Pratt drainage tube was placed in the gall bladder fossa. The gall bladder revealed multiple pigment gall stones and no varices. The patients had an uneventful recovery. Histopathological examination revealed chronic cholecystitis. The patients did well on follow-up.

DISCUSSION

Laparoscopy offers a paradigm advantage for cholecystectomy in the hands of an experienced laparoscopic surgeon. It does this through high-definition vision, precise dissection and haemostatic capability. This has been consistently described for laparoscopic cholecystectomy in cirrhotics and in early reports in EHPVO patients with portal cavernomas.[1234] In addition, all stratagems in extirpating the gall bladder pathology can be executed by laparoscopy, e.g., varying extents of a cholecystectomy. Furthermore, the normal hepatic architecture, coagulation profile, significant varices sparing the gall bladder in our experience, allows us to consider laparoscopic cholecystectomy in these patients. We suggest the use of laparoscopic cholecystectomy by an experienced surgeon in patients with cholelithiasis associated with portal cavernomas related to EHPVO with non-obstructive biliopathy.