Surgical Considerations and Techniques for Laparoscopic Cholecystectomy in Patients with Concurrent Portal Hypertension: Expert Perspectives

Title: Surgical Considerations and Techniques for Laparoscopic Cholecystectomy in Patients with Concurrent Portal Hypertension: Expert Perspectives

Introduction: Laparoscopic cholecystectomy (lap chole) in patients with portal hypertension presents unique challenges for surgeons. This article presents expert opinions from renowned surgical professionals who specialize in the field of hepatopancreatobiliary (HPB) surgery, gastroenterology, and liver transplantation. Their insights shed light on the complexities of performing laparoscopic cholecystectomy in patients suffering from portal hypertension, including those with cirrhosis and extrahepatic portal venous obstruction (EHPVO).

Expert Opinion 1: Dr. V K Kapoor, HOD, Department of HPB Surgery & Liver Transplantation, MGMCH, Jaipur

Dr. Kapoor emphasizes the criticality of surgical experience when attempting lap chole in patients with known portal hypertension. He highlights the presence of collaterals around the gallbladder (GB) and common bile duct (CBD) in EHPVO, making the procedure challenging even for experienced surgeons. He also cautions against underreporting of complications, stating that lap chole in EHPVO can be a potential nightmare for even skilled surgeons.

Expert Opinion 2: Dr. S K Mathur, Senior Professor, Surgical Gastroenterology, Mumbai

Dr. Mathur concurs with Dr. Kapoor’s observations and adds valuable surgical techniques for managing cholecystectomy in patients with portal hypertension. He suggests a unique approach of splitting the GB along its long axis and leaving the post GB wall on the liver, followed by fulguration of the mucosa and control of bleeding with sutures or modern energy devices. In cases of torrential bleeding from collaterals, he recommends administering IV Terlipressin.

Expert Opinion 3: Dr. Rajesh Bhojwani, Director, Department of Digestive Sciences, SDMH, Jaipur

Dr. Bhojwani shares his experience in performing lap chole in patients with cirrhosis and EHPVO. He mentions that collaterals are usually found around the Calot’s triangle, and a careful removal of the GB is possible with controlled traction and counter traction. Dr. Bhojwani’s recent paper challenges the necessity of portal decompression before cholecystectomy in all patients with EHPVO, presenting evidence of successful lap chole in selected cases.

Expert Opinion 4: Dr. Rajendra Desai, Professor of Surgical Gastroenterology, Hyderabad

Dr. Desai offers a consensus that cholecystectomy or Hepaticojejunostomy should be attempted in patients with portal hypertension. However, he suggests considering the patient’s condition, such as Child-Pugh classification in cirrhosis, before proceeding with the procedure. For patients with severe cirrhosis (Child B and C), the risk of increased mortality should be taken into account, and surgery should be reserved for patients with Child A and good Child B.

Conclusion: Performing laparoscopic cholecystectomy in patients with concurrent portal hypertension demands careful consideration and experienced surgical hands. The insights shared by these esteemed experts shed light on various techniques, challenges, and the importance of patient selection. Future research and collaborative efforts can further improve the outcomes for these complex surgical cases.