Cirrhosis is not a contraindication to laparoscopic surgery W. S. Cobb, B. T. Heniford, J. M. Burns, A. M. Carbonell, B. D. Matthews, K. W. Kercher Department of Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, 1000 Blythe Boulevard, MEB 601, Charlotte, NC 28203, USA Received: 3 April 2004/Accepted: 12 October 2003/Online publication: 23 December 2004 Abstract Background: Cirrhosis of the liver contributes signifi- cantly to morbidity and mortality in abdominal surgery. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic procedures in a series of consecutively treated patients with biopsy-proven cirrhosis. Methods: The medical records of all patients with biopsy-proven cirrhosis undergoing laparoscopic sur- gery at the authorsÕ medical center between January 2000 and December 2003 were retrospectively reviewed. Results: A total of 50 patients (27 men and 23 women) underwent 52 laparoscopic procedures. Among these 50 patients were 39 patients with Child-Pugh classification A cirrhosis, 10 with classification B, and 1 with classi- fication C, who underwent a variety of laparoscopic procedures including cholecystectomy (n = 22), sple- nectomy (n = 18), colectomy (n = 4), diagnostic lapa- roscopy (n = 3), ventral hernia repair (n = 1), Nissen fundoplication (n = 1), Heller myotomy (n = 1), Roux-en-Y gastric bypass (n = 1), and radical nephrectomy (n = 1). There were two conversions (4%) to an open procedure. The mean operative time was 155 min. Estimated blood loss averaged 124 ml for all pro- cedures, and 20 patients (40%) required perioperative transfusion of blood products. One patient required a single blood transfusion postoperatively because of anemia. No one experienced hepatic decompensation. Overall morbidity was 16%. There were no deaths. The mean length of hospitalization was 3 days. Conclusions: Although technically challenging because portal hypertension, varices, and thrombocytopenia frequently coexist, basic and advanced laparoscopic procedures are safe for patients with mild to moderate cirrhosis of the liver. Key words: Laparoscopy — Cirrhosis — Hepatitis — Portal hypertension — Thrombocytopenia Historically, cirrhosis has been considered a significant moniker of postoperative complications and death. Mortality after open abdominal operations ranges from 10% in patients with Child-Pugh classification A cir- rhosis to 82% in patients with Child-Pugh classification C [19]. A prothrombin time 2.5 s greater than for the control condition portends significant risk of bleeding complications and carries a mortality rate greater than 80% in open cholecystectomy [2]. In nonbleeding pa- tients with cirrhosis, the mortality rate is reportedly as high as 35% for biliary tract operations, 83% for pro- cedures treating the spleen and pancreas, and 23% for repair or resection of the gastrointestinal tract [8]. With the emergence of laparoscopic techniques, many abdominal pathologies are currently treated in this minimally invasive manner. Initially, cirrhosis was considered an absolute con- traindication to laparoscopy because of the risk for massive bleeding during dissection. However, with im- proved operative skills and techniques, several series have reported success with laparoscopic cholecystec- tomy in selected patients with cirrhosis. The literature reports 528 patients with cirrhosis who have undergone laparoscopic cholecystectomy. Most of these patients (81%) are classified as Child-Pugh A cases, and only 1.1% are classified as C cases. The overall morbidity is 16%, and the mortality rate is less than 1% (Table 1). These results compare favorably with those for open cholecystectomy and suggest that laparoscopic chole- cystectomy can be performed safely for patients classi- fied as Child-Pugh A and B cases. Cirrhosis portends an increase in postoperative mortality after appendectomy as well. In a cohort study performed in Denmark, the 30-day mortality rate was 9%, as compared with 0.7% for the noncirrhotic group [22]. In a comparison of laparoscopic and open appen- dectomies, the rates of wound infection and wound Correspondence to: K. W. Kercher Surg Endosc (2005) 19: 418–423 DOI: 10.1007/s00464-004-8722-3 Ó Springer Science+Business Media, Inc. 2004