الفهرس 
Liver CirrhosisOnly 14 pages are availabe for public view
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Abstract
Cirrhosis is a gradually developing, chronic
disease of the liver which always involves the
organ as a whole.
In most cases, no clear dividing line can be
drawn between cirrhosis and the preceding liver
disease.
Definitive classification of cirrhosis is
difficult. It can be categorized according to its
etiology, morphology, pathogenetic development,
clinical features and prognostic criteria.
Cirrhosis of the liver is a disease found all
over the world, affecting all races, age groups and
both sexes.
The causes of “liver cirrhosis” are numerous;
some of them are rare, appearing even in
childhood (e.g. drinking water from copper pipes).
Cirrhosis can be acquired or genetically based.
Cirrhosis clinically can be differentiated
into Latent cirrhosis or Manifest cirrhosis:
Various forms manifest as 1 hypersplenism,
2 increasing collateral varicosis with a
simultaneous rise in the splanchnic flow due to
hyperdynamic circulation and vasodilatation in the
area of the splanchnic vessels, 3 hepatic
encephalopathy, and 4 edema and ascites Cirrhosis can be diagnosed either by clinical
symptoms (easy fatigability, GIT disturbance,
etc), clinical signs as icterus, abdominal mass
(hepato-splenomegaly) or laboratory (liver
function tests) or radiological (abdominal
ultrasonography and CT) invetigations and finally
liver biopsy.
The prognosis for cirrhotic patients depends
upon the respective complications. The underlying
morphological processes, such as necrosis,
fibrosis and regeneration, combine to widely
differing degrees in the single cirrhotic patient.
Complications such as variceal bleeding,
hepatic encephalopathy, ascites, infections and
reduced renal function also influence the mortality
rate of liver cirrhosis. The main causes of death are
hepatic coma or liver failure, bleeding, infections
and HCC. Spontaneous bacterial peritonitis is fatal in
50-70.
Gall bladder stone disease is a wide range of
diseases affecting the gall bladder, several types
of methods are applied for a confident diagnosis.
These are explained below.
Cholecystectomy is a commonly performed
surgical procedure for patients suffering from
symptomatic gallstones. Open cholecystectomy
(OC) was the method of choice for gallbladder
surgery for almost a century and now the
laparoscopic cholecystectomy is considered as
first option for cholelithiasis.
About 70-80% of cholecystectomies are done
laparoscopically whereas 20-30% are still completed by open cholecystectomy in
compromised patients and patients with
complicated gallstones. Howeve LC can safely be
performed in cirrhotic patients and in cases of
acute cholecystitis by experienced surgeon.
Most studies focused on the comparison of
LC and OC and emphasized the better outcome of
LC. At present, it is well understood that patients
undergoing LC have a better and shorter recovery
time compared to those undergoing OC.
Patients with open cholecystectomy looks
more ill, feel more pain and have delayed
recovery as compared to laparoscopic
cholecystectomy where they have minimum
surgical stress, less postoperative pain, fast
recovery and early gastrointestinal motility and
feeding.
There is a consensus that the surgical cost of
LC is significantly greater than OC and SIC. The
reason is that LC requires expensive equipment
and it is harder to provide such equipment and
devices in less developed countries with major
obstacles in their healthcare system.
Complications from LC fall into two
categories. Those resulting from the laparoscopic
instruments and those associated with the
operation itself like bile duct injury etc and the
rates of complications in LC were much higher
during the initial era of laparoscopy.
Bleeding is a frequently encountered and
dangerous complication of laparoscopic
cholecystectomy. Factors contributing to operative site bleeding may include inadequate exposure,
acute inflammation, portal hypertension, adhesion,
coagulopathy and rough technique.
Cholelithiasis in patients with cirrhosis
occurs twice as often as in those in the general
population.
The morbidity and mortality rates, for open
cholecystectomy (OC) in patients with cirrhosis
were found to be as high as 5-23%, and 7-20%,
respectively and were mainly due to either
excessive blood loss with subsequent
postoperative liver failure, sepsis, or both.
Patients with liver cirrhosis have generally
been considered poor candidates for LC,
especially those with end-stage liver disease and
portal hypertension.
The overall risk factors include the type of
surgery (emergent or elective), Child-Pugh class
C, presence of ascites, encephalopathy, infection,
anemia, malnutrition, jaundice, portal
hypertension, hypoalbuminemia, prothrombin time
(PT) that does not correct with vitamin K, and
hypoxemia.
The difficulties in cirrhotics include:
1 Coagulopathy and increased risk of bleeding.
2 Preoperative optimization of patients.
3 Intraoperative management as:
a. Anesthesia management:
b. Insertion of ports:
c. Pneumo-peritoneum: 4 Difficulty in performing LC:
1. Adhesions with increased neovascularity.
2. Difficult retraction of the liver.
3. Inadequate exposure of the cholecystohepatic
triangle.
4. A high-risk gallbladder bed.
5. A high risk of hilum.
In recent reports, the rate of conversion to an
open procedure is noted in 0-15.7%. A low
threshold for conversion to OC should be
maintained. Absolute indications for conversion
are bleeding not readily controlled
laparoscopically and inability to define the
anatomy adequately. Uncertainty of safety and
efficiency warrants an immediate conversion to an
open procedure.
Laparoscopic cholecystectomy in cirrhotic
patients offers several advantages over OC and
include the following:
1. Reduced wound-related complications LC.
2. Inadvertent bacterial seeding and
contamination of the ascites is also
significantly reduced.
3. The magnification in LC allowing adoption of
modified subtotal cholecystectomy.
4. Guarding of the operating team from patients
with hepatitis C or B infection.
5. Decreasing the incidence of suspected
bleeding from coagulopathy due to less
manipulation. 6. Leads to fewer upper abdominal adhesion
especially some patients of cirrhosis may be a
candidat for future liver transplantation.