title: Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants.
abstract: BACKGROUND
  Open cholecystectomy is associated with considerable morbidity and mortality in cirrhotic patients. Laparoscopic cholecystectomy may offer a better option because of the magnification available and the availability of newer instruments like the ultrasonic shears. We present our experience of 265 laparoscopic cholecystectomies and attempt to identify the difficulties encountered in this group of patients.
  
  
  METHODS
  Between 1991 and 2005, 265 cirrhotic patients of Child-Pugh Classification A and B, with symptomatic gallstones, were subjected to laparoscopic cholecystectomy. We describe here our tailored approach and our techniques of subtotal cholecystectomy.
  
  
  RESULTS
  Features of acute cholecystitis were present in 35.1% of the patients, and 64.9% presented with chronic cholecystitis. In 81.5% of the patients, the diagnosis of cirrhosis was established preoperatively. In 8.3% of the patients, a fundus first method was adopted when the hilum could not be approached despite additional ports. Modified subtotal cholecystectomy was performed in a total of 206 patients. Mean operative time in the subtotal cholecystectomy group was 72 minutes; in the standard group, it was 41 minutes. There was no mortality. In 15% of patients, postoperative deterioration in liver function occurred. Worsening of ascites, port site infection, port site bleeding, intraoperative hemorrhage, bilious drainage, and stone formation in the remnant were the other complications encountered.
  
  
  CONCLUSIONS
  Laparoscopic cholecystectomy is a safe and effective treatment for calculous cholecystitis in cirrhotic patients. Appropriate modification of subtotal cholecystectomy should be practiced, depending on the risk factors present, to avoid complications.
authors.affiliation: Department of GI and Minimal Access Surgery, Gem Hospital, Coimbatore, Tamilnadu, India.
authors.forename: Chinnasamy
authors.initials: C
authors.lastname: Palanivelu
authors.forename: Pidigu Seshiyer
authors.initials: PS
authors.lastname: Rajan
authors.forename: Kalpesh
authors.initials: K
authors.lastname: Jani
authors.forename: Alangar Roshan
authors.initials: AR
authors.lastname: Shetty
authors.forename: Karuppasamy
authors.initials: K
authors.lastname: Sendhilkumar
authors.forename: Palanisamy
authors.initials: P
authors.lastname: Senthilnathan
authors.forename: Ramakrishnan
authors.initials: R
authors.lastname: Parthasarthi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000150:complications / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D016896:Treatment Outcome