title: Single-incision laparoscopic cholecystectomy for cholecystolithiasis coinciding with cavernous transformation of the portal vein: report of a case.
abstract: BACKGROUND
  Cavernous transformation of the portal vein (CTPV) is a rare vascular deformity. It is thought to be secondary to extra-hepatic portal vein obstruction, with formation of serpiginous collateral vessels around the extra-hepatic bile duct, and even the gallbladder. Surgery is difficult because the vessels have irregular courses, are somewhat fragile and bleed easily. Single-incision laparoscopic cholecystectomy, an emerging procedure for symptomatic cholecystolithiasis, has limitations especially in anatomically complex cases.
  
  
  METHODS
  We describe a 44-year-old woman with symptomatic cholecystolithiasis. Computed tomography revealed a series of tortuous collateral veins at the liver hilum, with the extra-hepatic portal vein occluded at the level of the spleno-portal junction. However, the distended vessels were not particularly close to the cystic duct. We performed single-incision laparoscopic surgery (SILS) for cholecystectomy via a trans-umbilical incision. By pulling the cystic duct out along with neighboring cavernous vessels, we were able to secure detachment of the cystic duct from Calot's triangle and ligation of the cystic artery. Total operating time was 132 minutes and blood loss was 370 grams. The patient was discharged on postoperative day 2 with no perfusion abnormalities in the liver.
  
  
  CONCLUSIONS
  We must pay meticulous attention to the area of Calot's triangle when performing SILS cholecystectomy with CTPV. SILS cholecystectomy might be an option in highly experienced facilities.
authors.affiliation: Department of Surgery, Kikkoman General Hospital, Chiba, Japan. shirasu-tky@umin.ac.jp
authors.forename: Takuro
authors.initials: T
authors.lastname: Shirasu
authors.forename: Yoneei
authors.initials: Y
authors.lastname: Kawaguchi
authors.forename: Junichiro
authors.initials: J
authors.lastname: Tanaka
authors.forename: Yoshiro
authors.initials: Y
authors.lastname: Kubota
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Watanabe
mesh_terms: D000328:Adult; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D041761:Cholecystolithiasis / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D011169:Portal Vein / Q000473:pathology* / Q000601:surgery; D016896:Treatment Outcome