Single-incision laparoscopic cholecystectomy for cholecystolithiasis coinciding with cavernous transformation of the portal vein: report of a case
© Shirasu et al.; licensee BioMed Central Ltd. 2013
Received: 4 August 2012
Accepted: 5 April 2013
Published: 11 April 2013
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.
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.
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.
KeywordsCavernous transformation of the portal vein (CTPV) Single-incision laparoscopic surgery (SILS)
In this era of minimally invasive procedures, single-incision laparoscopic surgery (SILS) has become a popular option for cholecystectomy [1, 2]. SILS has been widely applied for elective cholecystectomy, but has limitations. The surgical field is somewhat small and the working space is limited, making operative procedures difficult. Therefore, we must often convert to conventional laparoscopy with multiple ports or open laparotomy in cases with complex anatomical features anatomy or unexpected bleeding. Cavernous transformation of the portal vein (CTPV) is a rare vascular variant, arising from extra-hepatic portal vein obstruction . Tortuous vessels surround the hepatoduodenal ligament, making biliary surgery difficult due to the high risk of bleeding. More CTPV cases may be detected with advancements in radiological preoperative imaging. Herein, we describe a successfully managed case. To our knowledge, this is the first report of SILS cholecystectomy for cholecystolithiasis in a patient with concomitant CTPV.
We considered SILS to be feasible because the cavernous vessels were not close to Calot’s triangle, and most ran from the middle to the left side of the hepatoduodenal ligament and liver hilum. Two distended collateral veins flowed extra-hepatically to the edge of the posterior segment of the liver. We were determined that these vessels could be sacrificed during the surgical procedure.
The patient was quite well postoperatively, with slightly increased AST (134 U/l), ALT (109 U/l) and ALP (188 U/l) on postoperative day 1, which decreased to 53, 78 and 181, respectively, the next day. Postoperative CT revealed that two extra-hepatic meandering vessels had been sacrificed but there were no hepatic perfusion abnormalities. She was uneventfully discharged on postoperative day 2. The liver enzymes dropped within normal ranges and she was asymptomatic on her last outpatient day of postoperative day 8.
Discussion and conclusion
With the advent of less invasive operative procedures in every field of surgery, laparoscopic cholecystectomy has replaced open cholecystectomy for cholecystolithiasis. In recent years, SILS cholecystectomy has been widely accepted in numerous facilities . Its potential benefits include superior cosmetic results, reduced postoperative pain and faster recovery with shorter hospital stay. The incidence of intraoperative complications is reportedly 2.7% . A meta-analysis  indicated that SILS cholecystectomy takes longer but is as safe as multiport conventional laparoscopic cholecystectomy for uncomplicated cholecystectomy. Our experience with 54 SILS cholecystectomy and 157 conventional multiple-port laparoscopic cholecystectomy (except for converted) cases shows no statistically significant difference in either operative time or blood loss (mean operating time 67.8 min versus 67.1 min, p=0.897 and mean blood loss 6.8 g versus 26g, p=0.103). Furthermore, we have performed SILS in 17 cases and multiple-port laparoscopic cholecystectomy in 18 cases with acute cholecystitis, and the two groups had similar operating times and blood losses (mean operating time 95.8 min versus 81.4 min, p=0.285 and mean blood loss 37g versus 56g, p=0.546).
CTPV was first reported by Gibson et al.  in 1955, and is now thought to be secondary to chronic extra-hepatic portal vein obstruction arising from congenital, intra-abdominal inflammatory, traumatic, neoplastic or unknown causes. As Yoshida et al. pointed out , an increasing number of asymptomatic cases with CTPV may now be detected with advancements in radiological imaging for preoperative screening. Although there have been few reports examining the influences of CTPV on gallbladder surgery, this condition is a challenge for surgeons because the vessels arise from paracholedocal and pericholedochal venous plexuses, which are somewhat brittle. Takahashi et al. reported a case with asymptomatic CTPV of undetermined cause associated with early gastric cancer . They had difficulty performing lymph node dissection of the hepatoduodenal ligament due to profuse bleeding, amounting to 1500ml. Bockhorn et al.  reported surgical outcomes of CTPV with chronic pancreatitis, and noted that greater intraoperative transfusion of red blood cells was required in pancreatic disease patients with CTPV. Surgeons must often surmount the obstacle of bleeding in cases with CTPV.
The long operating time and major blood loss in this case might be points worthy of criticism. We think that the main cause of bleeding is that we tried to detach the cystic duct from neighboring cavernous vessels. These vessels were too fragile to be completely preserved in keeping the cystic duct. The small collateral vessels can be safely sacrificed to minimize bleeding. We believe that laparoscopic cholecystectomy for young women is feasible and that sudden bleeding in this case might have been overcome even if we had performed conventional multiport laparoscopy. A lesson learned from this case is that surgeons performing biliary operations in cases with CTPV might encounter unexpected bleeding. We must be prepared to control intraoperative bleeding regardless of operative procedures.
In conclusion, when we perform SILS cholecystectomy in a case with CTPV, we must pay meticulous attention in the area of Calot’s triangle. SILS cholecystectomy might be an option in highly experienced facilities, but we must always keep in mind that patient safety has the highest priority.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Cavernous transformation of the portal vein
Single-incision laparoscopic surgery.
We are thankful to Yasutaka Kanai for his expertise in radiological imaging.
- Antoniou SA, Pointner R, Granderath FA: Single-incision laparoscopic cholecystectomy: a systematic review. Surg Endosc. 2011, 25: 367-377. 10.1007/s00464-010-1217-5.View ArticlePubMed
- Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M, Deeba S, Ashrafian H, Darzi A, Athanasiou T, Paraskeva P: The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc. 2011, 25: 378-396. 10.1007/s00464-010-1208-6.View ArticlePubMed
- Gibson JB, Richards RL: Cavernous transformation of the portal vein. J Pathol Bacteriol. 1955, 70: 81-96. 10.1002/path.1700700108.View ArticlePubMed
- Markar SR, Karthikesalingam A, Thrumurthy S, Muirhead L, Kinross J, Paraskeva P: Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis. Surg Endosc. 2012, 26: 1205-1213. 10.1007/s00464-011-2051-0.View ArticlePubMed
- Yoshida T, Ono M, Muraoka N: Sonographic diagnosis of nonmalignant extrahepatic portal venous obstruction–incidence and background (In Japanese with English abstract). Nihon Igaku Hoshasen Gakkai Zasshi. 1991, 51: 626-631.PubMed
- Takahashi T, Kakita A, Inagi E, Furuta K, Izumika H, Yoshida M, Omiya H, Isobe Y: Cavernous transformation of the portal vein coinciding with early gastric cancer and cholelithiasis. Surg Today. 1994, 24: 840-803. 10.1007/BF01636319.View ArticlePubMed
- Bockhorn M, Gebauer F, Bogoevski D, Molmenti E, Cataldegirmen G, Vashist YK, Yekebas EF, Izbicki JR, Mann O: Chronic pancreatitis complicated by cavernous transformation of the portal vein: contraindication to surgery?. Surgery. 2011, 149: 321-8. 10.1016/j.surg.2010.06.011.View ArticlePubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/13/10/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.