Cirrhosis, the end stage of progressive liver inflammation and fibrosis, poses a serious health risk to our society. A wide variety of disorders can contribute to the development of cirrhosis including viral hepatitis, alcohol-related liver disease, nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis (NASH), as well as a variety of metabolic derangements to name a few.

Cirrhosis in general and portal hypertension in particular have been associated with significant morbidity and mortality in patients undergoing a variety of surgical procedures. Csikesz et al. reviewed data from the national inpatient sample from 1998 to 2005. During this time, 22,659 patients with cirrhosis of whom 4214 patients had concomitant portal hypertension were reviewed. Four elective index operations were chosen including cholecystectomy, coronary artery bypass graft. These patients were compared to approximately 2.8 million others without said comorbidities during the same period. Mortality rates were significantly higher is those with cirrhosis and cirrhosis with additional portal hypertension compared to controls. Additionally, increased cost and length of hospital stay were identified emphasizing the increased difficulty of managing such patients [1]. Further studies demonstrated similar trends with increased in-hospital morbidity and mortality in both elective and emergent cases [2]. As cirrhosis progresses and portal hypertension develops, morbidity and mortality rates increase further. Several scoring systems have been developed to stratify patients by the severity of their liver disease. The Childs–Pugh–Turcotte (CPT) system and the Model for End-Stage Liver Disease (MELD) scoring system represent the two most commonly utilized scales of the severity of liver disease. In one study of 92 patients undergoing elective and emergent surgery, mortality rates were 10, 30, and 82% respectively for Childs’ class A, B, and C respectively [3]. In another compelling study, 772 patients undergoing major surgery were evaluated. Thirty-day mortality was found to increase with increasing MELD scores. In this study patients with a MELD score up to 7 had a 5.7% perioperative mortality, while patients with a MELD of ≥26 had 90% mortality rates [4]. Both CPT and MELD can be used to stratify patients in order to assess feasibility and advisability of undertaking a surgical adventure in the nonemergent setting. While there is no specifically accepted maximum CPT or MELD score that necessarily precludes surgical intervention, these studies clearly demonstrate extremely high rates of mortality in patients who are CPT class C or with MELD scores in the 20s. As such, very careful consideration needs to be exercised as to which of these patients surgical interventions can be entertained, and which ones would any intervention be essentially futile. A variety of associated physiological derangements that area associated with cirrhosis predispose such patient to increased morbidity. Malnutrition, ascites, hyponatremia, coagulopathy in addition to associate renal and cardiac dysfunction that can often accompany cirrhosis all play a role in increasing the risk of complications and inhibiting the normal healing and recovery for such patients [5].

Laparoscopic surgery offers a variety of advantages over tradition open surgery. Numerous studies of various procedures have shown decrease post-operative pain, decreased -length of hospital stay, earlier return to work, often improvements in blood loss and infection rates [6–9]. Cirrhotics undergoing laparoscopic surgical are a unique surgical group. The possibility of small incisions, with less bleeding and less physiological stress is has the potential for improved tolerance of surgery in this high risk group. This improvement is balanced by the ability for patients with cirrhosis to tolerate the physiologic changes associated with laparoscopy. Laparoscopy requires the ability to insufflate the abdomen with gas. This pressurized gas causes a decrease in venous return to the right heart secondary to the increased intra-abdominal pressures. While a healthy person can tolerate this physiologic stress, cirrhotics, with there already vasodilated state could be more susceptible to this stress. Additionally, as the risk of bleeding is higher in cirrhotics compared to healthy controls, laparoscopy does not afford surgeons the same comfort in ability to control significant bleeding should it be encountered. Indeed in many series, one of the prime reasons for conversion to open surgery from laparoscopy is the onset of significant bleeding [10].

The remainder of this chapter will review some of the existing data for minimally invasive surgery performed in cirrhotics. We will address common procedures such as appendectomy and colon resection as well as procedures often linked to liver disease such as obesity related surgery and liver resections. We additionally will touch upon the data available for advanced endoscopic therapies in the cirrhotic patient. One of the most common procedures, the cholecystectomy, will be deferred. The next chapter is dedicated exclusively to this entity and as such we will only briefly touch upon this important procedure here.

Laparoscopic appendectomy is one of the most common procedures performed by the general surgeon. Appendicitis, the primary etiology leading to appendectomy occurs in all groups including patients with liver cirrhosis. Despite this, there is limited data as to the safety and complications associated with appendectomy, open or laparoscopic, in the cirrhotic patient. One early population based study was performed in 2000 in Denmark. Analyzing data from the Danish National Patient Cohort, 22,840 patients between 1977 and 1993 were identified with cirrhosis of which 69 underwent appendectomy (both laparoscopic and open procedures). In comparison to healthy controls, the 30-day mortality was found to be 9% in patients with cirrhosis compared to 0.7% in controls [11]. Furthering this line of study, Tsugawa et al. compared patients undergoing open vs. laparoscopic appendectomy. 40 patients with cirrhosis underwent appendectomy. 25 underwent open surgery and 15 underwent laparoscopic appendectomy. Complications including bleeding and wound infections were decreased in the laparoscopic group. The investigators noted as well a decrease in hospital length of stay and decreased pain in the laparoscopic group. Despite these relatively small numbers, this represents the largest group of patients with cirrhosis undergoing appendectomy in the literature [12].

The literature for laparoscopic colectomy is similarly restricted, represented by a few small case series. In one of largest series to date Martinez et al. reviewed their 10 year experience of laparoscopic colorectal surgeries performed and identified 17 patients with cirrhosis. Twelve were Childs’ A and 5 were Childs’ B cirrhotics. Morbidity rates were 29%, [13] which was similar to the 30–48% rates seen in other groups [14, 15]. As with similar procedures, a correlation between MELD score and post-operative morbidity and mortality has been demonstrated highlighting once again the importance of careful patient selection in cirrhotics undergoing any surgical procedure [16].

Liver cirrhosis is a known complication of long term untreated obesity. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are rapidly increasingly causes of liver disease in the obese population. The rates of NAFLD and NASH are estimated to be as high as 46% and 12% of the US population [17]. Increasingly, this has led to an increase in liver transplantation for NASH. Indeed, NASH over the first decade of the century increased from 1.2% of liver transplants to 9.7%, ranking it third behind only hepatitis C and alcohol related liver disease [18]. Some have projected that these processes will become the leading cause of liver transplant in the United States by 2025 [19].

Laparoscopic bariatric surgery has become standard for surgical treatment of obesity. These surgeries include the Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding and bilio-pancreatic diversion/duodenal switch among others. The data of these procedures is scarce in the cirrhotic patient, typically, reports are the results of procedures performed where the patient is discovered intra-operatively to have cirrhosis. Increasingly, bariatric surgery is being considered in patients with known, early and well-compensated cirrhosis [20].

The largest early reports of bariatric surgery came out of the University of Pittsburgh in the early part of the last decade. Dallal et al. reported on a retrospective cohort of 2119 patients undergoing laparoscopic Roux-en-Y gastric bypass. Thirty of these patients were identified to have cirrhosis of which 27 were identified intra-operatively. The group was notable for increased rates of other metabolic derangements seen with obesity including increased rates of diabetes, hypertension and the patients tended to be heavier than their noncirrhotic counterparts. Overall complications were comparable between those patients with and without cirrhosis in the cohort with no significant bleeding complications or liver related complications [21]. Similarly, Shimizu et al. reported on a prospectively maintained cohort of patients undergoing bariatric surgery with cirrhosis. Twenty-three patients were part of the cohort, 12 with known preoperative cirrhosis and 11 with cirrhosis discovered intraoperatively. Surgeries undergone include 14 patients undergoing roux-en-Y gastric bypass, 8 undergoing sleeve gastrectomy and 1 undergoing adjustable gastric band placement. Once again cirrhotics had a disproportionately high prevalence of comorbidities including over 80% having diabetes and hypertension [22]. Outcomes in both the Dallal et al. study and Schimizi et al. highlight low complications rates achievable with laparoscopic bariatric surgery in the cirrhotic patient though it is important to note that all of these patients were well-compensated cirrhotics.

While laparoscopic bariatric surgery may be safe and have utility in select well-compensated patients, an interesting corollary to this is whether bariatric surgery may be helpful in improving the status of the ailing liver and thus stave off the progression to liver failure and cirrhosis before they take hold. In another report out of University of Pittsburgh, Mattar et al. reviewed 70 patients undergoing laparoscopic bariatric surgery with NAFLD in varying degrees from steatosis to more advanced fibrosis. Liver biopsy was performed at the time of surgery and repeat biopsy performed 15 ± 9 months after surgery. Steatosis dropped from 88% to 8%, inflammation from 23% to 2% and fibrosis from 37% to 13% all of which were significant changes. Overall grade of liver disease dropped in 82% of the cohort and stage improved in 39% of the patients [23].

Endoluminal bariatric procedures hold potential for patients who might otherwise be unable to undergo laparoscopic or open bariatric procedures but who are still in need of an effective weight loss procedure. Such techniques include endoluminal vertical gastroplasty, transoral gastroplasty, transoral endoscopic balloon placement. Currently the only technique with any reports in cirrhotic patients include the intragastric balloon in a small series of six patients. Choudhary et al. described six patients with decompensated cirrhosis awaiting liver transplant. The balloon was endoscopically inserted to allow for weight loss during the pretransplant period in hopes of maximizing the patients preliver transplant status [24]. While data for endoscopic balloon shows that it is not nearly as effective as other surgical modalities in promoting weight loss [25], it would be an interesting option for those unable or unwilling to undergo traditional weight loss surgeries.