Utility of Laparoscopy for Identification of Hepatic Disease Before Aortic Surgery

Abstract

Postoperative hepatic failure is a significant yet unpredictable cause of death after elective aortic surgery. Routine preoperative evaluation is frequently insufficient to identify patients at risk. This study was designed to prospectively evaluate the utility of laparoscopy before aortic surgery in patients at a high risk for postoperative hepatic dysfunction. Patients at high risk for postoperative hepatic insufficiency were identified by history, physical examination, and routine blood work. Diagnostic laparoscopy was performed immediately before the planned aortic surgery through a single umbilical incision using standard technique. Liver biopsies were obtained in patients with equivocal findings. The planned operative procedure was undertaken based on the laparoscopic findings. The laparoscopic findings were correlated with those at laparotomy and the postoperative course. Eleven patients scheduled for aortic surgery (indication: aortoiliac occlusive disease [AIOD], five; abdominal aortic aneurysm [AAA], four; renal artery stenosis [RAS], two) were deemed high risk for postoperative hepatic dysfunction owing to alcohol abuse (11 patients), hepatomegaly (1 patient), or laboratory abnormalities (4 patients). Laparoscopy was performed in all patients without complication and required 24 ± 13 minutes (± sd). Laparoscopy revealed a normal liver in three patients, mild liver disease in five, severe cirrhosis in two, and equivocal findings in one patient (frozen section biopsy showed normal liver). The planned aortic procedure (AIOD, aortobiiliac bypass [ABF]; AAA, aortoaorto/aortobiiliac [ABI], RAS, bilateral aortorenal bypass) was performed in nine patients and aborted in the two patients with cirrhosis. The laparoscopic findings correlated reasonably well with those at laparotomy (identical, six patients, lapscope overestimate, two patients, lapscope underestimate, one patient). Postoperative hepatic failure and death occurred after aortic surgery (lapscope, normal liver) in one patient, and transient laboratory abnormalities were seen in two patients (lapscope, mild liver disease). The direct variable and total hospital costs for the laparoscopic study performed as an adjunct to the aortic surgery were $123 and $472 respectively. Diagnostic laparoscopy before aortic surgery is a safe, simple, inexpensive adjunct that may help further identify patients at high risk for postoperative hepatic dysfunction.