Incidental Detection of Normal-Sized Liver Cirrhosis During Laparoscopic Surgery

Introduction

Nowadays, laparoscopic surgery has become a common operation for treatment of both benign and malignant gynecologic conditions. Advantages of laparoscopic surgery are smaller incision, shorter hospital stay, less blood loss, and significantly less postoperative pain, compared to a traditional laparotomy. Furthermore, the benefit of laparoscopic surgery in exploring other upper abdominal organs, including the liver, was also reported. ¹

Most of the laparotomy incisions in gynecologic cases were made midline or lower midline; the upper abdominal region was often not completely evaluated. Previous study showed that liver abnormalities were found in 4.7% of 823 patients who underwent laparoscopic surgery for benign gynecologic conditions. ¹ The chance that the liver could be seen during the laparoscopic surgery for gynecologic conditions was ∼80.9%. ¹ The most common liver finding was the Fitz-Hugh–Curtis syndrome (68%), a rare condition of perihepatic adhesion between the liver and anterior abdominal wall or diaphragm, more commonly in the right lobe of the liver (66.7%). Other liver abnormalities were hemangioma (6.4%), hepatic cirrhosis (4.2%), and adenoma (2.1%). ¹

Cirrhosis is the late stage of progressive hepatic fibrosis commonly caused by alcoholism, hepatitis B, hepatitis C, and diabetes. ² Between 1999 and 2010, the prevalence of cirrhosis in the United States was ∼0.27%, corresponding to 633,323 adults. ² Common laboratory abnormalities of cirrhosis include elevated serum bilirubin, abnormal aminotransferases, elevated alkaline phosphatase/gamma-glutamyl transpeptidase, prolonged prothrombin time/elevated international normalized ratio, hyponatremia, and thrombocytopenia. Ultrasonography may see a change in the shape of the liver with nodular surface and parenchymal inhomegenicity. ³

In this report, a case of liver cirrhosis was found incidentally during laparoscopic hysterectomy for the treatment of cervical intraepithelial neoplasia (CIN) III.

Case Report

A 44-year-old woman, para3, had an abnormal Pap smear. Subsequently, the result of the biopsy of the cervix was classified as CIN III. She had no known underlying disease or history of alcohol abuse. Her physical examination results were normal, including a regular-sized liver by palpation. She was scheduled for laparoscopic-assisted vaginal hysterectomy. Her preoperative liver function tests were in normal ranges with aspartate aminotransferase (AST) of 34 U/L, alanine aminotransferase (ALT) of 37 U/L, and albumin level of 4.26 g/dL. The hepatitis B e-antigen (HBeAg) and the anti-hepatitis C virus (HCV) tests were nonreactive. However, her test of hepatitis B surface antigen (HBsAg) was reactive, which indicated acute or chronic HBV infection. Intraoperative findings revealed a normal-sized uterus and normal-sized uterine appendages (adnexa). The liver was seen to be in normal size with the nodular surface (Fig. 1a). Cirrhotic liver was suspected during the operation. Postoperative hysterectomy went as expected without any complication. Postoperative ultrasonography showed a normal-sized liver with heterogeneous parenchyma, uneven liver surface, obscure vasculature, fibrosis score 7, and no ascites. The patient was referred to a gastroenterologist for the treatment of liver cirrhosis.

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FIG. 1.

(a) Normal-sized liver with a nodular surface. (b) Ultrasonography showed a normal-sized liver with heterogeneous parenchyma.

Discussion

Laparoscopic surgery for gynecologic conditions has the benefit over a laparotomy in exploring throughout the abdominal cavity, especially in the upper abdominal part, which is usually missed in a traditional laparotomy. A review from Tulandi and Falcone showed that there is a very high chance of the liver being seen during laparoscopic surgery for gynecologic conditions (∼80.9%). ¹ The commonly seen conditions of the liver by a laparoscope were perihepatic adhesion (Fitz-Hugh–Curtis syndrome), hepatic cirrhosis, adenoma, and hemangioma. ¹

Although decompensated patients usually presented with jaundice, ascites, edema, upper gastrointestinal bleeding, or confusion, nearly half of the patients with cirrhosis were asymptomatic or had nonspecific symptoms such as fatigue, poor appetite, and weight loss. ⁴ The size of a cirrhotic liver can be normal, enlarged, or small. In the present case, the patient had no symptom of cirrhosis or chronic liver disease, no liver enlargement by palpitation, and no suggested laboratory abnormality for cirrhosis. Ultrasonography may show a change in the shape of the liver with nodular surface and parenchymal inhomegenicity. ³ In the past, the gold standard for diagnosis of cirrhosis was liver biopsy through a percutaneous, transjugular, laparoscopic, or radiographically guided fine-needle approach. ⁵ However, nowadays, liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis. During the laparoscopic surgery in this patient, the nodular surface of the liver was recorded and suggested a cirrhotic liver. Many studies showed that laparoscopy had a higher sensitivity and specificity in the diagnosis of cirrhosis, compared to a histologic result from a liver biopsy.^6,7 Ultrasonography in the upper abdomen was not routinely done preoperatively. In this case, laparoscopic hysterectomy had led to the diagnosis of liver cirrhosis incidentally.

Conclusion

A thorough inspection of the abdomen by a laparoscope, during an operation for gynecologic condition, should always be done to find other intra-abdominal abnormalities, especially in the upper abdomen. Conditions that are difficult to diagnose such as normal-sized liver cirrhosis can be done by inspecting the surface and size of the liver. These findings can be treated early by the specialist.