· Bilirubin, albumin, INR, ascites, encephalopathy
· Used to predict operative mortality based on cirrhosis severity
· Mortality in EGS:
– Child-Pugh A: 10% electively and 22% emergently
– Child-Pugh B: 30% electively and 38% emergently
– Child-Pugh C: 80% electively and up to 100% emergently
· creatinine, bilirubin, INR, and sodium
· MELD < 20 – 1% increase in mortality with each point increase
· MELD > 20 – 2% increase in mortality with each point increase
· Identification of cirrhosis with physical examination, bloodwork and imaging
· Involvement of other medical services (internal medicine, hepatology, ICU) as needed
· Cirrhosis optimization, if possible
· Abdominal wall mapping
- Communicate unexpected findings to the operative team and think of additional adjuncts you may need such as additional ports, topical hemostatic agents or energy devices.
- Think about why you are in the OR. If its an elective situation and can wait, consider bailing. If its emergent, you may have to do something more definitive.
- Exposure may be a challenge, you may have to alter your typical approach including where the assistant grabs and retracts. Extra hands are helpful.
- Bleeding can be a big deal. If possible, map out the abdominal wall ahead of time with cross-sectional imaging. Stay away from varices around the umbilicus or porta
· Ideally, control ascites pre-operatively, if you can’t consider leaving drains
· Small (< 2cm) hernias close primarily
· Larger (>2cm) hernias repair with mesh unless infected filed (controversial)
· Minimally invasive repairs can be performed
· Incidence of gallstones is 4-5 times higher in cirrhotic patients
· Prophylactic laparoscopic cholecystectomy (LC) generally not done
· LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis)
· Cholecystostomy and ERCP are safe
Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32
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