Hybrid laparoscopic Inokuchi shunt procedure for refractory pleural effusion and ascites associated with primary biliary cirrhosis: A case report

INTRODUCTION: Portosystemic shunts associated with portal hypertension are generally treated using non-invasive procedures, with open surgery required for refractory cases. Herein, we present a case of refractory pleural fluid and ascites associated with primary biliary cirrhosis (PBC), successfully treated using a hybrid laparoscopic Inokuchi shunt procedure. CASE PRESENTATION: The patient was a 74-year-old woman with a history of PBC, presenting with breathing difficulty. Computed tomography revealed massive pleural fluid and ascites and engorged coronary and azygos veins, indicative of a portosystemic circulation shunt and a 3-cm wide hepatocellular carcinoma (HCC) on liver segment 2. The Child-Pugh score was 11. With the portosystemic shunt outflow considered as the cause of pleural fluid and ascites; therefore, we proceeded with a hybrid laparoscopic selective Inokuchi shunt procedure and tumor enucleation. Laparoscopically, the greater omentum was divided for devascularization, a 7-cm right subcostal skin incision was made, and the abdomen was opened for HCC enucleation under direct vision. The left gastric vein was divided at its junction with the portal vein and connected to the vena cava using a left external iliac vein graft through the omental foramen. After this procedure, the pleural effusion and ascites disappeared, blood ammonium level decreased to normal, and Child-Pugh score decreased to 9. DISCUSSION: Using the Inokuchi shunt procedure, the portosystemic shunt, via the left gastric vein, was closed to increase portal blood flow and improve liver function. CONCLUSION: As a less invasive procedure, hybrid laparoscopic approach should be considered for portosystemic shunt via the left gastric vein.