Sarcoidosis is a chronic multisystem inflammatory disease characterized by the formation of non-caseating granulomas in affected tissues. While the lungs and lymph nodes are most commonly involved, sarcoidosis can also affect the liver, spleen, skin, eyes, and other organs. When a patient with sarcoidosis develops gallbladder disease such as symptomatic gallstones or cholecystitis, laparoscopic cholecystectomy becomes the treatment of choice. However, the co-existence of sarcoidosis poses unique challenges to anesthesia, surgical dissection, and postoperative care.

This article discusses the nuances of performing laparoscopic cholecystectomy in a patient with sarcoidosis, with emphasis on preoperative assessment, intraoperative modifications, and outcome optimization.

Understanding Sarcoidosis in the Surgical Context

Sarcoidosis may complicate surgery because of its multisystem involvement:

Pulmonary system: Interstitial lung disease, fibrosis, or restrictive lung pathology may impair oxygenation during general anesthesia.

Cardiac involvement: Sarcoid granulomas can cause arrhythmias, conduction abnormalities, or cardiomyopathy, increasing anesthetic risk.

Hepatic and splenic involvement: Granulomas in the liver or spleen may enlarge these organs, altering normal anatomy and complicating laparoscopic dissection.

Lymphadenopathy: Enlarged periportal or pericholedochal lymph nodes may obscure Calot’s triangle, raising the risk of bile duct injury.

Corticosteroid therapy: Many patients are on long-term steroids, which suppress immunity and impair wound healing, requiring perioperative stress dose steroids.

Because of these systemic factors, sarcoidosis patients undergoing laparoscopic cholecystectomy need meticulous planning and a multidisciplinary approach.

Indications for Surgery

As in the general population, the indications for laparoscopic cholecystectomy in sarcoidosis include:

Symptomatic gallstones with biliary colic.

Acute or chronic cholecystitis.

Gallstone pancreatitis.

Gallbladder dyskinesia with recurrent pain.

Suspicious gallbladder polyps.

In sarcoidosis, surgery may also be advised earlier because chronic inflammation and steroid therapy can predispose to complicated cholecystitis.

Preoperative Evaluation

A thorough preoperative workup is crucial:

Pulmonary assessment – Pulmonary function tests, chest X-ray or CT to evaluate lung involvement.

Cardiac evaluation – ECG and echocardiography to detect arrhythmias, conduction block, or reduced ejection fraction.

Liver function tests – To assess hepatic involvement since the gallbladder is anatomically close to the liver.

Medication review – Adjustment of corticosteroid dose; prophylactic antibiotics may be needed due to immunosuppression.

Anesthesia consultation – Planning to minimize perioperative hypoxemia, hypercarbia, and cardiac stress.

Surgical Technique in Sarcoidosis Patients

The laparoscopic cholecystectomy steps remain broadly the same, but surgeons must be alert to unique intraoperative challenges:

Patient Positioning and Access

The patient is positioned in reverse Trendelenburg with left tilt. If sarcoid-related splenomegaly is present, trocar placement may need slight modification to avoid injury.

Creation of Pneumoperitoneum

Carbon dioxide insufflation should be carefully monitored. Patients with restrictive lung disease may not tolerate high intra-abdominal pressure; thus, low-pressure pneumoperitoneum (10–12 mmHg) may be used.

Exploration and Identification

In sarcoidosis, the liver may appear enlarged or nodular due to granulomas. Enlarged lymph nodes in Calot’s triangle can make dissection technically demanding.

Dissection of Calot’s Triangle

This step can be particularly challenging. Fibrosis and lymphadenopathy may obscure the cystic duct and artery. Surgeons must ensure the Critical View of Safety (CVS) is obtained before clipping or dividing structures. In difficult cases, a fundus-first (dome-down) approach or subtotal cholecystectomy may be safer.

Cystic Duct and Artery Control

Clipping may be hindered by fibrosis; advanced bipolar or harmonic devices can be helpful. In the presence of distorted anatomy, intraoperative cholangiography may guide safe ductal identification.

Gallbladder Removal

The gallbladder is detached from the liver bed and retrieved via the umbilical port. Care must be taken to avoid bleeding, as sarcoidosis may cause fragile vessels.

Postoperative Care

Patients with sarcoidosis need tailored postoperative management:

Oxygen monitoring due to risk of pulmonary complications.

Pain control while minimizing respiratory depression.

Steroid supplementation in those on chronic corticosteroids to prevent adrenal crisis.

Infection prevention with vigilant wound care, as immunosuppressed patients heal slowly.

Histopathology – In rare cases, sarcoid granulomas may be found in the gallbladder wall itself, providing diagnostic insights.

Outcomes and Prognosis

When performed by experienced surgeons with proper preoperative optimization, laparoscopic cholecystectomy in sarcoidosis patients is generally safe and effective. Studies suggest:

Symptom relief is comparable to that in non-sarcoidosis patients.

Conversion rates to open surgery are slightly higher due to difficult anatomy from lymphadenopathy and fibrosis.

Complication rates remain low if CVS is meticulously obtained.

Most patients resume normal activities within 1–2 weeks, though recovery may be slower in those with advanced pulmonary or cardiac sarcoidosis.

Conclusion

Laparoscopic cholecystectomy in sarcoidosis patients is feasible and safe but requires special consideration of the disease’s systemic effects. Preoperative assessment of pulmonary, cardiac, and hepatic status is vital. Intraoperatively, surgeons must be prepared for altered anatomy due to granulomas, lymphadenopathy, or fibrosis, and should not hesitate to adopt alternative strategies such as low-pressure pneumoperitoneum, fundus-first approach, or subtotal cholecystectomy. With careful planning and expert technique, patients with sarcoidosis can achieve excellent surgical outcomes and symptom relief.