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American Board of Abdominal Surgery


Return to the Index of the Journal of Abdominal Surgery

ABDOMINAL SURGERY

Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 2012 / Spring 2013 issue of the Journal.

Hydatid Cyst of the Liver – Laparoscopic Management

Dr. Faris Dawood Alaswad, M.D., M.B.CH.B., F.I.C.M.S., F.I.C.S., F.A.C.S., F.E.B.S.
Specialist General Surgeon

Dr. Sukrett Shetty, M.D, M.C.H.
Specialist General Surgeon

NMC Speciality Hospital
Dubai, UAE


ABSTRACT

Hydatid Cyst disease is a very common disease in the middle east countries, it is caused by parasite called Echinococcus Granulosis which is acestode that inhibits the intestine of dogs and canines as a definitive host. Humans are accidental intermediate hosts due to ingestion of the parasitic eggs. The common sides of occurrence are the liver, lung, brain and other viscera. A variety of treatment modalities have been successfully employed starting from medical therapy for small cyst, procedures done by the interventional radiologists to the classic surgical procedures. Nowadays Hepatic Hydatid Cyst can be effectively treated by laparoscopic surgery on selected basis. Here we report a case of patient with two big Hydatid Hepatic Cysts which were treated successfully by laparoscopic surgery in our hospital, New Medical Center Specialty Hospital, Dubai, UAE.

Keywords: Hydatid cyst, Liver, Laparoscopic

INTRODUCTION

Echinococcosis is the most frequent cause of liver cysts in the world, it is very common in the states where sheep herding and breeding is a wide spread profession. The conventional operative procedures like encapsulation, cystectomy, evacuation, marsupialization, etc. involve a significant morbidity. Recently successful attempts have been reported for the management of Hydatid cyst of the liver by laparoscopic methods.1 The following case report illustrates the feasibility of this technique.

CASE REPORT

A thirty five year old male was admitted to New Medical Center Specialty Hospital, Dubai, UAE at June 2010 with pain in the right upper quadrant for the last eight months. There was no history of weight loss, fever. On examination the liver was palpable three fingers below costal margin at the midclavicular line. There was no icterus, no rash, and no oedema. All blood tests were normal. Chest X-ray showed a little raised right dome of the diaphragm. Caroni’s test and ELISA for Hydatid disease were positive. US and CT scan of the abdomen was done to note the exact site and dimensions of the cysts, there were two cysts one located at the left lobe measuring 7 by 9 cm and the other located at the superior aspect of the right lobe of the liver measuring 10 by 10 cm.

It was decided to manage this case laparoscopically so the patient was put on Albendazole 10 mg/kg/day for 14 days before operation.

At surgery patient was positioned in supine position, general anesthesia applied, head raised and left lateral tilt, pneumoperitonum was created via the umbilical port. The pressure was set at 12 mmHg, three more ports applied one 10 mm and two of 5 mm, camera changed from zero to thirty degree on need. Normal saline and betadine was used as scoilocidal. No special instruments like the Palanivelu1, 2 hydatid trocar system were used. Entire contents of cyst were evacuated with avoiding of spillage as much as possible. Patient recovered well postoperatively and was sent home at the third postoperative day. He was advised to do postoperative follow up for one year which shows no recurrence of the disease.

DISCUSSION

Majority of the hydatid cysts of the liver have been managed by conventional open surgical techniques which entail a lot of morbidity.1 The search for less invasive methods for managing this common benign disorder is continuing and it seems that laparoscopist will take a place of general surgery in this field too.1, 2, 3

Figure 1
Left Lobe Hydatid

click to enlarge
Figure 2
Aspiration Needle
Applied to the
Right Lobe

click to enlarge

Anti helminthics work best when used with small less than 4 cm cysts and they are unilocular.4 Rate up to 30% of success had been reported with mebendazole and up to 40% with albendazole.4, 5

Others report successful management of Hydatid liver cyst with percutaneous drainage techniques in a limited number of patients with the risk of cyst rupture, anaphylaxis reactions which give the impression that it is not so safe procedure to be done routinely.6

Surgery remains the treatment of choice for the majority of cases of Hydatid liver cyst and most of the general surgeons will be trained for that. 7, 8, 9 The main principle in any hydatid cyst surgery is to eliminate the scolices by evacuation without spillage, to check for any biliary communication, to sterilize and to obliterate the residual cavity.10

The most important factor to achieve a successful laparoscopic procedure is the selection of the patient with the good preparation.5, 6, 7 Patients with a deep seated cyst, multiple cysts and possible communication between the cyst and biliary tract should be excluded from laparoscopic approach.4 Evacuation of the cyst under pneumoperitoneum may not carry an increased risk of spillage and may even offer an advantage,1 when the proper technique is used, as the increase in intra cystic pressure is equal to or less than the increase in the intra peritoneal pressure after pneumoperitoneum.4 Aspiration of parasitic cysts by laparoscopic needle through a large cannula under vacuum has been found to be safe. A laparoscopic perforator – grinder – aspiratus has been designed. It penetrates the cyst by opening a hole in the cyst wall, grinds the particulate matter and sucks it all out if the cyst is small, management of the cavity is achieved by simple drainage.2

The disadvantage of the laparoscopic approach are the increased danger of contamination of the abdominal cavity with scolices, significant haemorrhage in case of cyst located deep in the parenchyma and difficulties to aspirate a highly viscous cyst content.6

Filling of the sub diaphragmatic space with povidone iodine (in right lobe cyst), filling the cyst with 20% hyper tonic saline and waiting for 5 minutes and using two aspirators reduces the risk of spreading.8

The main advantages of the laparoscopic approach in selected cysts, i.e., those which are located superficially and having a liquid content are less postoperative pain, early ambulation, minimal or no ileus, lower incidence of wound infection, a more aesthetic results and a shorter hospital stay.7

CONCLUSIONS

Laparoscopic management is an alternative and useful method of treating Hydatid cyst of the liver. It has results ready similar to open surgery with all the benefits of minimal access surgery and it is now the current treatment of choice on selected basis for Hydatid cyst of the liver.

Figure 3
Residual Cavity of the Left Lobe

click to enlarge
Figure 4
Hydatid Cyst Laminated Membrane

click to enlarge

REFERENCES

1. Ustunsoz B, AKHAN O, Kamiloglu MA, Percutaneous treatment of Hydatid cysts of the liver: long-term results. Am J Roentgenol. 1999;172:91-6.

2. Enrico Brunetti, Carlo Filice, Calum Macpherson. PAIR: Puncture, Aspiration, Injection, Re – Aspiration. An option for the treatment of Cystic Echinococcosis. WHO/ EMC Web site. Available at www.Who.Int/emcdocuments /zoonoses/whocdscsaraph20016.html. Accessed on 15.10.2004.

3. Guibert L, Gayral F. Laparoscopic pericystectomy of a liver Hydatid cyst. Surg Endosc. 1995;9:442-3.

4. Sever M, Skapin S, Laparoscopic pericystectomy of liver Hydatid cyst. Surg Endosc. 1995;9:1125-6.

5. Bickel A, Eitan A. The use of a large transparent cannula, with a beveled tip, for safe laparoscopic management of hydatid cysts of liver. Surg Endosc. 1995;9:1304-5.

6. Khoury G, Jabbour-Khoury S, Bikhazi K. Results of laparoscopic treatment of Hydatid cysts of the liver. Surg Endosc. 1996;10:57-9.

7. Bickel A, Daud G, Urbach D. Laparoscopic approach to hydatid liver cysts. Is it logical? Physical, experimental, and practical aspects. Surg Endosc. 1998;12:1073-7.

8. Ertem M, Uras C, Karahasanoglu T. Laparoscopic approach to hepatic hydatid disease. Dig Surg. 1998;15:333-6.

9. Verma GR, Bose SM. Laparoscopic treatment of hepatic hydatid cyst. Surg Laparosc Endosc. 1998;8:280-2.

10. Niscigorska J, Sluzar T, Marczewska M et al. Parasitic cysts of the liver -practical approach to diagnosis and differentiation. Med Sci Monit. 2001;7(4):737-741.

11. Yaghan R, Heis H, Bani – Hani K. Is fear of anaphylactic shock discouraging surgeons form more widely adopting percutaneous and laparoscopic techniques in the treatment of liver hydatid cyst? Am J Surg. 2004:187(4):533-7.



Journal CoverOFFICIAL PUBLICATION OF:
The American Board of Abdominal Surgery
The American Society of Abdominal Surgeons, Inc.
Foundation for Abdominal Surgery

Louis F. Alfano, Jr., M.D., Editor-in-Chief
Diane M. Pothier, Executive Editor and
Director of Continuing Medical Education


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Matter appearing in Abdominal Surgery is covered by copyright. Permission will be granted for use if request is made in writing and the proper credit is given.

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Figure 1: Left Lobe Hydatid

Figure 2: Aspiration Needle Applied to the Right Lobe

Figure 3: Residual Cavity of the Left Lobe

Figure 4: Hydatid Cyst Laminated Membrane