Giant hepatic cyst: laparoscopic fenestration and omentoplasty

Hepatic cysts are usually asymptomatic. Intervention is only indicated when they become symptomatic or when they grow at a rapid rate. This is the case of a patient presenting with a symptomatic giant hepatic cyst, a laparoscopic fenestration with omentoplasty is presented.

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Giant hepatic cyst: laparoscopic fenestration and omentoplasty

Authors

D Mutter, L Soler, J Marescaux

Abstract

Hepatic cysts are usually asymptomatic. Intervention is only indicated when they become symptomatic or when they grow at a rapid rate. This is the case of a patient presenting with a symptomatic giant hepatic cyst, a laparoscopic fenestration with omentoplasty is presented.

Mots-clés

Giant hepatic cyst, laparoscopic fenestration, omentoplasty

Type de vidéo

Vidéo chirurgicale

Durée

08'40''

Publication

2010-06

Popularité

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Sous-titres

E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2842.htm

Giant hepatic cyst: laparoscopic fenestration and omentoplasty

1. Introduction 00'21''

This is the case of a patient presenting with a symptomatic giant hepatic cyst. The cyst’s wall is very difficult to identify during the initial exploration of the liver. Underneath a portion of hepatic parenchyma, it is clear that this cyst remains concealed. The attentive examination of CT-scan images and the 3D reconstruction confirm the presence of a thin layer of parenchyma between the cyst and the peritoneal cavity. The cyst measures approximately 28cm in diameter. It is symptomatic since there are clinical signs of pain and the unesthetic presence of a dome in the anterior abdominal wall. For this reason, the cyst fenestration is decided upon. However, contrarily to many other cysts, it will not be possible to perform a massive resection of the bulging dome since this will lead us to resect some liver parenchyma with a great risk of bleeding but especially of postoperative biliary leak. By modifying the parameters of the reconstruction, it becomes clear that only a few elements of the cyst’s wall can be seen as they are surrounded by parenchymal elements. This will lead us to perform a small fenestration of this cyst. In order to prevent its early recurrence, an omentoplasty is immediately decided upon. The omentum that is fixed within the cyst should play the role of a natural drain preventing the cyst from forming again too rapidly.

2. Start of the procedure 02'09''

At the beginning of the procedure, at the highest portion of the cyst, bipolar cautery is started to achieve a coagulation of the liver parenchyma at the place of the incision.

3. Cyst incision 02'19''

An incision is then performed using the monopolar coagulating hook. The fluid leaking out of the cyst is totally clear as is usually the case for hepatic cysts. These liver cysts do not have any biliary component within the fluid.

4. Cyst aspiration 02'39''

First, a full aspiration of the cyst’s volume is carried out not only to avoid any peritoneal contamination but also to explore the inner part of the cyst and to safely resect the bulging dome. The aspiration may sometimes be difficult if the cyst’s fluid spreads diffusely through the abdomen. The cyst’s aspiration leads to completely modify the anatomical aspect of the inner part of the peritoneal cavity. It becomes clear that there are posterior necrotic areas associated with parietal adhesions. This is probably evocative of symptomatic episodes. These areas would also be the ones to be resected preferably.

5. Bulging dome resection 03'31''

The resection of the bulging dome is performed with the aid of a 5mm vessel-sealing device (Ligasure®). This instrument is useful for several reasons. First, it achieves an effective cauterization of the liver parenchyma and helps to prevent biliary leaks. It also carries a knife that ensures a particularly rapid resection. The resection is performed essentially towards the areas where there is very little hepatic parenchyma. The accidental resection or wound caused to significantly important biliary structures must be avoided at all cost. The vascular elements distended by the cyst are not really problematic. The resection is extended until the necrotic area that was previously identified. This piece of resected cyst will also be sent for pathologic examination to rule out its malignancy. The resection of this piece of the cyst’s dome is sufficient to obtain a complete voiding of the cyst and ensure the cyst’s exploration. The next step is the omentoplasty.

6. Omentum mobilization 04'59''

The omentum is mobilized until the identification of an omental fold that can be easily separated from the colon and be mobilized towards the diaphragm at the level of the dome. Once again, the use of the Ligasure® device is particularly rapid and effective. The inner part of the cyst is explored and shows no abnormalities. The omentum is easily mobilized thanks to the freeing that has been previously achieved.

7. Placement of omentum in the cyst\'s cavity 05'31''

It is positioned within the cyst’s cavity. Naturally, in order to avoid its early mobilization, it will be necessary to suture it. The objective is not to obtain a perfect or airtight fixation but to prevent the omentum from coming out as soon as the patient is mobilized.

8. Omentum fixation 06'24''

A few stitches of absorbable thread with an intracorporeal suture will ensure the omentum’s fixation. A first stitch is placed on the right part and another stitch is placed on the left part of the opening. As conventionally performed in hepatic surgery, stitches used are absorbable ones. A last stitch is positioned at the most superior part of the omentoplasty to ensure that a big omental fold is entirely situated within the cyst. All the needles are withdrawn to complete the procedure.

9. Suction drain placement 07'36''

A suction drain can be placed into the cyst in order to completely empty the cyst’s contents in the immediate postoperative period. Care must be taken that all suction orifices be situated within the cyst to avoid any contact with a digestive loop that would risk causing an adhesion of the drain onto a bowel loop by a suction effect. The procedure is therefore achieved without any additional maneuver. The drain is left in place during 48 hours.