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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

HEPATIC CYST


Pr D Mutter, Dr F Jamali, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


Liver cysts are common, congenital, benign entities. The workup and management of large non-parasitic liver cysts including the laparoscopic approach are illustrated in this case.

2. Keywords


Hepatic cyst, benign cyst, laparoscopic fenestration

3. Patient


Male, 45-year-old

4. Past medical history


Known polycystic liver disease

5. History of present illness


The patient presents with a sensation of fullness in the upper abdomen associated with early satiety. She denies abdominal pain, fever or weight loss. There is no nausea or vomiting.
The fullness sensation is aggravated in the supine position and the patient can palpate a distinct epigastric mass.

6. Physical examination


Confirms the presence of a firm movable mass in the epigastrium with no suspicious adenopathy. The remainder of the exam is normal.

7. Laboratory values


Screening laboratory values including liver function tests are within normal limits.

8. CT scan


Multiple cysts in both lobes of the liver, with a dominant large cyst occupying segment II and III, measuring 10 x 7 x 11 cm.

9. Procedure


The patient undergoes a laparoscopic cyst fenestration. This brief video illustrates the procedure.
video
Video 9

10. Discussion


Liver cysts are common, congenital, benign entities that occur more frequently in the right lobe. They are for the most part small in size and occur four times as frequently in females as in males. The most common presenting symptoms of large cysts are increased abdominal girth, vague pain, occasional bleeding or infection and rarely obstructive jaundice. Small asymptomatic cysts generally require no treatment. The preferred treatment of large cysts from which clear fluid is aspirated is excision. However, in cases of proximity of major vascular or ductal structures, unroofing and external drainage are also used. If the cyst contains biliary contents, a communication to the bile duct system should be presumed and excision or Roux-en-Y cystojejunostomy becomes the treatment of choice.
Polycystic liver disease often accompanies polycystic kidney disease. The number of cysts varies and rarely results in liver function compromise. Rupture, hemorrhage, and infection are rare. Simple aspiration of these multiple cysts is rarely effective. The surgical procedure of choice for a symptomatic dominant cyst in polycystic disease is the fenestration operation, in which the symptomatic cyst is made to communicate with the peritoneal cavity.
The laparoscopic approach to the management of non-parasitic cystic disease of the liver has been popularized lately. Several publications attest to its safety and feasibility. The recurrence rate after laparoscopic fenestration is highly variable but ranges from 11-40% in the various series. Transposition of an omental flap into the remaining cyst cavity has been described to minimize recurrences but its effectiveness remains unproven. Factors predicting failure include previous surgical treatment, deep-seated cysts, incomplete unroofing, location in the right posterior segments of the liver, and a diffuse form of PLD with small cysts.

11. References


  1. Gigot JF, Legrand M, Hubens G, de Canniere L, Wibin E, Deweer F, et al. Laparoscopic treatment of nonparasitic liver cysts: adequate selection of patients and surgical technique. World J Surg 1996;5:556-61.
  2. Kabbej M, Sauvanet A, Chauveau D, Farges O, Belghiti J. Laparoscopic fenestration in polycystic liver disease. Br J Surg 1996;12:1697-701.
  3. Krahenbuhl L, Baer HU, Renzulli P, Z'graggen K, Frei E, Buchler MW. Laparoscopic management of nonparasitic symptom-producing solitary hepatic cysts. J Am Coll Surg 1996;5:493-8.
  4. Zalaba Z, Tihanyi TF, Winternitz T, Nehez L, Flautner L. The laparoscopic treatment of non-parasitic liver cysts: five years experience. Acta Chir Hung 1999;2:221-3.