Laparoscopic pericystectomy for an 8cm hepatic hydatid cyst with 3D reconstruction

This is the case of a female patient presenting with epigastric pain. An 8cm liver cyst is identified on the examination. Given her previous medical and clinical history, the patient has a hydatid cyst. Serologic tests remain negative. This hydatid cyst is no longer active. Surgery is indicated given the symptomatology and the patient’s strong desire for the intervention. Indications for the surgical resection of non-active hydatid cysts remain rare. They mainly concern big cysts that may generate typical clinical signs of pain, heaviness and epigastric impairment. A standard pericystectomy performed in a stepwise manner should allow to resect this cyst without any resection of the liver parenchyma.

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Laparoscopic pericystectomy for an 8cm hepatic hydatid cyst with 3D reconstruction

Authors

D Mutter, L Soler, J Marescaux

Abstract

This is the case of a female patient presenting with epigastric pain. An 8cm liver cyst is identified on the examination. Given her previous medical and clinical history, the patient has a hydatid cyst. Serologic tests remain negative. This hydatid cyst is no longer active. Surgery is indicated given the symptomatology and the patient’s strong desire for the intervention. Indications for the surgical resection of non-active hydatid cysts remain rare. They mainly concern big cysts that may generate typical clinical signs of pain, heaviness and epigastric impairment. A standard pericystectomy performed in a stepwise manner should allow to resect this cyst without any resection of the liver parenchyma.

Mots-clés

Laparoscopic pericystectomy, 8cm hepatic hydatid cyst, 3D reconstruction

Type de vidéo

Vidéo chirurgicale

Durée

08'02''

Publication

2010-06

Popularité

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Sous-titres

E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2885.htm

Laparoscopic pericystectomy for an 8cm hepatic hydatid cyst with 3D reconstruction

1. Clinical case presentation 00'14''

This is the case of a female patient presenting with epigastric pain. An 8cm liver cyst is identified on the examination. Given her previous medical and clinical history, the patient has a hydatid cyst. Serologic tests remain negative. This hydatid cyst is no longer active. Surgery is indicated given the symptomatology and the patient’s strong desire for the intervention. The cyst measures 8 by 6cm as measured by a 3-Dimensional CT-scan reconstruction. The cyst’s wall is well calcified confirming herein an old cyst. A standard pericystectomy without resection of liver’s parenchyma is decided upon. This is corroborated by the 3D reconstruction, which clearly shows the absence of significant hepatic parenchyma at the cyst’s periphery. In addition, no vascular anomaly is demonstrated.

2. Exploration of peritoneal cavity 01'14''

The procedure is begun by an exploration of the peritoneal cavity, which shows nothing particular. Massive adhesions related to the cyst’s active history are identified immediately.

3. Dissection of adhesions 01'29''

Dissection is performed in contact to the cyst. Monopolar cautery is used preferably. The different anatomical structures are identified progressively. Monopolar cautery through the use of a coagulating hook may prove effective in certain areas. The gallbladder turns out to be adherent and is meticulously dissected, even if the preoperative reconstruction demonstrated that the gallbladder was totally away from the cyst localized exclusively in contact to segments II and III of the liver. Coagulation is performed strictly in contact to the cyst.

4. Dissection for cyst exposure 02'13''

Dissection is pursued progressively on to the cyst’s left borders in order to free the stomach and on to the cyst’s right border in order to free the gallbladder. Dissection is then carried out progressively posteriorly until the hepatic pedicle is identified. Once again, the preoperative view demonstrated that at first sight the cyst might not be in continuity with the hepatic pedicle. This will be confirmed with the dissection carried out progressively to the posterior and inferior part of the cyst. The major difficulty of the procedure lies in the cyst’s manipulation. Indeed, the cyst’s size is large and it is not possible to grasp it fully with one’s hand as performed in the open approach. Therefore the progressive cyst’s retraction using forceps that are repositioned each time adhesions are taken down will allow to explore its aspects successively. The peritoneal adhesions are also freed at the cyst’s inferior part. At this moment, only the part of the cyst that is in contact to the liver parenchyma remains to be freed. A cleavage plane between the cyst’s wall and the liver parenchyma will be rapidly found. The objective is to avoid any hepatic wound that may be associated either with a hemorrhage or with a biliary leak.

5. Pericystectomy 03'51''

The pericystectomy is carried out progressively in contact to the cyst. Monopolar and bipolar cautery and/or ultrasonic dissectors may be used in turn in order to mobilize the liver.

6. Liver parenchymal division and cyst excision 04'04''

Here ultrasonic dissectors are used to achieve divisions of the liver parenchyma; this allows to ensure a correct hemostasis and bilistasis, hence progress is made in contact to the cyst. Since the dissection is performed lateral to the liver parenchyma, no previous vascular control has been carried out. The standard pericystectomy should normally not penetrate the liver parenchyma. Attention must be paid to stay in contact to the cyst at all times in order to prevent entrance into the liver parenchyma. In certain cases as in the present one, a bipolar cautery may be useful to complete hemostasis. The liver’s retraction is carried out progressively centimeters after centimeters in strict contact to the cyst. A good preoperative evaluation is mandatory to make sure that no major vascular structure will impair the dissection. Here a few adhesions in contact to the liver’s segment I may be taken down without requiring the need for resection of the liver parenchyma. When certain areas are slightly hemorrhagic, bipolar cautery is used to complete hemostasis. The ultrasonic cauterization helps to free the last few adhesions very posteriorly. These are fibrous adhesions to the diaphragm that are still attached to this lesion. The indications for the surgical resection of non-active hydatid cysts remain rare. They mainly concern big cysts that may generate typical clinical signs of pain, heaviness and epigastric impairment. A standard pericystectomy performed in a stepwise manner should allow to resect this cyst without any resection of the liver parenchyma. The postoperative outcome will be strongly simplified. The last remaining adhesions to the omentum of the lesser curvature are taken down using an ultrasonic dissector.

7. Specimen extraction 06'44''

The large-sized cyst that has been freed totally will be introduced into a bag. This will allow to morcellate it before its extraction through a small incision. The manipulation of this cyst remains difficult since it is strong and calcified. The division slice at the level of the liver is controlled meticulously in order to rule out the presence of biliary leak or residual bleeding. The exploration confirms that there is no other anomaly within the peritoneal cavity.