Laparoscopic fenestration of a symptomatic cyst of the liver

Simple liver cysts are always benign. The only patients who require treatment for one or multiple liver cysts are those who develop symptoms. Simply removing the fluid from the cyst with a needle is not effective because the cyst fills up again within several days. Laparoscopic fenestration has become the standard treatment for benign cysts of the liver, both solitary and multiple. This is a video of a patient presenting with a symptomatic benign liver cyst measuring 18cm in diameter in whom a laparoscopic fenestration is performed.

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Laparoscopic fenestration of a symptomatic cyst of the liver

Authors

D Mutter, L Soler, J Marescaux

Abstract

Simple liver cysts are always benign. The only patients who require treatment for one or multiple liver cysts are those who develop symptoms. Simply removing the fluid from the cyst with a needle is not effective because the cyst fills up again within several days.
Laparoscopic fenestration has become the standard treatment for benign cysts of the liver, both solitary and multiple.
This is a video of a patient presenting with a symptomatic benign liver cyst measuring 18cm in diameter in whom a laparoscopic fenestration is performed.

Classification

clinical cases

Keywords

Laparoscopic fenestration, symptomatic cyst, liver

Media type

Surgical video

Duration

06'28''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2592.htm

Laparoscopic fenestration of a symptomatic cyst of the liver

1. Introduction 00'10''

We report the case of a patient presenting with a huge liver cyst. It is a benign cyst but due to its size, it is a symptomatic one - the patient presenting with epigastric abdominal pain - and as seen in this reconstruction, with a big anatomical abnormality due to the cyst size measuring 18cm in diameter. Multiple other little cysts are located in diffuse parts of the liver.

2. Freeing the adhesions 00'53''

The surgical procedure started with the freeing of several adhesions due to previous surgical operations. These adhesions are freed using monopolar, or bipolar cautery or the Ligasure device.

3. Cyst puncture 01'10''

After a brief exploration of the abdomen, the main cyst is punctured. A suction drain is placed close to the opening and the main part of the liquid is suctioned out of the abdomen. In this patient, a global volume of about 1 litre was taken out.

4. Cyst fenestration 01'37''

In order to avoid an early recurrence of this cyst, its upper part is resected. This resection is performed using an ultrasonic dissector. This offers the advantage of coagulating part of the liver parenchyma that can be present in this part of the parietal wall of the cyst. The main risk in this case is to have a biliary fistula after the surgical procedure. Other cysts of significant size are also opened in order to decrease the global volume of the liver. No cyst located deeply in the parenchyma is opened in order to avoid any hemorrhage or bile leak. The freeing of several adhesions due to a previous cholecystectomy allows to have an access to others cysts. Here the cyst located in segment 5 is isolated and also emptied from the liquid. It is well-known that this cyst has the possibility of an early recurrence but in the immediate postoperative course, the patient ends with a smaller abdomen and a better sensation. The cysts are located in segments 3 and 4 and they are also separately opened. After resection of the parietal wall of the cyst, a careful examination is performed in order to detect a very early bile fistula. Here in this patient, we see that there is a little bile leak coming from the parietal wall of the cyst.

5. Bile leak closure 04'00''

This bile leak must be sutured with absorbable suture material in order to avoid a postoperative biliary peritonitis. This is performed with absorbable intra-abdominal suturing.

6. Final control 04'23''

Finally, a careful control of the internal part of the cyst must be performed. This patient probably presented with a preoperative hemorrhage of the cyst, and in order to completely explore the internal part of the cyst, we had to introduce a 4th trocar so as to present the parietal wall of the cyst. Then the camera could be inserted into the cyst and no major bleeding or bile leak were observed at this stage. As there is a major risk of postoperative recurrence, two procedures can complete the intervention at this stage. The first one is to take some omentum and place it into the cyst, thus avoiding its early closure. But in this patient with intra-abdominal adhesions due to prior surgical procedures, this was not possible. In this case, we decided to place a suction drain into the cyst, which will be kept for 2 to 3 days in order to witness a potential bile leak and avoid an early recurrence of the cyst during the early healing period. The postoperative course in uneventful and the patient is discharged on postoperative day 3.