Pericystectomy for Hydatid Liver Cyst
Lucas McCormack
Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgical techniques have improved, considerable controversy still exists regarding the most effective operative technique. The main principle of the surgery is to eradicate the parasite and prevent intraoperative spillage of cyst contents avoiding peritoneal spread.
Pericystectomy provides a radical treatment removing the whole cyst “en bloc” including the adventitia without resection of healthy liver tissue.
Preoperative Treatment
Albendazol orally 10–14mg/kg/day in two doses administered 2–4weeks before and after surgery.
Indications and Contraindications Indication
■Peripheral hydatid cyst of the liver
Contraindications
■Intrahepatic major vascular invasion
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Invasion of right or left hepatic duct
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Deep cyst within the liver parenchyma (>2–3cm from liver surface)
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General contraindication of liver resections
Procedure
STEP 1
Incision, exposure, and staging
Access is performed as shown in the chapters on liver resection. Careful exploration of the abdominal cavity is done to exclude extrahepatic disease. The liver should be completely mobilized as for a major liver resection. Since accidental opening of the cyst may occur during mobilization, always have a cup with povidone-iodine (or hypertonic saline solution) ready to use in case of intraoperative spillage of cyst contents.
Inspection and manual exploration of both lobes of the liver need to be done with caution. Intraoperative ultrasound using a 5-MHz T-shaped probe is used to assess the number and location of the cysts. Particular attention is directed toward the relationship of the cysts with the portal veins, major hepatic veins, and the vena cava. In addition, meticulous examination of the cyst and the adjacent liver parenchyma can sometimes demonstrate a biliary communication.
STEP 2
Definition of the surgical approach
Most of the cysts located in the right liver are easy to dissect away from the diaphragm.
If not safely feasible, a partial resection of the diaphragm must be performed.
In case of major vascular involvement or with invasion of the left or right hepatic duct, an anatomical liver resection is indicated.
In case of a cyst located deep within the liver, liver resection is also recommended.
However, when depth from the liver surface is less than 2–3cm, a hepatotomy allows the cyst to be reached and a standard pericystectomy can be performed.
For cysts located close to the vena cava in segments 6 or 7, the liver needs to be
mobilized as for a right hepatectomy.
STEP 3
Preparation prior to pericystectomy
The central venous pressure should be below 3mmHg before starting the liver transec- tion. A tourniquet is placed around the porta hepatis for inflow occlusion in case of bleeding. To prevent accidental spillage of the cyst contents, the whole space around the liver is packed using gauze swabs. A pack placed behind the right liver usually offers better exposure. The contents of the cyst should never be evacuated before resection.
Stay sutures should not be placed in the cyst wall. However, stay sutures with silk 2-0
are placed in the liver parenchyma around the emerging part of the cyst to enable
traction and better exposure during resection.
STEP 4
Resection of the cyst
The liver capsule is incised with diathermy. Careful identification of the correct plane of cleavage is crucial to avoid bleeding or spillage of the cyst contents (A). Intrahepatic vessels are coagulated selectively with bipolar forceps or ligated with metallic clips, ties or suture-ligatures depending on the diameter. Although several possible techniques for liver parenchyma dissection can be used (see chapter “Techniques of Liver Parenchyma Dissection”), we prefer the water jet, which enables a selective and safe separation of the cyst wall from the liver parenchyma (B). Small bile ducts should be carefully identified and tied. Hemostasia of the exposed raw surface of the liver can be improved with argon beam coagulator or topical fibrin derivates.
A
B
Postoperative Complications
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Same complications as in liver resections
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Biliary fistula is less common than in partial resection
Tricks of the Senior Surgeon
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Use magnification loops to control bile leaks after pericystectomy. Careful repair should be done with suture-ligatures with Prolene 4-0 to 5-0.
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At least two drains with powerful suction should be available in case of rupture of the cyst to avoid peritoneal spread of the contents.
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Always have a cup with povidone-iodine (or hypertonic saline solution) ready to use in case of intraoperative spillage of cyst contents into the peritoneal cavity.
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