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Indian Journal for the Practising Doctor

Laparoscopic Treatment of a Giant Non-parasitic Hepatic Cyst: A Case Report

Author(s): Chalkoo M

Vol. 5, No. 6 (2009-01 - 2009-02)

Chalkoo M

Dr Mushtaq, MBBS, MS, FMAS, Consultant Laparoscopic Surgeon, Government Medical College, SMHS Hospital, Srinagar.

Correspondence: Dr Mushtaq Chalkoo, Gulberg Colony, Sector -1 Hyderpora.
[Email: mushtaq_chalkoo(at)rediffmail.com; Cell: 9419032292]

ISSN: 0973-516X

Abstract

We present a case of an old lady, 65 yrs of age, with clinical features of pain in the upper right quadrant of abdomen on exertion, normal liver function tests, with false positive Elisa test for ecchinococcus granulosus. The USG and CT scan showed a giant hepatic cyst about 10×9 cm in dimension in the right lobe of liver and another small cyst(4×3cm) in the posterior-superior aspect of the left of liver, encroaching the left triangular ligament touching the left dome of the diaphragm. Laparoscopic deroofing was performed in both the cysts. This operation causes only slight discomfort to the patient, the postoperative morbidity is low and relapses are rare.

Keywords: Non-parasitic hepatic cyst, laparoscopic deroofing

An old female presenting with pain and fullness in the right upper quadrant of abdomen was evaluated. Her haemogram and liver function tests were normal. ELISA for ecchinococcus granulosus was reported as false positive since it turned out to be a non-parasitic simple cyst on laparoscopic exploration. The USG and CT scan were performed which showed two cysts in the liver. The one in the right lobe of liver was huge with a size of 10×9cm in dimension and was superficial. The other one was small in size (about4×3 cm), in the posterio-superior aspect of the left lobe of liver. Other investigations were reportedly normal. We performed laparoscopic deroofing of both the cysts. The pneumoperitoneum was caused through the umbilicus by Vereess needle. The 10mm camera port was introduced through the umbilicus. Other ports were conventionally made as in laparoscopic cholecystectomy: the 10mm port in the epigastrium; 3mm port in the right hypochondrium. The cyst was dealt with like the hydatid cyst of liver as the provisional diagnosis was that. Betadine-wrung gauzes were introduced and the cyst was surrounded by them. Aspiration was performed and the cyst deflated. The deroofing was done using monopolar cautery. It turned out to be a simple non-parasitic hepatic cyst. We used 30 degree endoscope for better visualization. The cyst-biliary communication was checked. The cyst wall was removed through the umbilical port in a sterile polythene bag and sent for histopathology. The rim of the excised cyst was cauterized and haemostasis achieved. It was difficult to reach the other cyst so we mobilized and excised the falciform ligament after ligating it. Another 3 mm port, was created in the left hypochondrium in the mid-axillary line to facilitate the dissection. A small cyst on the posterior-superior aspect of the liver encroaching the left triangular ligament was aspirated and deroofed. The suction and irrigation was performed and a drain was put in the right parahepatic space. The pneumoperitoneum was deflated and the ports were closed. The patient was sent to the recovery room.

Endoscopic view of the giant non-parasitic
hepatic cyst
Fig 1: Endoscopic view of the giant non-parasitic hepatic cyst in the right lobe of liver.
falciform ligament
Fig-5: The falciform ligament being ligated and cut to reach the small cyst in the left lobe of liver.
Aspiration of the cyst
Fig 2: Aspiration of the cyst; betadine-wrung guaze can be seen.
small cyst
Fig 6: The small cyst in the postero-superior aspect of left lobe of liver.
cyst being deroofed
Fig 3: The cyst being deroofed by hook using monopolar cautery
deroofed cyst
Fig 7: The deroofed cyst in the left lobe encroaching the left triangular ligament
deroofed cyst
Fig 4: The deroofed cyst wall being removed in the polythene bag.
deroofed cyst
Fig 8: The drain being put in the parahepatic space

The postoperative period remained uneventful and the patient was discharged on the 3rd postoperative day.

Discussion

The nonparasitic cysts of the liver may be single or multiple, diffuse or localized, unilocular or multilocular. The rare varieties include blood and degenerative cysts, dermoid cysts, lymphatic cysts and endothelial cysts. The more common lesions are retention cysts which are solitary, simple cysts or part of the polycystic disease. Their incidence is 2-4%, and the cysts are often asymptomatic. They are often found at physical examination. Sonography is sufficient to diagnose them. They present as round or oval cystic lesions, ranging in size from a few mm to 20 cm. The common complications are rupture, bleeding into the cyst, obstructive jaundice, portal hypertension, IVC syndrome, and malignant degeneration being exceedingly rare. The differential diagnosis of the cyst includes parasitic cysts of the liver, hamartomas, hepatic cyst adenoma and cystic metastasis. The asymptomatic cysts donít generally need treatment and for symptomatic cysts different approaches have been described. Open surgery is done only when the diagnosis is in doubt, then simple unroofing is sufficient. With laparoscopic deroofing, long-term follow up demonstrates that, although recurrence is frequent, the recurrent cyst remains asymptomatic and patient satisfaction is high. Alternatively, interventional radiology with instillation of alcohol or tetracycline is done which carries the risk of infection or secondary sclerosing cholangitis. The simple aspiration is useless since the cysts refill almost immediately.

References

  1. Akriviadis EA,Steindel H,Ralls P,et al: Spontaneous rupture of nonparasitic cyst of the liver. Gastroenterol 1989; 97:213-5.
  2. KlinglerPJ, GadenstatterM, Schmid T et al: Treatment of hepatic cysts in the era of laparoscopic surgery. Br J Surg 1997; 84(4): 438-44.
  3. Krahenbuhl L,Baer HU,Renzulli P,et al(1996) Laparoscopic management of nonparasitic symptom producing solitary hepatic cysts. J Am Coll Surg 1996;183: (5);493-8.
  4. LaiEC,Wong J: Symptomatic nonparasitic cysts of the liver. World J Surg 1990; 4(4): 452-6.
  5. Morino M,Deguili M,Festa V et al: Laparoscopic management of symptomatic nonparasitic cysts of the liver-indications and results. Ann Surg 1994; 19: 157- 64.
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