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 Table of Contents     
UNUSUAL CASE
Year : 2019  |  Volume : 15  |  Issue : 2  |  Page : 167-169
 

Resection of giant hepatic cyst by hybrid minilaparoscopy


1 Department of General Surgery, Faculty of Medical Sciences, University of Pernambuco; Videolaparoscopic Surgery Clinic Gustavo Carvalho; Member of UNIPECLIN (Clinical Research Group of the University of Pernambuco), University of Pernambuco, Recife, Brazil
2 Department of General Surgery, Faculty of Medical Sciences, University of Pernambuco, Recife, Brazil
3 Department of General Surgery, Oswaldo Cruz University Hospital, Recife, Brazil
4 Department of General Surgery, Pernambuco Health College, Recife, Brazil

Date of Submission07-Apr-2018
Date of Acceptance14-Jun-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Gustavo Lopes Carvalho
Avenida Boa Viagem 5526B Ap. 1902, Recife, PE CEP: 51030-000
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_68_18

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 ¤ Abstract 

A female patient, 59-year-old, was complaining of abdominal pain in the right hypochondrium and mesogastrium for 6 months. Ultrasonography and abdominal computed tomography were performed, both confirming a large hepatic cyst (10.6 cm × 7.6 cm × 7.3 cm) on the left lobe. A hybrid minilaparoscopic resection was proposed. We opted for unroofing the cyst, and the procedure was uneventfully performed, with a total surgical time of 60 min. In the post-operative the patient did well, with minimal abdominal pain, being discharged on the 5th post-operative day, after drain removal due to the use of intravenous antibiotic therapy.


Keywords: Hepatic cyst, liver cyst, microlaparoscopy, minilaparoscopy, minimally invasive surgery, needlescopic surgery


How to cite this article:
Carvalho GL, Góes GH, Furtado RH, Cordeiro RN, Quintas Calheiros EM. Resection of giant hepatic cyst by hybrid minilaparoscopy. J Min Access Surg 2019;15:167-9

How to cite this URL:
Carvalho GL, Góes GH, Furtado RH, Cordeiro RN, Quintas Calheiros EM. Resection of giant hepatic cyst by hybrid minilaparoscopy. J Min Access Surg [serial online] 2019 [cited 2019 Jun 26];15:167-9. Available from: http://www.journalofmas.com/text.asp?2019/15/2/167/245153



 ¤ Introduction Top


Hepatic cysts are classified into parasitic and non-parasitic, with a prevalence of 2.5%–5% in the general population,[1],[2] being more common in women, aged 50–60 years.[2] Small cysts are usually asymptomatic, whereas large cysts can cause pain, nausea or a feeling of early satiety.[1],[2]


 ¤ Case Report Top


A 59-year-old female patient was complaining of abdominal pain located in the right hypochondrium and mesogastrium starting 6 months before surgery. Abdominal ultrasonography was performed, which confirmed a large heterogeneous anechoic liver cyst measuring approximately 13.0 cm × 6.5 cm. A computed tomography of the abdomen demonstrated a complex cyst occupying the topography of the liver left lobe (segment II–III), measuring 10.6 cm × 7.6 cm × 7.3 cm [Figure 1]. The diagnosis was a giant hepatic cyst, and surgical resection with a hybrid minilaparoscopy approach was proposed.
Figure 1: Computed tomography showing a giant cyst, occupying the left hepatic lobe, measuring 10.6 cm × 7.6 cm × 7.3 cm

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Surgical description

The surgery was performed with the patient in the dorsal decubitus. The pneumoperitoneum was made using the open transumbilical technique, introducing a 10 mm trocar into an umbilical incision, as described previously.[3] Two working mini low-friction trocars of 3 mm (one subxiphoid and one at left lower quadrant) were inserted. A 5 mm trocar on the left flank was inserted to use a harmonic scalpel. The stomach was emptied with an orogastric tube to improve the visualization [Figure 2].
Figure 2: (a) Gastric emptying, with orogastric tube, for better visualization of the liver, where the main cyst (segment II–III) and smaller cysts are observed. (b) Cyst perforation with suction-irrigation cannula for complete emptying of abscessed contents. (c) Cyst unroofing with harmonic scalpel. (d) Ending unroofing and cyst borders cauterization. (e) Final appearance of the liver after cyst unroofing. (f) Suction drain exiting through the 5 mm trocar site

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A giant cystic mass with thickened walls was found in segment II and III of the liver. Due to suspicion of malignancy, the possibility of resection of segment III was considered, but trans-operatively, it was decided to do the unroofing. The decision proved right following observation of the abscessed cyst contents after perforation of the cyst with the suction [Figure 2]. Consequently, the patient benefited from the simpler procedure, less invasive, less traumatic and with shorter surgical time.

The resection of a large part of the cyst anterior wall was performed using harmonic scalpel. After the unroofing and cauterization of the cyst borders [Figure 2], the capsule was retrograde removed through the 10 mm umbilical portal. Cautious revision of the haemostasis was performed, in addition to the placement of a low-pressure suction 19F drain, exteriorised by the 5 mm portal incision. The histopathological study confirmed a non-parasitic hepatic cyst with no signs of malignancy.

The procedure was uneventfully performed, with a total surgical time of 60 min. The patient did well, without abdominal pain, being discharged on the 5th post-operative day, when the drain was removed. The long hospital stay was due to the use of intravenous antibiotic therapy.


 ¤ Discussion Top


Simple liver cysts are formations that contain clear fluid that does not communicate with the intrahepatic biliary tree. In a small fraction of patients, symptoms, such as abdominal pain, early satiety, nausea and vomiting, arise as a result of a mass effect, as observed in the present case. Complications such as haemorrhage, rupture and biliary obstruction are uncommon, presenting a higher probability of occurring in larger cysts.[1],[2]

In the majority of cases, non-parasitic hepatic cysts do not require treatment, and expectant follow-up is performed with serial ultrasonography. Surgical treatment is indicated only for cysts with a diameter ≥6 cm, those with associated symptoms or exhibiting increased diameter on ultrasound monitoring.[3]

Among the most used techniques are marsupialisation, partial hepatectomy, cystectomy or partial decapsulation (Unroofing) of the cyst. Conventionally, management of non-parasitic cysts would be by partial or total resection by laparotomy, but minimally invasive surgery has been shown to be efficacious in treating this disease.[2],[3],[4]

Minilaparoscopy, compared to conventional laparoscopy, causes less post-operative pain due to less abdominal wall trauma, provides improved dexterity, better visualization of the operative field and is associated with a shorter hospital stay.[4] These methods lead to the possibility of greater preservation of the hepatic tissue in analogy to the resection of splenic cysts. Minilaparoscopy has also been shown to be safe and effective for other complex approaches.[5]

This case reports a successful hybrid minilaparoscopic approach for the treatment of a non-parasitic giant hepatic cyst. Although there is no consensus on the ideal approach, cyst unroofing by hybrid minilaparoscopy in this case was a safe, effective and a low-morbidity option.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Kisiel A, Vass DG, Navarro A, John AK, Isaac J, Marudanayagam R, et al. Long-term patient-reported outcomes after laparoscopic fenestration of symptomatic liver cysts. Surg Laparosc Endosc Percutan Tech 2017;27:e80-2.  Back to cited text no. 1
    
2.
Macedo FI. Current management of noninfectious hepatic cystic lesions: A review of the literature. World J Hepatol 2013;5:462-9.  Back to cited text no. 2
    
3.
Carvalho GL, Lima DL, Silva FW, Belarmino de Góes GH. Giant nonparasitic spleen cyst treated by minilaparoscopy. CRSLS e2017.00030. DOI: 10.4293/CRSLS.2017.00030.  Back to cited text no. 3
    
4.
Firme WA, Carvalho GL, Lima DL, Lopes VG, Montandon ID, Santos Filho F, et al. Low-friction minilaparoscopy outperforms regular 5-mm and 3-mm instruments for precise tasks. JSLS 2015;19. pii: e2015.00067.  Back to cited text no. 4
    
5.
Carvalho GL, Abreu GF, Lima DL, Góes GH. Type IV mirizzi syndrome treated with hepaticoduodenostomy and minilaparoscopy. CRSLS 2016;e2016.00057:3. p. e2016.00057. [Doi: 10.4293/CRSLS. 2016.00057].  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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