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Year : 2017  |  Volume : 13  |  Issue : 4  |  Page : 296-302

Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst

Department of Surgery, Selcuk University, Faculty of Medicine, Konya, Turkey

Date of Submission08-Nov-2016
Date of Acceptance16-Feb-2017
Date of Web Publication5-Sep-2017

Correspondence Address:
Ilhan Ece
Department of Surgery, Selcuk University, Gazi Avenue, 42075, Selcuklu, Konya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_238_16

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 ¤ Abstract 

Background: The aim of this study was to compare the mid-term outcomes of open and laparoscopic partial cystectomy (LPC).
Methods: The medical records of patients who underwent conventional partial cystectomy (CPC) and LPC for liver hydatid cyst from May 2010 to February 2015 were retrospectively reviewed. Operative time, blood loss, length of hospital stay, post-operative morbidity, mortality and mid-term follow-up outcomes were evaluated.
Results: Amongst 130 patients, 38 patients were underwent LPC and 92 underwent CPC. Blood loss and post-operative complications were similar in both groups. The mean operative time in the LPC and the CPC groups was, respectively, 95.4 ± 13.1 and 63.5 ± 15.6 min, which showed a significant difference between the both groups. The mean length of hospital stay in CPC group was significantly longer when compared the LPC group. The mean diameter of cyst in LPC group was 6.1 ± 1.1 cm and 7.8 ± 2.1 cm in CPC group with a significant difference. The overall complication rates were 13.1% in LPC group and 17.3% in CPC group without significant difference. The most common complication was biliary leakage and surgical site infection.
Conclusion: LPC for the surgical treatment of liver hydatid cyst appears to be safe and effective method with low morbidity rates in selected patients.

Keywords: Cystectomy, hepatic, hydatid cyst, laparoscopic surgery

How to cite this article:
Ece I, Yilmaz H, Yormaz S, Çolak B, Acar F, Alptekin H, Sahin M. Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst. J Min Access Surg 2017;13:296-302

How to cite this URL:
Ece I, Yilmaz H, Yormaz S, Çolak B, Acar F, Alptekin H, Sahin M. Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst. J Min Access Surg [serial online] 2017 [cited 2021 Dec 6];13:296-302. Available from:

 ¤ Introduction Top

Hydatid disease is a chronic parasitic infectious disease and is endemic in many parts of the world such as Turkey. The liver is most commonly affected organ by the parasite.[1] When parasite settled in the liver, the hydatid cyst gradually grows at a rate dependent on the resistance of the surrounding tissues.[2] The growing cyst can lead to serious complications such as localised infection, biliary tract occlusion, infection caused by biliary fistula and rupture of hydatid cyst into the abdominal or thoracic cavity. Spontaneous regression is very rare in liver hydatid cyst. Therefore, it is necessary to treat all viable cysts. There are a variety of treatment modalities for hepatic hydatid cysts, including medical therapy, puncture-aspiration-injection-reaspiration (PAIR) and open or laparoscopic surgery, depending on the size and characteristics of the cyst.[3],[4],[5],[6] Medical or PAIR treatment can be applied in the early stage of hydatid cyst. Nevertheless, surgery remains the most effective treatment modality of multivesicular cysts.[7] The main purpose of the surgery is to provide elimination of scolices in the cyst cavity, removal of all viable parts of the cyst and obliteration of the remaining cavity.[8] Open surgical treatment for hydatid disease has been widely accepted by the surgeons all around the world. Recently, the laparoscopic technique has also been applied in the practice of liver hydatid cyst surgery due to short hospital stay, fast recovery and favourable cosmetic results. A broad spectrum of surgical technique ranging from laparoscopic simple drainage to radical liver resection has been reported.[9],[10],[11]

The aim of this study was to compare the mid-term outcomes of laparoscopic partial cystectomy (LPC) with conventional partial cystectomy (CPC) and evaluate its feasibility and safety for the treatment of hepatic hydatid cyst.

 ¤ Methods Top


We performed a retrospective cohort study after institutional review board approval, and follow-up data of patients were obtained from hospital charts and office records. Patients who underwent LPC and CPC from May 2010 to February 2015 in the Department of Surgery Clinic of our university research hospital were included in this study. The study has been performed in accordance with the ethical standards laid down in the Declaration of Helsinki. After the patients were informed about the surgical procedure and potential complications of the surgery, written informed consents were obtained from all the participants.

Pre-operative evaluation

All patients underwent conventional liver function tests (serum bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and gamaglutamyl transpeptidase), immune haemagglutination testing and haematological studies. The pre-operative evaluation included abdominal ultrasonography and contrast-enhanced computed tomography scan of the abdomen was performed in all patients. All patients in the study were consulted by interventional radiology clinic and confirmed that were unsuitable for PAIR treatment. Patients with liver cirrhosis, peritonitis and patients who were high risk for general anaesthesia were excluded from the study. Liver hydatid cysts located segment 1 or 7, previous upper abdominal surgery, severe obesity and deeply located intrahepatic cysts were also additional exclusion criteria for the laparoscopic group, and this group was subjected to an open surgical procedure. Patients with a body mass index lower than 35 kg/m 2 were included in the LPC group. Cysts with a diameter of smaller than 13 cm or superficially located cyst were additional inclusion criteria for LPC group. Radiologic evidence of cysto-biliary communication was not considered as a contraindication of laparoscopic treatment of liver hydatid cyst. In patients with features of obstructive jaundice, an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was performed preoperatively. Both groups were compared with regard to the patients' demographics, operative time (skin incision to skin closure), American Society of Anesthesiologists (ASA) classification score, blood loss, length of hospital stay (defined as operation day to discharge day from the hospital), operative complications, short-term and mid-term outcomes.

Medication and follow-up

Patients received oral 10 mg/kg albendazole (Andazol ; Biofarma, Istanbul, Turkey) for 10 days before surgery. After surgery, albendazole was administered for three cycles in the same dosage. A cycle consisted of a 3-week period of medication and 1-week gap between two cycles.

All patients were followed up for at least 20 months; the mean follow-up period of groups was 33.2 months. The follow-up protocol included a medical control every 2 weeks during 1st month with liver tests and clinical examination, then ultrasonography or abdominal computed tomography control was included every 6 months during the follow-up.

Surgical procedure for laparoscopic partial cystectomy group

All operations were performed after the administration of a single intravenous dose of antibiotic prophylaxis (cefazolin 1 g) under endotracheal general anaesthesia. In LPC, the patient was placed in a supine position on the operating table with the legs spread in a slight reverse Trendelenburg and the right side up. The first 10 mm trocar was inserted infraumbilically, and carbon dioxide pneumoperitoneum was established. Intra-abdominal pressure was adjusted at 12 mmHg. In cases with hydatid cysts of the right lobe, the other trocars were inserted into the abdominal cavity at the junction of the subcostal line and midclavicular line and in subxiphoid area. After routine exploration, gauze pads soaked with hypertonic saline (20% sodium chloride) were placed around the site where the cyst protruded from the surface of the liver, in Morrison's pouch and in the subhepatic area [Figure 1]. Half of the cyst fluid was aspirated with a Veress needle, and hypertonic saline was injected into the cyst [Figure 2]. Hypertonic solution left for 10 min and then reaspirated. After inactivation procedure, the cyst wall was punctured with a perforator grinder aspirator [Figure 3], and the daughter vesicles in the cyst were aspirated completely. The puncture site was enlarged by a 10 mm LigaSure™ (Valleylab, Boulder, CO, USA). The protruding wall of the cyst was excised by LigaSure™ [Figure 4], placed in a plastic bag and extracted with the trocar. During surgery, laparoscopic ultrasonography (BK Medical ; Pro Focus 2202, rigid laparoscopic probe 8836, Herlev, Denmark) examination was performed to detect the missed cysts in all patients of LPC group. When the bile duct communication was observed, it routinely closed with non-absorbable sutures. After ensuring that there was no evidence of a biliary leak, the operation was completed by inserting a 20-F Nelaton drain to the posterior of the liver.
Figure 1: Placement of gauze pads soaked with hypertonic saline

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Figure 2: Puncture of the cyst capsule and injection of scolicidal agent

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Figure 3: Aspiration of cystic fluid containing daughter vesicles and membranes by a grinder aspirator system

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Figure 4: Excision of the protruding wall of cyst and observation of cysto-biliary communication in the cystic cavity

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Surgical procedure for conventional partial cystectomy group

For conventional surgical approach, we used a subcostal incision. The neighbouring organs were isolated with gauze pads soaked in hypertonic saline solution. To inactivate the parasites, injection of 20% hypertonic saline solution into the cyst was performed. After 10 min, the cystic content was aspirated. A grinder perforator aspirator (Sahin Aspirator, Bahadir Corp, Turkey) was inserted into the cyst, and then germinal membrane and daughter vesicles were extracted. The cystic cavity was explored for potential biliary openings [Figure 5]. When cyctobiliary fistulas were detected, a metal clip or suture tie application was performed. A silicone drain was left back to the liver.
Figure 5: Exploration of cystic cavity for potential cysto-biliary communication in conventional partial cystectomy group

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Statistical analysis

Data collection was performed on Microsoft Excel 2007 (Microsoft, Redmond, WA, USA), and statistical analysis was performed using SPSS 16.0 (SPSS Inc., Chicago, IL, USA). Student's t-test was used for comparison of continuous variables, and Chi-square test for categorical variables. Categorical variables were reported using percentages. Continuous variables were expressed as a mean ± standard deviation. P <0.05 was considered statistically significant.

 ¤ Results Top

Patient characteristics

During the study period, a total of 374 patients with liver hydatidosis were admitted to our surgery clinic, and 224 of the patients were evaluated as suitable for PAIR treatment, and all of them referred to interventional radiology clinic. The remaining 150 patients were treated surgically. A total number of 38 patients (26 females and 12 males) with 47 hydatid cysts underwent LPC and 92 patients (58 females and 34 males) with 122 hydatid cysts underwent CPC. Twenty patients who were subjected to radical liver resection or pericystectomy were excluded from the study. All patients were selected according to our management algorithm of liver hydatid cyst for both groups [Figure 6].
Figure 6: Management algorithm of liver hydatid cyst

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Pre-operative conditions

Pre-operative characteristics of the patients are presented in [Table 1]. There was no statistically significant difference between the both groups with regard to the age, gender, concurrent comorbidities and ASA scores. Obese or overweight patients were more numerous in CPC group (7.8% vs. 25%), and significant differences were found between the CPC and the LPC groups (P< 0.05). Hydatid disease was more common in females in both groups. The anatomical site and WHO/IWGE classification of the hydatid cysts were similar in both groups. The average diameter of the liver hydatid cysts was 6.1 ± 1.1 cm (range, 3–11 cm) in LPC group and 7.8 ± 2.1 cm (range, 5–19 cm) in CPC group [Table 2]. When the groups compared with regard to cyst diameter, a statistically significant difference was found between the CPC and the LPC groups (P< 0.05).
Table 1: Demographic data, concurrent comorbidities and WHO classification of the population

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Table 2: Intra- and post-operative parameters, complications

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Intraoperative data

The operative data including blood loss, intraoperative and early post-operative complications and recurrence rate were similar in both groups. The mean duration of operation in the LPC and the CPC groups was 95.4 ± 13.1 and 63.5 ± 15.6, respectively, and significant differences were found between two groups (P< 0.05). The mean length of hospital stay was 4.3 ± 1.6 days in the LPC group and 6.5 ± 2.7 days in the CPC group. The difference between the two groups was significant (P< 0.05). In both groups, no mortality, intraoperative anaphylactic shock and intraoperative spillage of cystic content were observed during the study period. In LPC group, choledochoscopic (Karl-Storz, flexible video choledochoscope, 2.8 mm, Tuttlingen, Germany) examination of choledoch was intraoperatively performed in one patient due to a failed pre-operative ERCP.

The overall morbidity in LPC group was 13.1% (5/38) compared to the CPC group i.e. 17.3% (16/92) with no statistical significance. The main post-operative complications were surgical site infection and biliary leakage. Surgical site infection is the most common complication that occurred in nine patients (2 in LPC group, 5.2%; 7 in CPC group, 7.6%) followed by biliary leakage and cystic cavity infection. All patients who had surgical site infection were treated with drainage and oral antibiotics. Eight patients (2 in LPC group, 5.2%; 6 in CPC group, 6.5%) had experienced a biliary leakage. In CPC group, 2 of biliary leakages (<300 ml/day output) closed spontaneously within 1 week. The other patients were needed ERCP sphincterotomy. Three patients with cystic cavity infection were treated by percutaneous drainage (1 in LPC group, 2.6%; 2 in CPC group, 2.1%). No recurrence was noted during the follow-up period.

 ¤ Discussion Top

In this study, we have evaluated CPC and LPC with respect to perioperative complication and mid-term outcomes. The novelty of this study includes the routine use of perforator grinder aspirator and laparoscopic ultrasound for reducing the risk of post-operative missed cyst or early recurrence. However, there were several limitations of this study as it is retrospective in nature, the groups were not randomised and the follow-up was not long in duration. These limitations should be kept in mind while evaluating the results of study.

In past three decades, although treatment choices for liver hydatid disease have increased including medical treatment, PAIR or a combination, surgery currently remains the mainstay of therapy. The use of other modalities is restricted to certain stages of the disease and is associated with inadequate treatment or recurrence. A broad spectrum of modalities including simple drainage, cystectomy, pericystectomy and radical liver resection is being considered for the surgical treatment of liver hydatid disease.[12] The first successful laparoscopic resection of liver hydatid disease was performed in 1992.[13] Until now, laparoscopy was not quickly accepted or widely used in the treatment of hydatid disease. There are still some concerns for the recurrence rate, spillage and anaphylactic shock under the high abdominal pressure induced by the pneumoperitoneum until the evidence that the increase in intracystic pressure was no greater than the increased intra-abdominal pressure and that pneumoperitoneum was protective against spillage.[14] Current studies have demonstrated that the surgically created pneumoperitoneum is not associated with the risk of intraperitoneal dissemination.[15] The reported recurrence rate of liver hydatid cyst for open surgery varies from 0% to 30%, and recurrence rate for laparoscopic surgery varies from 0% to 9%.[16],[17] In our study, no recurrence or missed cyst was noted during the follow-up period due to the attention to the technical details and the use of technical devices such as perforator grinder aspirator, laparoscopic ultrasound and video choledochoscope.

The reported advantages of laparoscopy are minimal invasiveness, more detailed cyst inspection, reduced wound complication, reduced hospital stay and cost-effectiveness.[18],[19] Partial cystectomy and drainage procedures were the most preferred laparoscopic surgical techniques in previous practice. Due to the development in technology and especially the increasing number of more experienced surgeons, a broad spectrum of laparoscopic surgery ranging from pericystectomy to radical liver resection has been currently reported.[20],[21],[22] The use of laparoscopic ultrasonography is known to facilitate surgical interventions in cysts with a posterior localisation or in those neighbouring large vessels.[23] In LPC group, laparoscopic ultrasonography was routinely used to detect the borders of the cyst and to determine a possible missed cyst.

The most feared complication of the laparoscopic treatment of hydatid disease is the spillage. The most dangerous step in terms of possible spillage is the initial puncture and aspiration of cyst fluid. Having gauze soaked with scolicidal agents surrounding the puncture site, and the suction catheter ready can reduce the risk of spillage. For this purpose, a new perforator-grinder-aspirator has been produced by a local manufacturer. The use of this aspirator instrument functioning as both perforator and aspirator at the same time was minimised the risk of spillage. Therefore, no patients experienced an early recurrence of liver hydatid cyst or intra-abdominal cysts.

One of the most important advantages of laparoscopic surgery is that the laparoscope can be inserted inside the cystic cavity and allowing a detailed inspection. Potential bile duct communications could be easily observed with the 3 times larger image of laparoscope. Furthermore, remnants of the germinal membrane can be identified and removed, reducing the incidence of recurrence or risk of intra-abdominal dissemination. Observed bile duct communications can be closed through a clip application or suture tie. However, laparoscopy still is limited in terms of liver resection, closure of biliary communications and application of pericystodigestive anastomosis. Recently, an increasing number of surgeons have reported satisfying results for laparoscopic pericystectomy or radical liver resection and cystojejunostomy anastomosis.[21],[22],[23],[24] In previous years, the indications for a laparoscopic approach to the treatment of liver cyst were limited to small and peripherally located liver hydatid cysts (<5 cm) without daughter vesicles. Recently, for surgeons experienced in liver surgery, working in centres with adequate technical equipment, giant or deeply located cysts, the presence of biliocystic communication or obesity are relative contraindications that can be overcome with laparoscopic technique. During surgery, we were used a laparoscopic choledochoscope to remove the daughter vesicles into the choledoch because of a failed pre-operative ERCP sphincterotomy. Laparoscopic treatment of liver hydatid cysts was commonly preferred 5–10 cm sized cysts.[17] An oversized cyst may cause limited space, difficulty in emptying the cyst and difficulty in inspecting the intracystic biliary leakage which may lead to unnecessary conversion. In our study, no conversion to open surgery was required, and this is partially due to our careful selection of patients.

The perioperative morbidity after open surgery ranges from 0% to 53.8%, based on several factors including age, size of the cyst, cystobiliary communication and the type of surgical procedure.[17] In our study, surgical site infection and biliary leakage were the common post-operative complications. The overall morbidity in the laparoscopic and conventional groups, respectively, was 13.1 and 15.5% with no statistical significance. In patients with biliary leakage, ERCP sphincterotomy could be considered as a good treatment modality. Percutaneous drainage and antibiotic drug administration were effective treatment modality for residual cavity infection. Relaparotomy was not necessary in any patient. In CPC group, surgical site infection and pleural effusion were two of the most common reasons of longer hospital stay.

 ¤ Conclusion Top

In the hands of experienced laparoscopic surgeons with appropriate technical tools, laparoscopic drainage and partial cystectomy seem to be safe and effective techniques in carefully selected patients in the surgical treatment of liver hydatid cysts. Technical devices such as grinder aspirator and laparoscopic ultrasonography may expand the indication for laparoscopy. However, further multisentric, prospective and randomised studies are needed to define the role of laparoscopy as the gold standard for the treatment of liver hydatid cysts.

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Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]

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