Laparoscopic Treatment of a Giant Nonparasitic Cyst in Cirrhotic Liver

Abstract

Introduction: The detection of single simple liver cysts has become more frequent in the general population (2.5%–5%) because of the routine use of ultrasonography. Between 10% and 16% of cysts become symptomatic and require treatment. Among the various treatment options, which range from simple aspiration to hepatic resection, laparoscopic cyst “unroofing” is generally considered to be the standard of care by allowing for cyst decompression and preventing recurrences while simultaneously decreasing postoperative pain and hospitalization time. However, relative contraindications include cirrhosis and posterior localization of the cyst. Case Report: The authors present the case of a 65-year-old cirrhotic woman positive for hepatitis C virus who was referred for abdominal pain, anemia, and scleral jaundice. Computed tomography scan of the abdomen demonstrated a giant hepatic cyst (19 × 14cm) in the right lobe of the liver compressing the right branch of the portal vein, inferior vena cava, right and middle hepatic veins, gallbladder, and right kidney. In addition, the celiac trunk and superior mesenteric artery were dislocated. After ultrasound-guided partial aspiration, the cyst diameter was reduced from 22 to 13 cm; the left portal branch and vena cava were decompressed, with relief from symptoms, and an improvement in liver function. When liver laboratory tests were normal, the patient underwent laparoscopic exploration. The scope was introduced via an umbilical trocar. Three more ports, at the subxiphoid, right flank, and left hypochondrium, were placed, and the patient was positioned in a steep reverse Trendelenburg position and rotated to the left. A small amount of ascitic fluid was found. Adhesions between the cyst and the abdominal wall were cut to expose the entire surface of the cyst that occupied the major part of the right lobe. After aspiration of ∼1 L of dark serous liquid, a part of the cyst wall was taken and sent for frozen section analysis (pathologic result: simple cyst wall). Then, a complete unroofing of the cyst was performed by removing the entire cystic anterior wall, which was placed into an endobag and extracted. A large amount of fibrous tissue was removed, but no solid vegetation was seen on the posterior wall. The posterior wall of the cyst, treated by monopolar coagulation, became a planar surface, and there was no need to position the omentum to fill the residual cavity. No biliary leakage was observed. A cholecystectomy was performed, and two drains were left in the cystic and cholecystic beds. Postoperative course was uneventful; the patient was fed on the third day after surgery, and discharged from the hospital on the eigth postoperative day. At the 1-year follow-up examination, the patient was asymptomatic, and a computed tomography scan showed regeneration of the right hepatic lobe with no sign of relapse. Conclusion: Laparoscopic treatment of symptomatic simple liver cysts can also be accomplished safely in cases of very large cysts and in cirrhotic patients, when compensated. Preoperative partial aspiration of the cyst allows relief from symptoms (thus confirming that they are caused by the lesion), and improve hepatic function. No competing financial interests exist. Runtime of video: 6 mins