IS THERE A ROLE FOR

LAPAROSCOPY IN RECURRENT
HYDATIC DISEASE

V. Surlin, A. Nicolaescu, S. Patrascu, S. Ramboiu,

A. Patru, E. Georgescu, Ion Gerorgescu
1st Surgery Clinic, SCJU of Craiova, UMF of Craiova
ACG GUIDELINES
PAIR (puncture, aspiration, injection, and
reaspiration) is a percutaneous treatment
alternative to surgery
•With adjunct antihelminthic chemotherapy is as
effective as open surgical drainage with fewer
complications and lower cost
• PAIR is recommended for patients with active
hydatid cysts >5 cm who are not candidates for
or decline surgery, or who relapse after surgery.
•PAIR is not recommended in patients with biliary
fistulas or communications with the biliary tree
because of the risk of biliary sclerosis.
•PAIR is also contraindicated in patients with
inaccessible cysts, or with complicated,
multivesiculated cysts
 Surgical treatment, either radical pericystectomy or conservative
deroofing, has been reserved for complicated cysts that have
fistulas, multiple daughter vesicles, rupture, hemorrhage, or
secondary infection.
 Surgery also remains an option when percutaneous treatment
such as PAIR is not available. Laparoscopic approaches have
been reported to be effective, but quality data on comparison
with open surgical approaches or PAIR are highly limited .
Overall, the majority of studies are heterogeneous small series,
 Retrospective reports with overlapping patients, limiting the
quality of the evidence on which to make strong
recommendations on management
BRUNETTI GUIDELINES
 Radical resection is the primary goal - excision of the entire
parasitic lesion should follow the rules of tumour surgery,
classified according to the quality of resection: R0: no
residue; R1: microscopic residue; R2: macroscopic residue.
 Non-radical liver surgery,previously regarded as beneficial
for reducing the parasitic mass, does not appear currently
to offer advantages over conservative treatment (Kadry et
al., 2005; Buttenschoen et al., 2009)
 ENDOSCOPIC AND
PERCUTANEOUS INTERVENTIONS
(EPI)
INDICATIONS
 EPIs are indicated for complications if surgery is felt to be too high
a risk and total resection of the lesions cannot be safely
performed.
 Main indications include liver abscess due to bacterial infection of
necrotic lesions, jaundice due to bile duct obstruction with or
without acute cholangitis, hepatic or portal vein thrombosis and
bleeding of esophageal varices secondary to portal hypertension.
CONTRAINDICATIONS
 EPIs may spread parasite material and should be avoided if
postinterventional
 BMZ is not possible.
LAP MANAGEMENT OF LHC

• Simple Can be achieved

drainage
laparoscopically
• Deroofing
• Introflexion
• Omentoplasty
• Pericystectomy
• Liver resection
INDICATIONS
 liver hydatid cysts not located in segment 1 or 7 of the liver
(Couinaud’s segmentation), with corticalization on the surface
of the liver and no evidence of intrabiliary rupture.
 Knowing the relationship between the cyst and the biliary tree
is essential in choosing the appropriate patients for the
laparoscopic technique, although considering that laparoscopic
hepatic resection is a growing option in the field of hepatic
surgery
CONTRAINDICATIONS
 the only absolute contraindication to the laparoscopic approach
in the treatment of liver hydatid cyst is posterior location of the
cyst (segments 7 and 1).
  Recurrent HC
• Intraparenchymal cysts  Dense
• Multiple cysts, bilobar adhesions

• Posterior localization
• Biliary communications dg
preop

• If a gesture more than

suture is required is more
easy to perform it by open
 ADVANTAGES
 laparoscope can be inserted inside the cystic cavity,
allowing its inspection
 If a biliocystic communication is observed, it can be
approached by applying a clip or an X-shaped wire
 remnants of the germinal membrane can be identified and
removed, reducing the incidence of recurrence or
suppurative complications.
 Postoperative morbidity ranges from 8 to 25 % in
laparoscopic studies and from 12 to 63 % in open series
 shorter hospital stays and operation times, less blood loss,
faster recovery, and lower wound infection rates
DISADVANTAGES
Laparoscopy is still limited in terms of:
 liver resection
 closure of biliary communications
 achievement of pericystodigestive anastomoses
 TREATMENT
 Lagrot partial pericystectomy involves resection of the
corticalized pericyst up to the border with the liver parenchyma.
After this procedure, the part of the intrahepatic pericyst
(residual cavity) communicating with the remainder of the
peritoneal cavity remains in situ.
 total pericystectomy - requires total excision of the pericyst
after prior inactivation of the hydatid content.
 If the presence of a biliocystic fistula is detected (small fistulous
orifice) during surgery it can be solved by applying a metal clip
and performing a suture (X-wire at this level).
 When occult cystobiliary fistula is suspected (avital hydatid
cysts or secondary infected cysts) but biliocystic
communication could not be visualized intraoperatively, the
choice after Lagrot partial pericystectomy is double external
drainage of the residual cavity.
 If necessary, ERCP can be performed to decrease the pressure
in the biliary tract
PERITONEAL HYDATIDOSIS
Peritoneal echinococcal disease is most frequently
secondary to the spontaneous or iatrogenic rupture
or splitting of hydatid cysts in the liver or, more
rarely, in the spleen.

 Almost always secondary to a liver disease related

to a previous surgery
 Remains silent for many years until cyst become
symptomatic
 Careful and complete surgical excision
 BMZ to prevent recurrence

Costamagna D, Case Reports in Medicine, 2010

CASE REPORT
 SEX: M
 AGE: 21
 SYMPTOMS: pain in right hypocondrium, nausea, loss of
apetite
 ABDOMINAL CT:
-left liver lobe with cystic formation with multiple septs,
88.2/49.1mm
-right hepatic lobe, in VII and VIII segments cystic formation
72.5/59.5mm
 ABDOMINAL MRI:
-left liver lobe (segments II-III), 78/56mm
-right hepatic lobe (segments VII-VIII), 75/57mm
-intergastro-parieto-splenic place 52/45mm
 Treatment – laparoscopic aproach
 After inactivation of the cysts with 96%

alcohol:
-fenestration, content evacuation and
drainage of the restant cavity for the VIII
segment cyst
-partial cystectomy, content evacuation
and drainage for the II-III segments cyst
-ideal cystectomy for the cyst from the
gastrosplenic ligament
MOVIE
Postop –bile leackeage from the VIII segment cavity wich was
managed conservatory with good tolerance from the
pacient, and closed spontaneously after 2 months from
surgery
In conclusion the laparoscopic
approach is safe, with an acceptable
mortality and morbidity for both
conservative and radical resections in
selected patients.