肝包虫囊肿的腹腔镜手术治疗

LAPAROSCOPIC MANAGEMENT OF LIVER HYDATID CYST

Chandrakant D Shivsharan                                                                                                                                                                     
Member World Association of Laparoscopic Surgeons,
                                                                                                                                                                                                      
ABSTRACT:

Laparoscopic management of hydatid disease of the liver has encouraging and promising results, though its feasibility and safety have been questioned hence, the aim of this article is to evaluate the role and safety of laparoscopic procedures in treatment of liver hydatid cyst
                                                                                                                                       
KEYWORDS :  

Laparoscopic management hydatid cyst liver, Hydatid cyst, Complication of Hydatid Cyst
   
INTRODUCTION
   
Hydatid disease is a rare entity primarily affecting the population of developing countries. Septation and calcification of the cysts with a high antibody titre in the patient's serum confirm the diagnosis, although more sophisticated tests have been applied recently. Surgery constitutes the primary treatment, with a variety of techniques based on the principles of eradication and elimination of recurrence by means of spillage avoidance. (1)  Hydatid disease is endemic mainly in the Mediterranean countries, the Middle East, South America, India, northern China, and other sheep-raising areas; however, owing to increased travel and tourism all over the world, it can be found anywhere, even in developed countries.
                                                                    
Hydatid disease is a zoonotic infection caused by adult or larval stages of the cestode Echinococcus granulosus.2 The prevalence of hydatid disease among human was determined as 9.1% in a world health organization study in central Peruvian Andes.3 In human most hydatid cyst occur in the liver and 75% of these are single cyst other common organs included are lung, spleen and kidney.(4 )The hydatid cyst of the liver has two layers; the ectocyst, a dense fibrous host reaction to the parasite, and the parasite-derived endocyst, which has an outer laminated and an inner germinal layer. The single-celled germinal membrane gives rise to broad capsules, which contain the scoleces, and daughter cysts, which float freely in the clear cyst fluid.(5) Surgery remain the gold standard in term of therapy for patients with hepatic hydatid cyst despite significant advances in medical treatment and interventional radiology, the conventional operative procedures of the hydatid cyst of the liver like enucleation, cystectomy, evacuation, marsupilisation, etc. Which involve a significant morbidity     especially in term of wound infection. Laparoscopic treatment of hepatic hydatid disease has been increasingly popular parallel to the progress in laparoscopic surgery.6 Controversies about the role of laparoscopy in the management of liver hydatid cyst have not been resolved; these controversies include selection of patients and surgical technique

MATERIALS AND METHODS

A literature review was performed using Springer link, Highwire Press Journal of MAS, Google search engine.   The search terms were laparoscopic management and liver hydatid cyst. Criteria for selection of literature were the number of cases (excluded if less than 20), methods of analysis, and the institution where the study was done. The most common complaints were dull pain at the right hypochondrium or/and epigastrium   and palpable mass. Patients were diagnosed by ultrasonography (US) computed tomography (CT), Magnetic   resonance (MRI) and confirmed by serological examination (immuno-electrophoresis which has a high sensitivity.  We excluded cases with multiple liver hydatid cysts more than two or cyst located in blind area for laparoscopic procedures like segments 1, 2 and 7. Our exclusion criteria also included intraparenchymal location of the cyst, or cysts with thick and calcified walls. All procedures were performed under general anesthesia and in the supine position. Prophylactic antibiotics were administered 30 minutes before the operation. The surgeon and the camera assistant standing on the left side of the patient with the assistant and scrub nurse standing on the right side of the patient. Four ports were placed, a supraumblical 10 mm port through which a 0° telescope inserted, another 10 mm port inserted at the epigastrium as near as possible to the cyst and used as working channel fig. 2, and two additional 5 mm ports inserted according to cyst location. From the epigastric port gauzes soaked with 20% hypertonic saline as a scolecidal agent were introduced into the abdominal cavity and placed around the cyst. The cyst was punctured with long laparoscopic needles connected to vacuum suction through epigastric port; another sucker was introduced through the right 5 mm port to avoid accidental spillage of the cyst content. Cystic fluid was aspirated and then 100 ml of 20% hypertonic saline was injected inside cyst via the same needle then aspirated fig. 3, this procedures repeated three times and then the needle was withdrawn while still connected to suction to prevent back spillage from needle, and then deflated cystic wall was suspended by 2 graspers, and cystotomy was performed by electocautry and the laminated membrane was carefully removed and put into endobag and retrieved through epigastric port, then the laparoscope was inserted into the cyst to exclude any biliary communication or retained daughter cysts. The cystic cavity was irrigated with 20% hypertonic saline several times, and partial or near-total cystectomy was done using harmonic scalpel fig. 5, then a drain was placed in the remaining cystic cavity, and gauzes were placed in an endosac and removed.

Postoperative follow up was very smooth, Oral fluid intake was allowed next day of operation, drain was removed 48 hours after operation if no apparent bile in the drain, patients were discharged home and advised for follow up at two weeks, three months and six months and then yearly by ultrasound and serological test (immunoelectrophoresis test).

Symptoms:

1. Right upper quadrant pain
2. Nausea and vomiting
3. Right abdominal tenderness
4. Jaundice
5. Allergic reactions

Diagnosis:

The diagnosis is established by ultrasonography and computed axial tomography; in doubtful are undertaken immunological tests and detection of anti-echinococcal antibodies. Particular technique called ELISA (Enzyme Linked Immuno Sorbent Assay) has a high specificity and accuracy.

Techniques:

Open Surgery Procedures:

The open conservative approach is applied for giant cysts and consists of: neutralization of the parasite, evacuation of cystic components, treatment of the pericystic cavity and management of cist-bile duct communications if present. In the surgical simple drainage the abdomen is protected with gauze packs around the cyst to reduce the peritoneal contamination risk. Once aspirated, the cavity is sterilized with antiscolecoidal agents ( e.g. albendazole, hypertonic solutions ) and the cyst is unroofed and drained.Marsupialization and capitonnage procedures are not use anymore because of the high complications rate. There are more aggressive operations how hepatectomy and total pericystectomy that often cause immunologic reactions, infection of hepatic parenchyma and postoperative bile leakage.

Indications:

1. Single superficial cyst that may rupture
2. Large cyst with multiple daughter cysts
3. Cysts in communication with the biliary tree
4. Infected cysts
5. Cysts giving compression to the near vital organs

Contraindications:

1. Dead cysts
2. Multiple cysts
3. Cysts difficult to access
4. Small cysts

Laparoscopic Procedure:

Although there aren’t randomized clinical trials comparing laparoscopic versus open surgical treatments, more and more, in the last fifteen years laparoscopic management of liver echinococcosis has gain ground producing encouraging results. Palanivelu planned a recent technique, the so-called PHS(Palanivelu Hydatid System. The PHS consists of a complex system of fenestrated trocar and cannulas through which it’s reduced at least the peritoneal spillage).

Contraindications:

1. Deep intraparenchymal cysts
2. Posterior Cyst
3. More than 3 cysts
4. Cysts with tick and calcified walls.
5. Cysts characterized by heterogeneous complex mass (Gharbi type 4 )
6. Cyst less than 3 cm in diameter
7. Serious coagulation abnormalities

Technique:

After creating of pneumoperitoneum through the umbilicus and after identifying the hydatid cyst, the PDS trocar is introduced into the peritoneal cavity directly over the hydatid cyst. Once the trocar is removed only the cannula is advanced until its tip is in contact with the hydatid cyst surface. After suction with cannula, a 5 mm trocar jointed to another suction machine is introduced into the cannula and is pushed into the cyst. The suction is immediate and happens either into the body of the hollow trocar and into the suction cannula, or into cannula and then into the suction side-channel. The trocar is removed, the peritoneal cavity is irrigated by the main channel while the suction is maintained all the time. After removing fluid, the telescope is introduced to visualize the interior of the cavity for control any cyst-biliary communication; a scolicidal agent is instilled into the cyst cavity and after 10 minutes it is suctioned and the cyst is marsupialized. In case of bile leakage use of scolicidal agent is avoided for the cholangitis risk. Omentoplasty is done in all case and a drainage tube is put near the cyst.

Complications:

The most common complication is the creating of external biliary fistula ( 5-25% ). Some authors suggest a conservative therapy when the daily bile output is < 300 ml replacing the patient’s daily fluids and electrolyte losses. For high –output fistulas > 300 ml more than 1 week duration and low-output fistulas of more than 3 weeks duration were treated by endoscopy sphinterotomy. Other immediate complications can be anaphylactic shock due to spillage caused during puncture cyst maneuver, bleeding and post-operative infection with creating of perihepatic abscesses. A later complication is the recurrence; the rate of short-time recurrence ( by some authors ) varies from 0% to 9% after laparoscopy, it is higher in open ( 0% to 30% ).

DISCUSSION:

The choice of the better management of hydatid cyst of the liver is very difficult because of variable clinic-pathologic aspects. The treatment should be individualized to the morphology, size, number and location of the cysts. The progresses fulfilled in the latest years by laparoscopic management have made the applications of this technique possible to a number more and more growing of cases. It is sure that the Palanivelu Hydatid System ( PHS ) have revolutionized the treatment of hydatid cyst of the liver because its sealed procedure not only avoids any spillage of the fluid , but also allows intracystic magnified visualization for cyst biliary communications. By its application field are excluded only deep intraparenchymal or posterior cysts situated close to the vena cava. Consequently it is reduced time range hospitalization that is for the laparoscopy, in the opinion of some authors, of 3-12 day against the mean hospitalization time range in the open that is of 9-20 days; mortality with the laparoscopic procedure goes down almost 0% as morbidity as that has determinate a dramatic and sensible reduction of the recurrence

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