Laparoscopic excision of hepatoduodenal ligament cyst.

Hepatoduodenal ligament cysts are rare. These may be confused with hepatic cysts even on advanced investigative modalities like Computerized tomography scanning or Magnetic Resonance Imaging. Diagnosis is often an intraoperative surprise. Laparoscopic treatment of such hepatoduodenal cysts is not described in available medical literature. We report one such case treated laparoscopically.

INTRODUCTION

Cystic lesions of the right hypochondrium can be a diagnostic surprise even with advanced imaging techniques. We present a rare case of a non parasitic non choledochal cyst of the hepatoduodenal ligament treated laparoscopically.

CASE REPORT

A 65 year old male presented with pain and lump in the right hypochondrium since 3 years which was not associated with jaundice or fever. There was no history of trauma or previous episodes suggestive of pancreatitis. Clinical examination revealed a smooth cystic lump in the right hypochondrium which moved with respiration and was continuous with the liver dullness. Routine hematological and biochemical investigations were normal. Contrast enhanced computed tomography (CECT) reported a 10.52cm × 9.9cm × 6cm unilocular cyst arising from the segment V of the liver. [Figure 1] Other organs were normal.

Figure 1

Contrast enhanced computed tomography (CECT) showing a large hypodense lesion measuring 10.52 cm × 9.9 cm × 6 cm in the subhepatic region and arising from the segment V of the liver.

A provisional diagnosis of cystic lesion in the liver was made. The differentials were simple cyst, biliary cystadenoma or a hydatid cyst. Serum Immune Haemeagglutination Assay (IHA) for Echinococcus was negative. Laparoscopy revealed a large cystic lesion occupying the right subhepatic space with the common bile duct (CBD) plastered over it. [Figure 2] On careful aspiration of one liter of dark hemorrhagic fluid from the cyst, it was seen to be arising from the hepatoduodenal ligament between the CBD and the portal vein. The thickwalled cyst was carefully dissected from the surrounding structures [Figures 3 and 4]. It was densely adherent to the CBD and portal vein. A small strip of the wall was left behind to avoid injury to the CBD and portal vein and the cyst was delivered through a small subcostal incision. There was no evidence of a laminated membrane or daughter cysts. Postoperative recovery was smooth. Histopathology revealed a cystic lesion with a fibrous wall.

Figure 2

Intraoperative picture during laparoscopy showing a large cystic lesion (thin arrow) in the right subhepatic space and the Common bile duct (thick arrow) anterior to it.

Figure 3

Intraoperative picture of dissection of the cyst from the common bile duct.

Figure 4

Intraoperative picture showing cyst being dissected off from posterior aspect.

DISCUSSION

Cystic lesions in the right hypochondrium may arise from the liver, gall bladder or pancreas and rarely from other organs like the diaphragm.[1] Investigative modalities like a CECT or Magnetic Resonance Imaging (MRI) often reveal the organ of origin.[2] Operative surprises are however likely specially when a large cyst arises from the hepatoduodenal ligament and occupies the right hypochondrium. Cystic lesions of the hepatoduodenal ligament are rare and those that have been reported in literature include epidermoid cyst,[2] dermoid cyst,[3] Tubercular abscess[4] and hydatid cyst.[5] All have been operated by open technique.

Laparoscopic approach is well established for hepatic cysts of various etiologies including hydatid cyst.[6] We decided on a laparoscopic approach with a presumption of liver cyst in mind. To our surprise however, the cyst was found originating from the hepatoduodenal ligament. With patient and careful dissection, the cyst could be dissected successfully and excised. We propose that laparoscopic dissection of hepatoduodenal ligament cyst is possible and should be attempted to give the patient benefits of laparoscopic intervention.

CONCLUSION

Cysts arising in the hepatoduodental ligament are rare and can be diagnostic surprise even with advanced imaging techniques. Literature supports them more often as operative surprises. While reported cases have been tackled by open technique, we propose that such rare cysts arising from the hepatoduodenal ligament can successfully be operated laparoscopically.