A simplified protocol of combined thoracoscopy and laparoscopic excision for large subdiaphragmatic hepatic hydatid cysts.

Human hydatid disease caused by echinococcus granulosus is one of the commonest zoonosis and it primarily affects the liver. Amongst, the various treatment options, surgical management with removal of its contents and pericystectomy under the cover of anti-helminthic is the treatment of choice. Large hydatid cysts located in the posterosuperior aspect of liver often require thoracic approach. In this context, we describe an innovative combined thoraco-laparoscopic technique for the surgical treatment of large subdiaphragmatic hepatic hydatid cyst.

INTRODUCTION

Echinococcosis a zoonosis occurs primarily in sheep-grazing areas of the World, though it is common Worldwide.[1] The commonest site in human body is the right lobe of liver. The treatment of hepatic hydatid cysts is primarily surgical.[2] A wide range of operations have been reported in literature. Though, the general surgical principles are complete abdominal exploration, adequate liver mobilization to expose the cyst, drainage of its contents and obliteration of the cyst. With the advent of advanced laparoscopic era, reports of laparoscopic techniques for drainage and deroofing of the cyst are on the raise.[345] But, large postero-superior hepatic hydatids usually require thoraco-laparotomy to complete the procedure, which is associated with major pulmonary morbidity. Here we report an innovative minimally morbid technique for a large subdiaphragmatic hepatic hydatid cyst.

CASE REPORT

A 30 year old lady presented with epigastric pain, dyspepsia and dyspnoea of 4 months duration. There was no history of jaundice or fever. On clinical examination there was moderate hepatomegaly. Routine blood investigations and liver function tests were normal. Ultrasonographic examination of abdomen was suggestive of a large cyst measuring 18 × 16 cm in the right lobe of liver with a typical rosette appearance. Computed Tomography (CT scan) of abdomen was suggestive of a 16x15 cm, hypodense space occupying lesion (SOL) in VII and VIII segments of liver and abutting the right dome of diaphragm [Figure 1]. Chest X-ray posterior-anterior view showed an elevated right dome of diaphragm. In view of the location and size of the hydatid cyst, we planned a combined thoracoscopy and laparoscopic approach for pericystectomy, to minimize the morbidity of thoraco-laparotomy

Figure 1

Computerized tomography - hypoechoic SOL in VII, VIII segments of liver

Patient was treated with 2 weeks course of Albendazole 10 mg/kg/day and was then posted for surgery.

Surgical Technique

Under general inhalational anaesthesia in supine position, an umbilical 10 mm trocar was placed by open technique. Laparoscopy was done and whole of the abdomen was inspected. There was a solitary hydatid cyst, but only a crescent of it was visible posterosuperior to the right lobe of liver. One 10 mm epigastric and one 5 mm right sub-costal ports were placed under vision. Cyst was assessed for the feasibility of its dissection, but dense adhesions present between the dome of diaphragm and cyst wall, obliterated the subdiaphragmatic plane for dissection. [Figure 2] At this stage we proceeded to thoracoscopy.

Figure 2

Port placements – subcostal margin (white arrow): above it are 3 thoracic ports and below it are laparoscopic ports (black arrows)

A 10 mm port was placed in right 6th intercostal space (ICS) in mid-axillary line. Thoracoscopic inspection was done. There was tenting of right dome of diaphragm. A 5 mm working port in anterior axillary line in 5th ICS and 10 mm port in mid-axillary line in 7th ICS were placed. Port placements are shown in Figure 3. Veress needle was passed through 7th ICS under vision and the cyst was punctured through diaphragm [Figures 3 and 4]. Diagnostic aspiration was done, which was suggestive of hydatid cyst as evidenced by clear fluid and daughter cysts in the aspirated content. 100 ml of fluid was aspirated and same quantity of 10% hypertonic saline was injected in to the cyst for its scolicidal effect for 15 minutes. The Verress needle was removed and replaced with a 10 mm trocar in to the cyst cavity. Cyst contents were aspirated with 10 mm suction cannula passed through the trocar. 10 % hypertonic saline and 10% povidone Iodine were alternatively used as scolicidal agents and instilled in to the cyst. Approximately 2 liters of the cyst fluid with daughter cysts was aspirated out. The inner wall of cyst was inspected with telescope passed through intracystic trocar, for any biliary communication, bleeding and residual contents. After ensuring the removal of cyst contents and inner wall; the rent in the diaphragm was sutured with prolene no 2-0 by intra-corporeal knotting. Inter-costal drain was placed. Then re-laparoscopy was done. Now it was possible to visualize most of the cyst wall as it was decompressed thoracoscopically. Also the cyst wall got separated substantially from the diaphragm, as few of the adhesions got divided after decompression facilitating easier liver mobilization. Partial cystectomy was done with monopolar hook. An endobag was introduced through 10 mm trocar in to the peritoneal cavity. The inner wall of cyst was scraped using gauze soaked in hypertonic saline. All the residual daughter cysts were collected in the endobag without spillage. Proper haemostasis was achieved at the edge of Cyst. The entire pericyst was removed. A tube drain was placed in the residual cyst cavity with an omental plug. All trocars were removed and port sites (thoracoscopic and laparoscopic) were closed. Post-operative period was uneventful. Inter-costal drain and abdominal drain were removed on 4th and 5th post-operative day respectively. Patient was treated perioperatively with broad spectrum antibiotics, analgesics, Albendazole and chest physiotherapy. Patient was discharged on 5th post-operative day and is asymptomatic at 9 months follow-up period.

Figure 3

Laparoscopic view – roof of hydatid seen between liver (black arrow) and diaphragm with dense adhesions (white arrow)

Figure 4

Thoracoscopic view – pushed up dome of diaphragm (black arrow), collapsed lower lobe of lung (white arrow) and aspiration with Verres needle (hollow arrow); external view of irrigation and aspiration is seen in Figure 2

DISCUSSION

In human beings, hydatid disease most frequently occurs in the liver in 50-80 % of cases. Generally, hepatic hydatid cysts are single, uncomplicated and located in right lobe of the liver.[1678] Treatment options for liver hydatid cyst are surgery, anti-helminthic drugs and per-cutaneous drainage. Treatment should be instituted to prevent complications like infection, calcification, cirrhosis, atrophy and rupture of the cyst in to the adjacent structures or anaphylaxis.[9] Surgery is the commonly performed and well accepted modality, as it has the potential to remove the cyst and cure the disease. Hepatic hydatid cysts can be dealt with various ways like cystotomy, capitonnage, marsupialization, pericystectomy, enucleation and hepatic resection.

Laparoscopy is the minimal invasive procedure and it is proved by many successful series published in the recent past.[345] The only disadvantage is chances of dissemination of the hydatid disease due to spillage of hydatid fluid in to peritoneal cavity. Laparoscopy is feasible for the cysts, which are present over the anterior and inferior surfaces of liver. Deep seated intra-hepatic cysts are difficult to access. Those cysts which present over the posterior and superior surface of the liver are also difficult to remove by laparoscopy and even open surgical techniques. In open surgical technique large posterosuperior cysts often necessitate thoraco-abdominal approach. But, it is associated with increased morbidity of excess scar, post-operative pain, atelectasis and other lung complications especially in the elderly subjects.[10]

In the present case, hydatid cyst was located in the VII and VIII segments of the liver and abutted to the right dome of diaphragm with adhesions. Hence combined thoracoscopy and laparoscopic approach was chosen. Through thoracoscopic approach, decompression of the cyst and instillation of scolicidal agent in to the cyst without spillage was performed.

Role of thoracoscopy in postero-superior hydatid cyst is prompt and safe decompression of the cyst, which facilitates easier abdominal dissection without the fear of spillage and thus recurrence. While thoracoscopic procedure was described for lung hydatidosis,;[3] thoracoscopic transdiaphragmatic approach for hepatic hydatid disease is rarely reported. It also helps in preventing injury to abdominal structures like liver or bowel in an attempt to tackle spillage of daughter cysts in to abdomen if it is suddenly decompressed. Primary purpose of thoracoscopy is safe drainage and decompression before pericystectomy and avoidance of a morbid thoracotomy. In addition this technique has additional safety, as it is performed under conventional double lung ventilation with hypoventilation during creation of low pressure carbothorax (6 mm Hg). The intrapleural space created by partial lung collapse is enough for visualization of right dome of diaphragm, costophrenic recess; for fluid drainage and diaphragmatic repair. Various thoracic procedures like esophagectomy, pneumonectomy, empyema drainage, sympathectomy, thyroidectomy etc., have been performed safely using this technique of anaesthesia in the past.[1112] Additional advantage is we can combine this thoracoscopic technique with laparotomy if needed, as highlighted in this case.