Laparoscopic management of hydatid cyst in the lesser sac.

Hydatid cyst is a disease caused by Echinococcus granulosus. Various anatomical location of hydatid cyst has been described in literature. Liver is the most common site of hydatid cyst and lungs are the second most common site. Hydatid cyst of lesser sac is a rare entity. Here we present a rare case report of laparoscopic management of hydatid cyst in lesser sac.

INTRODUCTION

Management of hydatid cyst mainly depends on the location and size of the cyst. The first line of management of most uncomplicated cysts is drug therapy with albendazole in a dosage of 10-15mg/kg/day.[1] But drug therapy is contraindicated or not useful in pregnancy, calcified cyst, and honeycomb cyst. Puncture-aspiration-injection-reaspiration (PAIR) can also be used in the management of hydatid cyst but it is associated with high recurrence rate. Surgery is the treatment of choice for uncomplicated cyst. Laparoscopic management achieves all the objectives of open surgery combined with all the advantages of minimal access surgery. In this case, the hydatid cyst was located in the lesser sac, which is a rare location for hydatid cyst. Only a few cases of management of hydatid cyst in the lesser sac have been described in the literature including one case of management of hydatid cyst in the lesser sac by PAIR technique.[2] Laparoscopic management of hydatid cyst in the lesser sac has not been described in the literature before. So, here we describe a case report of laparoscopic management of hydatid cyst in the lesser sac.

CASE REPORT

A 35-year-old female presented to our hospital with abdominal discomfort since 9 months and abdominal pain and abdominal fullness after eating since 2 months. Physical examination revealed a firm, epigastric mass that did not move with respiration. Her computed tomography (CT) scan report showed a lobulated, cystic mass lesion in the lesser sac of size 10 cm × 9 cm × 8 cm (Figure 1). The enzyme-linked immunoadsorbent assay (ELISA) test for echinococcal antigens was positive. After that, the patient was started on albendazole and it was given for 3 months. After all pre-operative preparations, the patient was put under general anaesthesia in modified lithotomy position. The pneumoperitoneum was created with a veress needle (ETHICON US, LLC, part of the Johnson & Johnson family of companies). One 10-mm telescopic umbilical port, one 5-mm epigastric port, one 12-mm port 4 cm below the epigastric port and two 5-mm ports in the right and left iliac fossa in the midclavicular line were created. The gastrocolic omentum was divided with a harmonic scalpel and the cyst wall was freed of all omental attachments (Figure 2). The stomach was separated from the cyst wall (Figures 3 and 4). The spleen and splenic hilum were totally free from the cyst. Then, the cyst was aspirated with Palanivelu hydatid system (PHS) under negative pressure of 15 mmHg to minimise leakage and 20% hypertonic saline was instilled into the cyst cavity and after 20 min, it was reaspirated. Then, the anterior wall of the cyst cavity of approximately 6 cm × 6 cm was removed with the harmonic scalpel and all the remaining scolices were removed under vision (Figure 5). Then, the omentum was sutured to the cyst cavity. An abdominal drain kit (Romo ADK, ROMSONS, India) was put into the cavity. The post-operative period was uneventful. The patient was started on oral liquids the next day and the sutures were removed on the third post-operative day and the drain was removed on the fifth post-operative day. Albendazole was continued for 3 months after surgery. The patient was discharged on the sixth day and follow-up was done after 1 month and then after every 3 months.

Figure 1

CT scan of hydatid of the lesser sac

Figure 2

Omental attachments of the cyst being separated

Figure 3

Cyst being separated from the stomach

Figure 4

Cyst totally separated from the stomach

Figure 5

Scolices being removed

DISCUSSION

The word “hydatid” is derived from Latin and means “watery vesicle.” It is caused by dog tapeworm (Echinococcus granulosus). Dogs are the definitive hosts and humans are the intermediate hosts; humans get infected by the ingestion of ova from the faeces of dogs[3] and through the portal vein, it reaches the liver (the most common site). The lung is the second most common site. Hydatid cyst of the lesser sac is a very rare presentation. Cyst wall consists of three layers, namely, endocyst, ectocyst and pericyst. The patient commonly presents with asymptomatic mass per abdomen, jaundice, abdominal pain, discomfort, etc. Ultrasound is diagnostic in most of the cases as it may reveal a rosette of daughter cysts, double-layer membrane and calcification of the cyst wall. CT scan is more accurate in the diagnosis, showing typical cartwheel appearance. A serological test such as ELISA is helpful in diagnosis and has a specificity of about 85%. Magnetic resonance cholangiopancreatography (MRCP) is useful where biliary communication or communication to the pancreatic duct is suspected. Management includes drug therapy, PAIR and surgery. Drug therapy, many a time, gives poor results and many controversies exist regarding its use as a sole mode of treatment.[4] Treatment of the hydatid cyst by PAIR is now an acceptable method but it has got a high recurrence rate and a high complication rate. Various operative methods have been described in the literature such as simple drainage, deroofing, capitonnage, introflexion, omentoplasty and pericystectomy that were used either in isolation or in combination. As with any other method of hydatid cyst surgery, laparoscopic method must fulfil all the basic requirements for the safe management of hydatid cyst disease. First the adequate exposure of cyst and a clear delineation of its relationship with adjacent structure laparoscopy with better lighting and magnification can show details of the anatomy of cyst with its adjacent organ that cannot be achieved by open surgery or any other method. Second for removal of the contents of the cyst cavity without spillage into the abdominal cavity that can lead to recurrence and anaphylactic shock, various methods have been described in the literature for safe removal of cyst contents without spillage. Simple needle aspiration of contents may lead to spillage. Large transparent bevelled cannula, as described by Bickel et al.,[5] leads to spillage and recurrence. Puncture of the cyst cavity with simultaneous suction may also lead to spillage. The aspirator-grinder apparatus described by Saglam[6] is a better way of reducing spillage and for the safe evacuation of contents of the cyst. But in our opinion, PHS is a simple yet effective means of removal of the contents of cyst without spillage. PHS consists of a trocar of length 29 mm, cannula of length 26 mm and an internal diameter of 12 mm. During the puncture of cyst, the cannula is under negative pressure, thereby minimising the risk of spillage. Also, all the daughter cysts can be removed under magnified intracystic view. In our opinion, the PHS system effectively addresses the second requirement. Third is the identification of biliary communication; this requirement is also addressed by PHS due to magnified intracystic view. Fourth is the instillation of scolicidal agent; this requirement is also addressed by PHS by using its irrigation channel and instillation of the scolicidal agent through that channel. Fifth is the management of the cyst cavity; marsupialisation and omentoplasty can be done to obliterate the cavity.

Thus, all the requirements can be safely addressed by the laparoscopic method with all the other advantages of minimal access technique. But laparoscopic management of hydatid cyst in the lesser sac has its own advantages. The lesser sac is a complex anatomical entity with anterior boundary of quadrate lobe of the liver, stomach and lesser omentum; it has a posterior relation of the pancreas. Its left lateral margin is made by the left kidney and adrenal gland and its boundary on the right is made by the epiploic foramen and lesser omentum. Whether the cyst is free from these structures or not can be lucidly delineated by laparoscopy, which is difficult to delineate in open surgery.

CONCLUSION

We, hereby, report a case of laparoscopic management of hydatid cyst of the lesser sac, probably the first one reported in the world literature to the best of our knowledge.[278]

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.