Laparoscopic management of benign nonparasitic hepatic cysts: a prospective nonrandomized study.

Background: Nonparasitic benign hepatic cysts are relatively rare, and are usually detected fortuitously while investigating a patient for some other illness. However, they may reach huge proportions and present as an upper abdominal mass. With the advent of laparoscopy, a minimally invasive technique is available to manage these cases, which is described along with results and a discussion of the concerned literature.

Methods: Since 1995, 27 patients underwent cyst fenestration at our institution. The team setup, port placement, instruments and technique are described.

Results: All of our patients had a single cyst. Of the 27 patients, 17 were symptomatic with the most common complaint being upper abdominal distension and pain. Twenty patients had a right-sided cyst. In 16 patients, omentopexy was done to deal 0with the residual cavity. Eleven patients underwent simultaneous cholecystectomy. The average operating time was 72 minutes. There have been no recurrences after an average follow-up period of 7.2 years.

Conclusions: Laparoscopic management of congenital hepatic cysts has become the new gold standard, associated with minimum morbidity and good long-term outcome.

Key Words: benign nonparasitic hepatic cysts, laparoscopy, congenital hepatic cyst

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Hepatic cysts are rare. The first case of nonparasitic cystic disease of the liver was reported by Bristowe in 1856, (1) who stressed its association with polycystic liver disease. Michel recorded the first sporadic nonparasitic hepatic cyst in the same year. These cysts have been referred to in the literature by a variety of names, such as biliary cyst, nonparasitic cyst of the liver, benign hepatic cyst, congenital hepatic cyst, unilocular cyst of the liver and solitary cyst of the liver. They are usually fortuitous discoveries by the surgeon when operating for some other condition. With the increased utilization of noninvasive imaging tools, especially ultrasonography, their frequency is rising. However, most cases are either detected incidentally during imaging or when they become symptomatic. The most common nonparasitic hepatic cyst is the congenital or developmental cyst. (2)

Lin et al (3) first described the technique of fenestration or deroofing of the cyst in 1968. Laparoscopic management was first reported in 1991 by two separate groups (4,5); however, laparoscopy was used before this for diagnosis. The first use of diagnostic laparoscopy for hepatic cyst was documented in 1955. (6) In fact, laparoscopic ultrasonography was used for diagnosis of liver disorders as early as 1989. (7) Currently, laparoscopy plays a significant role in the management of primarily sporadic hepatic cysts.

Materials and Methods

Our team began performing laparoscopic cyst fenestration for benign hepatic cysts in 1992. Preoperatively, all patients underwent routine hematology, ultrasonography, chest x-ray and ECG. The diagnosis indicated by ultrasonography was confirmed by CT scan, which also gave further information regarding the extent of the tumor and its proximity to any vital structures within the liver. Thereafter, the patients were scheduled for laparoscopic cyst fenestration.

Team setup

The operating surgeon and the camera surgeon stood on the left of the patient facing the monitor, while the assistant surgeon stood on the right side of the patient, similar to the North American approach for laparoscopic cholecystectomy.

Ports

1. 10 mm camera port in the umbilicus or supraumbilically, depending on the position of the cyst.

2. 10 mm right-hand working port in the patient's left upper quadrant, the exact site of which was determined by the size and location of the cyst.

3. 5 mm left-hand working port in the right upper quadrant.

Instruments

Apart from the routine set, we use a special trocar-cannula set which we designed (the Palanivelu Hydatid System, PHS) for spillage-free decompression of the cyst, since hydatid cysts can easily mimic a congenital hepatic cyst, with only histopathological examination of the cyst wall and cytological examination of the fluid providing the final diagnosis. The PHS consists of a trocar and cannula along with 5-mm and 3-mm reducers. The trocar is 29 cm in length. It is hollow to accommodate a suction cannula. The tip is pyramidal-shaped with each facet of the pyramid bearing a fenestration to enable any leaking fluid to be suctioned into the hollow body by the cannula. Its long shaft also bears 2 fenestrations opposite each other at a distance of 17 cm from the tip. The cannula is 26-cm long with an inner diameter of 12 mm. It has 2 side channels, one for gas insufflation and another for suction. The suction channel has an inner diameter of 10 mm. Its outer nozzle is designed so that the suction tube will fit in an airtight manner (Fig. 1). For excision of the cyst wall, bipolar cautery forceps, ultrasonic shears or LigaSure is needed.

Operative technique

After the introduction of the camera port, the cyst is identified. The right- and left-hand working ports are inserted under vision. The Veress needle is used to puncture the cyst and aspirate fluid to confirm the absence of biliary staining. Alternately, if a hydatid cyst cannot be ruled out, the hydatid trocar-cannula is used to puncture and aspirate the cyst. Once the possibility of hydatid cyst is ruled out, the cyst wall is excised using Ultrasonic shears or Ligasure 2 to 3 mm from the hepatic parenchyma-cyst wall junction. (Fig. 2) If a large part of the cyst extends above the liver, excision of the cyst wall will result in wide opening of the cystic cavity and no further procedure is required. (Fig. 3) If the cyst wall is largely intrahepatic, excision of the external cyst wall will create a small opening in the cyst wall relative to the size of the cyst cavity. In such cases, we prefer to obliterate the cavity by omentopexy. If the edges are oozing, they are over run with continuous suture of 3-0 polygalactin. (Fig. 4) After confirming hemostasis, a drain is placed intra-abdominally, as there may be a temporary serous secretion from the cyst.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Postoperative

Patients are typically discharged after 24 hours. In cases of significant drain output, patients are discharged with the drain in situ, which is then removed on follow up.

Results

Of the 27 patients, 22 were male and 5 were female. Their ages ranged from 22 to 65 years with the average age being 48.6 years. All patients were symptomatic, complaining of abdominal distension; vague abdominal pain which was aching in nature, or heaviness in the upper abdomen. The patients had been symptomatic for an average of 6.4 months (range of 4-18 months) before seeking treatment. The patient characteristics are summarized in Table 1.

[FIGURE 4 OMITTED]

All our patients had a single cyst. Right-sided cysts were overwhelmingly common, constituting 20 of our patients, with only 7 patients having a cyst in the left lobe of the liver. Five patients had a thick-walled cyst in the right lobe of the liver. Thick, yellow fluid was aspirated, containing shiny flecks, which on microscopy proved to be cholesterol crystals. Histopathological examination of the excised cyst wall established a diagnosis of intrahepatic choledochal cysts, sequestered from the biliary tree. The maximum diameter of the cysts ranged from 5.4 cm to 42.6 cm, with a median of 16.2 cm on ultrasonography. In 11 patients, simultaneous cholecystectomy was performed for incidental cholelithiasis. Omentopexy was carried out in 16 patients. The operative time ranged from 55 minutes to 104 minutes, with an average operating time of 72 minutes. There was no major postoperative morbidity. Three patients had prolonged drainage of ascitic fluid which responded to conservative measures. The median hospital stay was 4 days. The follow-up period has ranged from 12 years to 2 months with an average follow-up of 7.2 years. There have been no recurrences to date.

Discussion

Benign hepatic cysts are not a common condition. The true incidence of this disease is difficult to estimate, as it is usually asymptomatic in most patients. Between 1 to 5% of the population may have asymptomatic disease, with an increasing incidence with age, and found more commonly in females. (8-10) Although the common age of presentation is late in life, a giant hepatic cyst has been diagnosed in a fetus in utero. (11)

The majority of our cases were simple hepatic cysts, with the cyst wall lined by a single layer of cuboidal or columnar epithelium containing thin, serous, straw-colored fluid. However, in five patients, the histopathology revealed sequestered intrahepatic choledochal cysts. These cysts were thick-walled as compared with the other simple hepatic cysts, containing viscous dark yellow fluid with shiny specks, which on histopathology proved to be cholesterol crystals. The detection of cysts had increased with the advent and routine use of ultrasound and CT scan. All of our cases were initially diagnosed by ultrasonography. In addition to the diagnosis, it provides information about the cyst wall, fluid content and surrounding liver tissue. CT was carried out to further delineate the anatomy and rule out proximity of vital structures. Hydatid serology may be useful to differentiate from hydatid cysts, especially in patients living in areas endemic for echinococcosis. Before surgical therapy, hydatid disease must be ruled out, especially in patients residing in endemic areas or having traveled from endemic areas. Other cystic lesions must also be excluded, such as cystadenoma and cystadenocarcinoma, where cystic septations, papillary structures, or multiloculated cystic formation may be seen radiologically. (12,13) Despite improvement in imaging techniques, the probability of preoperatively mistaking a hydatid liver cyst for a simple liver cyst remains about 5%. (14) Therefore, laparoscopic fenestration, planned for a liver cyst, could be performed unintentionally for an undiagnosed hydatid liver cyst. For this reason, we advocate using the Palanivelu Hydatid System for spillage-free aspiration of the fluid in all suspicious cases. (15) Percutaneous aspiration of cystic content is the simplest treatment for symptomatic, nonparasitic cysts. However, this is associated with a high rate of recurrence (12,16,17) and carries a considerable risk of infection. Nonsurgical management in the form of percutaneous aspiration under ultrasonographic guidance, followed by injection of sclerosant-like ethanol or minocycline has been advocated. (18-21) We advised surgery for all our patients, as the minimally invasive approach afforded the least morbidity and also enabled histopathological confirmation of the clinical diagnosis.

Surgical procedures described for treatment for liver cysts include intraoperative aspiration, unroofing, cystojejunostomy, total excision of the cyst, partial liver resection, hepatic lobectomy and liver transplantation. Since the first report of laparoscopic management of a congenital hepatic cyst, it has become the preferred mode of management of this disease. (20,22-25)

Laparoscopic management of the cyst consists of cyst fenestration wherein the protruding wall of the cyst is widely excised to allow the cyst to drain intraperitoneally (IP) and to allow for cyst excision. The excised edge must be oversewn or cauterized for hemostasis, and the cystic cavity must be inspected for the presence of bile. If a biliary communication is found, it should be oversewn as well. Leaving viable cyst-lining epithelium behind allows for the possibility that another cyst will form; however, these cysts are usually small and only rarely require subsequent treatment. Wide unroofing, or cyst fenestration, has been reported to give good results. (2,26)

Although laparoscopic management has had its detractors, (27) the benefits have made it a popular mode of management for this disease. Besides achieving similar results as open surgery with fewer complications, shortened hospital stay and reduced sick leave, laparoscopy offers the advantage of allowing inspection of the inner surface of the cyst wall for signs of malignancy and biopsies of suspicious lesions. (28) Various methods have been described as adjuvant to laparoscopic fenestration to achieve lasting relief. This includes injection of ethanol into the residual cyst cavity, (29,30) fulguration of the cyst cavities by electrocoagulation or argon beam coagulation, (31) and placement of an omental transpositional flap onto the cyst cavity itself. (32) According to Emmermann et al, (29) omental flap keeps the cyst cavity open to the abdomen and also resorbs some of the fluid produced by the cystic epithelium. We believe that if partial cyst excision has removed more than 50% of the estimated surface area of the cyst, no further therapy other than IP drainage of the residual cyst is necessary. The adjuvant maneuvers are required only if less surface area is excised or the majority of the cyst resides within the liver parenchyma.

Complications of laparoscopic management of hepatic cysts have ranged from 0 to 15% and include dyspnea, pleural effusion, ascites, hemorrhage, infection and subhepatic bile collection. (33) However, we did not have any major morbidity in our patients except for prolonged abdominal tube drainage in three patients. The median hospital stay was 4 days (it was 11, 13 and 18 days in the patients mentioned above). The rapid recovery allowed early return to normal activities.

Laparoscopic deroofing (combined with omentoplasty and/or oversewing) of uncomplicated liver cysts is associated with a recurrence rate of 10 to 25%, with less morbidity and mortality as compared with open surgery. (32,34) This is borne out by the fact that over an average follow up of 7.2 years, we have not had a single recurrence. We attribute this to our principle of wide unroofing of the hepatic cyst cavity. In cases where we felt that an intraparenchymal location of the majority of the cyst precluded wide unroofing, we performed omentopexy (16 patients) to prevent closure of the cyst and recurrence. By this technique, though there may have been occasional prolonged serous drainage, long-term results were excellent. Recurrence of a simple hepatic cyst following laparoscopic deroofing has been attributed to a failure to ablate the secreting lining of the cyst wall; and to provide adequate measures to prevent early closure of the cyst such as may occur when the resected window is relatively small as compared with the overall size of the cystic cavity. (26) Factors predicting failure include previous surgical treatment, deep-seated cysts, incomplete deroofing technique, location in the right posterior segments of the liver, and a diffuse form of polycystic liver disease with small cysts. (22) Our results have been compared with some major series in Table 2. Thus, laparoscopic management of symptomatic solitary nonparasitic liver cysts is permanently successful in a large majority of cases when the diagnosis is correct.

Laparoscopic management of congenital hepatic cysts is the gold standard. It is associated with minimal morbidity and good long-term outcome. The major advantages of laparoscopic surgery also include decreased pain, earlier mobilization, shorter convalescence and high acceptability by patients.

References

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C. Palanivelu, MCh, MNAMS, FACS, FRCS (Ed), Kalpesh Jani, MD, MS, DNB, MNAMS, and Vijaykumar Malladi, MS

From Gem Hospital, Tamil Nadu, India.

Reprint requests to Dr. Kalpesh Jani, Gem Hospital, 45a, Pankaja Mill Road, Ramanathapuram, Coimbatore-641045, Tamil Nadu, India. Email: [e-mail]

Accepted June 14, 2006.

RELATED ARTICLE: Key Points

* Nonparasitic benign hepatic cysts are usually asymptomatic. They become clinically evident due either to their enlarging size or the onset of complications such as infection or intracystic hemorrhage.

* Surgery is indicated for the management of symptomatic cysts. Laparoscopic surgery is an attractive option, given its low morbidity and rapid recovery.

* When the cyst is protruding from the surface of the liver, wide excision of the visible cyst wall is adequate. An intraparenchymal location of the majority of the cyst requires additional measures to obliterate the cavity, like omentopexy or cauterization of the secretory mucosa to prevent recurrence.

Table 1. Patient characteristics

                                                   No. of patients

Total number of patients                           27
Male/female                                        22/5
Associated surgery (laparoscopic cholecystectomy)  11
Omentopexy                                         16
Right lobe/left lobe                               20/7
Histopathology
  Simple hepatic cyst                              22
  Sequestered choledochal cyst                      5

Table 2. Comparison of major series

                            Patients        Maximum
                  Patients  requiring       follow up
Author            (n)       conversion (n)  (months)   Recurrence (n)

Gigot et al       17        2                48        3
  (1996) (22)
Martin et al      13        0                80        1
  (1998) (24)
Emmermann et al   18        1                43        2
  (1997) (29)
Marks et al       10        1                67        0
  (1998) (35)
Palanivelu et al  27        0               144        0
  (2005) (15)