Background Compared to open resection for hepatic hydatid cysts, a laparoscopic approach may combine the benefit of reduced morbidity with complete cyst removal. Nonetheless, intraoperative cyst rupture during a laparoscopic approach due to reduced tactile feedback is a valid concern.(1-3) Today, the laparoscopic experience remains limited even in high incidence regions.(4) Here, a structured approach to laparoscopic pericystectomy is demonstrated. Patient A 37-year-old male from Uruguay presents with worsening abdominal pain, nausea, and vomiting. A 4-phase liver CT shows a large complex liver cyst (8.8 x 8.2 x 11.3 cm), encompassing the left hepatic lobe while abutting right hepatic vein (RHV), anterior fissure vein (AFV) and inferior vena cava (IVC). Further, the cyst causes mass effect on the hepatic vein vasculature. CT appearance is consistent with a large hydatid cyst with distorted hepatic anatomy resulting in compensatory hypertrophy of segments II, VI and VII. Appropriate institutional review board (IRB) and inform consent was obtained. Technique Following neoadjuvant albendazole for 4 weeks to minimize any effects in case of inadvertent cyst spillage, the patient tested negative for echinococcal antibody. For surgical planning, the patient's anatomy was modeled to optimize the understanding of the complex spatial relationship between cyst, portal pedicle and hepatic veins. Further, port sites were preoperatively modelled to optimize port placement in the context of the altered anatomy from compensatory hepatic hypertrophy. During surgery, with the patient in a modified French position, the liver was completely mobilized. Then, a parenchymal transection plane was developed guided by RHV, AFV and IVC, while biliary radicals entering directly into the cyst were controlled individually. The complex transection plane resulted in preservation of the unaffected liver segments I, II, VI and VII. Conclusion The multimodal approach demonstrated here included pretreatment with albendazole followed by safe laparoscopic pericystectomy. In the preoperative setting, albendazole can reduce the risk of recurrence if spillage occurs during surgery. In inoperable patients, it has been previously shown to be an effective monotherapy for small (< 5 cm) CE1 and CE3a cysts.(5) For preoperative planning, an automated image reconstruction software (Fujifilm Synapse 3D) is used. The software creates a 3D model of the liver segmentation and vessels from contrast-enhanced CT and MR images. In addition to modelling the liver, port placement in relation to the liver is being simulated prior to surgery to optimize port placement at the time of surgery. During the case, the parenchymal transection is guided by RHV, AFV and IVC. The common postoperative complication of persistent biliary leakage was avoided by controlling each biliary radicals entering the cyst from the liver parenchyma. Biliary leaks are a common complication and have been positively correlated with the cyst diameter (similar to 79% of cysts with diameter of 7.5 cm or greater have cysto-biliary fistula).(6) In this context, indocyanine green may help to identify relevant biliary radicals entering the cyst or aid in recognizing bile leaks. If the stepwise approach described here is followed, minimally invasive pericystectomy represents a safe alternative to open surgery, harnessing the advantages of minimal risk of recurrence due to complete cyst removal and low morbidity.
