Laparoscopic approach to an echinococcal liver cyst in a boy with giant 3 organ cystic manifestation
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Although humans are accidental intermediate hosts for echinococcal infection, physicians may encounter the disease sporadically because of increased travel and immigration. The most common site of occurrence of hydatid cysts in humans is the liver (50–93%).  Liver hydatid cysts when left untreated may stay unnoticeable at the beginning, however can grow and follow several courses, like develop fistulae with adjacent organs rupture into the peritoneal cavity seeding daughter cysts, and develop daughter cysts. Application of minimal invasive techniques such as laparoscopic management gained ground despite the initial exaggerated fear of complications such as anaphylaxis and spillage. Indeed, hydatid cysts in multiple organs rarely occur .
For the liver lesion, the laparoscopic approach was opted. The first trocar was placed via a small infraumbilical open access to reduce the risk of puncturing the lesion. A pneumoperitoneum with a high pressure (12 mmHg) was created to enable optimum vision of the cyst. After this, the cyst was punctured with a 2-mm cannula (Fig. 1b). Approximately, 50-ml cystic content was aspirated and replaced with 40 ml of 10% NaCl solution. The reduction in the tension of the cyst enabled grasping of the cyst wall around the puncture site to prevent dislocation of the needle and spillage into the abdominal cavity (Fig. 1c). After exchanging the entire volume of the cyst (estimated to be 1L) and waiting for about 15 min, an incision was made on the outer capsule of the cyst that is of part the organ parenchyma (the liver) to reveal the fibrous parasitic cyst wall. Since the fibrous cyst wall was stiffened due to contact with hyperosmolar saline, it was easy to detach from the capsule and retrieved using an endoscopic retrieval bag (Fig. 1d). Marsupialization of the capsule was finally performed.
Over the years, the techniques described for the surgical treatment of echinococcal lesions are total pericystectomy, puncture and aspiration of contents followed by marsupialization, unroofing and drainage or omentoplasty [3, 4]. Anaphylactic shock during injection of the scolicidal agent as well as chemical cholangitis in case there is communication with the biliary tree and spillage with secondary hydatidosis are the main risks of the procedure . The remaining residual cavity bears the risk of secondary bacterial infection and abscess formation. The main difficulties faced during laparoscopic orthography in liver cysts are the initial puncture without spillage and the maintenance of the needle in place after partial evacuation. Furthermore, there is difficulty in evacuating individual daughter cysts, and laminated membrane, especially if it penetrated into the liver parenchyma. Despite these risks, echinococcosis of the liver should be treated medically with albendazole, and laparoscopic surgery is feasible for the removal of the cyst successfully without complication. The unusual findings of giant manifestation of these cysts in 3 organ systems (pulmonary, hepatic and renal) underline the unique presentation of such findings in Europe.
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