Laparoscopic unroofing of simple liver cyst - general and visceral surgery

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date of publication: 26.04.2009

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  • Minilaparotomy


    After skin prepping and draping of the surgical field perform an infra-umbilical minilaparotomy. Insert Verres needle and establish pneumoperitoneum.

  • Trocar positioning


    Insert one 11 mm trocar for the laparoscope and the other 11 mm trocars left laterally (working trocar for, e.g., the scissors) and in the epigastrium (working trocar for, e.g., a grasper): Insert one 5 mm trocar in right upper quadrant (working trocar, e.g. for suction).

  • Exploration

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    Expose the cyst and open it with the electrocautery scissors. Suction the cyst contents.

    Tips: Depending on the thickness and quality of the cyst wall, resect it with the mono-/bipolar scissors or even the harmonic scalpel!

    Perform careful hemostasis!

    Deeper cysts (e.g., in polycystic liver disease) may display a blueish tinge and must be differentiated from veins: In these cases, laparoscopic ultrasound with vascular Doppler capability can be quite helpful!

  • Inspecting the cyst for neoplasia

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    Carefully inspect the cyst wall for any neoplastic changes.

  • Circular resection of cyst wall

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    Unroof the cyst by circular resection along the cyst margin with the monopolar scissors.

  • Inspecting the cyst bed

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    Inspect the cyst bed for bleeding and biliary leaks; carefully coagulate bleeders and clip or suture any biliary leaks.

  • Removing the trocars

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    Remove the trocars under vision and perform hemostasis, if needed.

    Tip: When ascites is present, close the fascia at all trocar sites to prevent any ascites channel formation!

  • Suturing the trocar site fascia

    External fascia sutures at the trocar sites, subcutaneous sutures and subcuticular absorbable suture, sterile dressing