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

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    44-4

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

  • Trocar positioning

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    44-5

    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