Evidence - Laparoscopic unroofing of simple liver cyst

The literature search did not identify any randomized controlled trials on laparoscopic unroofing of liver cysts. However, there are several papers on non-randomized controlled trials. This review of the literature excluded any studies with less than 6 patients and clinical research studies.

In general, the number of cases was rather small, with 8 to 17 liver cysts in congenital cystic disease and 6 to 104 cysts in echinococcosis. These small numbers must be considered when looking at the operating times, recurrences and complication rates.

Technique

For solitary large liver cysts unroofing by itself resulted in good outcomes with low recurrence rates. In polycystic liver disease with a limited number of type I cysts in the anterior segments of the liver, these cysts should be resected.1). Type II cysts, on the other hand, are found as numerous small cysts in all regions of the liver, including the posterior segments.

The level of evidence for cysts in echinococcosis is weak as well. Nevertheless, there is a tendency favoring radical surgical extirpation either by pericystectomy, partial resection of the liver, or fenestration of the cyst accompanied by excision of the cyst wall. When it comes to omentoplasty and the use of drains, the literature is conflicting [2-4]. The issue of drains still is open for debate. Authors not employing drains, and even discouraging their use, point to the high rates of infection, while no impact on the rate of recurrence is seen [5,6].

Operating times

In congenital solitary cysts, the mean operating time varies between 48 and 87 minutes [Kathkouda, Zacherl], and for polycystic lesion between 95 and 141 minutes [Kathkhouda, Kornprat]. In echinococcal cysts, operating times are somewhat longer, since they require a different technique; here, the times vary between 80 and 179 minutes [3-5, 7, 8].

Conversion rate

The rate of conversion to open surgery is low for all types of cysts [2-5, 8, 9] and primarily depends on patient selection. Higher conversion rates are seen in patients with polycystic liver cysts type II.

Length of hospital stay

In the literature, the mean length of hospital stay is reported as 1.3-10 days [2, 5]. In most case, the mean length of stay is between two and three days [4, 5, 8, 10].

Complications and mortality

Most authors report a mortality of 0% [4, 5, 8-11]. Only Bickel et al. 3 describe one lethal outcome in a patient being treated for two complex cysts. The patient died of multi-organ failure in candida sepsis

The morbidity for solitary cysts is between 0% and 6.2% [5, 9, 10], and for polycystic liver disease between 0% and 33%. The morbidity reported for liver cysts in echinococcosis varies between 0% and 33%. The complications are varied and primarily involve biliary leaks,

Abscess, pleural effusion, but also bleeding and anaphylactic reactions in infectious cysts.

Recurrence rate / Follow-up

The mean follow-up is between 30 and 49 months. The rate of recurrence is low and usually varies between 0% and 18.2% [2-5, 8-11].

Conclusions

Apart from the general benefits of laparoscopic surgery in liver cysts, one drawback is that cysts may be hard to access in some parts of the liver. Routine unroofing of liver cysts in echinococcosis is not recommended because of the numerous complications possible and the special expertise in liver surgery required in these cases  5. In addition, there is also the risk of spilling the cyst contents into the abdominal cavity. If the contents of the cysts are rather viscous, laparoscopic suction may be rather difficult. For a good outcome, Manterola et al. 8 considers patient selection paramount, particularly when dealing with cysts in liver segments I, VII and VIII. Despite the very low rates of recurrence and mortality reported in the literature [3-5, 8, 11], preoperative patient selection is the decisive risk factor, particularly for recurrence. Since higher rates of recurrence are seen in patients with multi-/polycystic liver disease (type I), other treatment modalities should be considered, e.g., partial resection of the liver. However, the current literature demonstrates that laparoscopic unroofing of symptomatic solitary liver cysts can be undertaken with very low rates of conversion and morbidity, and that this technique can be recommended as standard treatment.

Assessment of Treatment With Laparoscopic Fenestration or Aspiration Sclerotherapy for Large Symptomatic Hepatic Cysts (ATLAS): a Randomized Clinical Trial.

1. Morino M, De Giuli M, Festa V, Garrone C. Laparoscopic management of symptomatic nonparasitic cysts of the liver. Indications and results. Ann Surg. 1994 Feb;219(2):157-64
Kornprat P, Cerwenka H, Bacher H, El-Shabrawi A, Tillich M, Langner C, Mischinger HJ. Minimally invasive management of dysontogenetic hepatic cysts. Langenbecks Arch Surg. 2004 Aug;389(4):289-92.
2. Bickel A, Loberant N, Singer-Jordan J, Goldfeld M, Daud G, Eitan A. The laparoscopic approach to abdominal hydatid cysts: a prospective nonselective study using the isolated hypobaric technique. Arch Surg. 2001 Jul;136(7):789-95.
3. Khoury G, Abiad F, Geagea T, Nabout G, Jabbour S. Laparoscopic treatment of hydatid cysts of the liver and spleen. Surg Endosc. 2000 Mar;14(3):243-5.
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