Endocystectomy for Echinococcus granulosus infection of the liver

The abdomen is opened by a median upper abdominal laparotomy, which is extended horizontally to the right supraumbilically. After draping the wound edges with abdominal towels, a pulley system with a Mercedes retractor is applied.

Typically, the cysts show massive adhesions to the surroundings. Initially, the adhesions of the left-sided cyst to the omentum are dissected. Accidental opening of the cysts must be strictly avoided. Then it becomes apparent that the pericyst is adherent to the gastric antrum. These adhesions are now carefully dissected, sometimes using Overholt clamps.

Once the pericyst protruding over the liver surface is dissected free, it is initially surrounded with abdominal towels moistened with 0.9% NaCl solution. Over these, differently colored towels soaked with 20% saline are placed to prevent the spread of parasites in the situs.

Note 1: The towels soaked with 20% saline solution must not come into contact with the intestine or other organs, as 20% saline solution is tissue-toxic.

Note 2: Instillation of hypertonic saline solution (20%) into the cyst before opening should be avoided if there is suspicion of communication between the cyst and the bile ducts, to avoid the risk of chemically induced sclerosing cholangitis.

Now the endocyst must be opened and removed in a controlled manner.

In the easily accessible part of the pericyst, four holding sutures and a purse-string suture with monofilament suture material are placed. Then, insertion of a trocar with a conical obturator without any leakage of cyst contents. Through the trocar, thorough aspiration of the gelatinously solidified contents. Then the cyst is repeatedly filled and aspirated with 0.9% saline solution.

The cyst wall protruding beyond the liver surface is resected and sent for histology. Any remaining solidified parts of the endocyst are mobilized and removed using a suction device and 0.9% saline solution.

Finally, an abdominal towel is temporarily placed.

The chronic inflammatory layer (pericyst) remains on the liver and protects against bile leaks.